Decisions, decisions...

Now that I'm due to move to New York City in less than six months' time, I've started thinking about where to live. It's entirely too early to reserve an apartment given the quick housing turnover rate there, but it would be nice to have the plans firmed up in my mind at least.

For a person who has difficulty ordering in restaurants because everything looks good, choosing between Manhattan neighborhoods can be a challenge. When it came time to rank anesthesiology programs, I had a list of my top five programs, each with something unique to offer. In the end, it came down to choosing a city: New York, besides being close to my extended family in Philadelphia, is a city that has more to offer than perhaps any other American city and is a place where I hope friends will want to visit!

Now it's time to decide on Manhattan neighborhoods. On the cardinal-directionally-correct map below, I've listed a few advantages of two of the main contenders.

Parking lot code!

So there are two types of "code blue" at this hospital:

1. MET, which is a true medical emergency (Medical Emergency, True???)
2. ART (I have no idea what this stands for) which is not a medical emergency. We, the code team, do not have to respond to them.

On a recent code, I was paged "CODE BLUE: MET, PARKING LOT 5." Part of me wondered if this shouldn't be an ART...was there really a nurse around to determine that this patient's heart had stopped? But then glamorous images of me intubating the patient in the middle of the parking lot on this sunny cold day compelled me to hurry downstairs.

After consulting a map of the hospital campus, I determined which one was parking lot five and jogged over to the adjacent professional building. There, in a stairwell, an elderly man had tripped and fallen. He had a couple lacerations on his forehead, but a passerby had stopped and given him a napkin. I quickly made sure the bleeding was controlled and did a brief neurological assessment. He was fine. It should have been an ART. Actually, they should have just called 911 rather then going through the hospital pager system.

The code at 7:45 AM the following call day was a little more legitimate. I had decided to take a quick nap after seeing my ICU patient. (Since the team on call the day before my team only has one intern, my call room goes unused, and is ready for napping virtually the moment I arrive.) Being awakened by my pager, I stumbled downstairs to the eighth floor and met my resident in the stairwell. There were a few nurses in the room, but that was it. Since the respiratory therapist hadn't arrived yet, I dug through the "crash cart" and found an appropriate laryngoscope and endotracheal tube.

We did the usual thing: chest compressions, a few medicines. Intubating the patient was surprisingly easy, given that he was such a large man. I always feel much more comfortable in codes once we have an airway, and I'm not sure if it's because I'm a budding anesthesiologist, or if others feel the same way too. A few people congratulated me on the smooth intubation, which made me feel a little guilty because it was so easy...but sometimes it's best just to accept the compliment.

The rest of the code wasn't so smooth...four times we got a pulseless ventricular tachycardia which meant four shocks with the defibrillator, each one bringing back a regular rhythm at least temporarily. In the meantime, he got bicarbonate, calcium, lidocaine, vasopressin, multiple doses of epinephrine, and two boluses of amiodarone. Finally after thirty minutes, we were still in pulseless v tach. My resident "called" the code, that is to say, we had done everything we could do, and it was time to stop.

Like a machine being powered-down, the room quickly grew quiet: the humming faded, the activity stilled, the oxygen flow was cut off. And then, much to our amazement, the patient's jaw moved--he was trying to breathe! And then, slowly, his right arm lifted off the bed! "Uh, resume compressions!" my resident ordered.

Shortly after this point, the cardiologist showed up. His first question was how long we'd been coding the patient. Thirty minutes. "Have you thought about calling the code?" was his second question! When we explained what had happened, the cardiologist tried a couple shocks with the manual paddles (like you see on TV) rather than the sticker pads. Maybe the cardiologist believed the extra pressure would do some good....maybe he did it just for style points.

In the meantime, both of the patient's arms were rising. Given that the unfortunate guy didn't have a perfusing rhythm, the cardiologist informed us he was simply "posturing", that is, having involuntary muscular reflexes. We decided to try one last shock and one last amiodarone bolus. (Even though one amiodarone bolus is usually sufficient, this would be this patient's third.) Wouldn't you know, that did the trick! He had a pulse and a blood pressure after a grueling 45-minute code. We wheeled him to the ICU (rather than discharge him, as the primary team had been planning to do that day) and let the specialists take over from there.

As if that weren't enough about this remarkable code, the story doesn't end there...by the following afternoon, the patient was ready to be extubated! Evidently he's had full--and rapid--recovery with no neurological deficits after being dead for the better part of an hour!

I also learned a lesson about napping. Right after I'd intubated the patient, my resident turned to me and asked, "Jonathan, were you asleep in the call room? There's a line on your face!" (The lesson is to sleep on my back during my daytime naps.)

Christmas gift exchange

Dad Wish List

• Pedometer

Mom Wish List

• Kitchen utensils http://www.potterybarn.com/products/p8121/index.cfm?pkey=ctenholent&cm%5Fsrc=campaign

Jonathan Wish List

• See my Amazon.com wish list
• Trinity hymnal (can be found at http://www.gcp.org/search.asp?id=987765982)

Charity Wish List

• Gift Ideas (I also have updated my amazon list)
• A pair of shoes I've been looking at for over a month now: http://www.dillards.com/webapp/wcs/stores/servlet/ProductDisplay?catalogId=301&langId=-1&storeId=301&productId=500996776&view=80&N=1590141+4294967286&searchUrl=%2Fendeca%2FEndecaStartServlet%3Fview%3D80%26N%3D1590141%2B4294967286&R=SJD502
• Hat in Purple… Go frogs: http://www.coach.com/content/Product.aspx?category_id=868&product_no=8863
• Black Sweater Size: small petite http://www.anntaylor.com/IWCatProductPage.process?Merchant_Id\u003d1&RestartFlow\u003dt&Section_Id\u003d2967&Product_Id\u003d843949
• I love, love, love these: Did I mention that I love them? http://www.crateandbarrel.com/family.aspx?c=1910&f=13938
• Dish Towels In blue of course: http://www.williams-sonoma.com/products/sku4300281/index.cfm?pkey=chkgktdi&cm%5Fsrc=None

Charity Stocking Stuffer

• http://www.restorationhardware.com/rh/catalog/product/product.jsp?productId=prod1203053&navCount=2
• Pizza Cutter

What I learned from my mother

Another significant part of the week was the theme of death and loss which emerged in many instances. In grand rounds this morning, one of the assistant program directors--Dr S--gave a "Tribute to a Teacher," which was dedicated to a rather unusual, complex, and challenging patient with Marfan's Syndrome among a host of other problems. Her many phsyicians (including residents who helped admit her to the hospital 24 times over the last few years) often found themselves mired in frustration. This patient died rather suddenly and unexpectedly not too long ago.

The time since has allowed Dr S a period of reflection. Her tribute was warm-hearted and even sentimental, which contrasted sharply with the frustration I knew many felt with this patient. However, at the end, she reminded us what our job as physicians really was: to take care of patients both in health and as they die. Dr S asked herself regarding this diffcult patient, "Did I inquire into her faith journey? Did I ask her about her biggest fears? Did I let her know that I understood her fears?"

This reminds me of a relatively young patient I've taken care of recently (see link) who is now at home on hospice care. I felt the urgency and gravity of somehow meeting more needs of this patient than simply managing hypertension and arranging for hospice care. Much time I spent with the family as they hung tenaciously to hope and faith. And yet I had the feeling that there was something I wasn't facing head on. This was it. I think I was afraid to delve into acknowledging this woman's fears. It's one thing to pray with her for grace and peace; perhaps it's another to open myself up to sharing in her fears. The least I could do is acknowledge them.

And this is why a poem I ran across this week stood out to me. It is written by Julia Kasdorf, and its title is "What I Learned from My Mother."

I learned from my mother how to love
the living, to have plenty of vases on hand
in case you have to rush to the hospital
with peonies cut from the lawn, black ants
still stuck to the buds. I learned to save jars
large enough to hold fruit salad for a whole
grieving household, to cube home-canned pears
and peaches, to slice through maroon grape skins
and flick out the sexual seeds with a knife point.
I learned to attend viewings even if I didn't know
the deceased, to press the moist hands
of the living, to look in their eyes and offer
sympathy, as though I understood loss even then.
I learned that whatever we say means nothing,
what anyone will remember is that we came.
I learned to believe I had the power to ease
awful pains materially like an angel.
Like a doctor, I learned to create
from another's suffering my own usefulness, and once
you know how to do this, you can never refuse.
To every house you enter, you must offer
healing: a chocolate cake you baked yourself,
the blessing of your voice, your chaste touch.

Skyscrapers and menus

Sometimes I feel like I'm enjoying life too much to be in internship...this week is one of those times. Last night found me winding through the terminal of the local airport, crowed by holiday travelers. Soon I found friends Phil and Kathleen at their baggage claim; they were on their way back to Texas from interviews in North Carolina.

The night was cool and drizzly, but we were greeted by a warm apartment back at my place. Dan and Kristen joined the three of us for dinner, which I had fun planning.

And where do skyscrapers come in? I'd stopped and browsed at the bookstore on Saturday, where I spent twenty minutes purusing a book about architecture. One trend in the mid-to-late twentieth century was to define the base, mid-portion, and top of these giant structures. (It seems many earlier structures did just so, but then the box-like skyscraper emerged in the fifties.) I had fun patterning the menu after these skyscrapers, with a different drink for each segment.

New York City strike

See article. This irritates me on a number of levels. Most of all is the fact that the union decided to shut down the daily public transportation for seven million people after they rejected a compromise offered by the MTA, and they did so in flagrant disregard for the law and a recent judicial injunction.

Now, I'm sure there are two sides to every story, but the union's demands must be put into context. 1. MTA has already offered raises that are above the rate of inflation. The union wants even bigger yearly raises. 2. The union workers get paid more than resident physicians in NYC. Something's wrong when the bus driver, who makes more than a doctor, is on strike for more money.

And why am I posting at 4:45 in the morning? Let's just say my irritation extends to my own work. I'm seeing ever more clearly how patients themselves get in the way of my taking care of them. My ICU transfer in the middle of the night: "I don't want a catheter!" "I don't want to stay in bed!" "I want to go home!" "I'm really starting to get worked up!"

To this last comment, I was pleased with my off-the-cuff reply: "Well you should be worked up! This abnormal heart rhythm can kill you! That's why we moved you here to the unit."

Good photo

I recently discovered my friend Melissa's blog. She's working as a midwife in the Philippines. Here's a photo I stole from her most recent post...

Dinner with friends...

Clay and Lori were so gracious as to host us for dinner last night at their sleek new townhome...this is "The Gang 2.0". It includes newer members Ashley and Kristin, and sadly, is missing Dave and Louisa. And Alison.


We spent the first fifteen minutes letting Clay and Lori's golden retriever Cosmo meet Clint and Kristin's golden retriever.

I am intern, hear me roar!

Nothing beats earning nearly a full afternoon off as the result of getting one's work done quickly and efficiently. I was awakened from a snooze on the couch, however, by my pager...fortunately, nothing to worry about--just a Code Blue. (It surprises me and even bothers me how sometimes I feel relieved when it's "just" a code, because when I'm not on call, it's not my responsibility.)

However, the page I received a few minutes later seemed harmless enough: "Please call 6-east." When I did, the nurse began speaking rapidly, "Doctor, the patient is satting only 85% on oxygen, and the respiratory therapist says the patient sounds wet. I think he needs some Lasix." (Lasix is a diuretic which we use very commonly to get rid of excess fluid in a patient's heart or lungs.)

Nothing bugs me like a nurse being pushy with orders. It's one thing to convey information, and even to make suggestions like the ICU nurses are so good at doing (e.g., "I think the patient might be volume overloaded. Do you think he could benefit from some Lasix?"). The problem is that it's the doctors job to decide what to do, and it helps to receive the pertinent information without having the relayer of information interpret it for you. If an intern makes the wrong decision because he was influenced by a nurse, it's still the intern's fault.

I asked the nurse to request a stat chest x-ray and arterial blood gas. She seemed to think this was reasonable, but then she said, "And then you want Lasix?" "No, just get the tests, and I'll come assess the patient," I replied. Within a minute, I was in the car on the way back to the hospital.

Turns out it's a good thing I wasn't biased by the nurse's suggestion. When I viewed the chest x-ray beside the patient's totally clear admission chest x-ray, there was a roaring pneumonia! The patient was breathing thirty times a minute and was simply not getting enough oxygen, even with his 100% oxygen mask.

After a quick history and exam (after which I viewed the chest x-ray), I told the unit secretary that my patient would be going to the ICU. I sat down to begin writing orders as I paged my attending. Since July, my approach to attendings has changed from, "This is what happened today; what do you want to do?" to "Here's what's happening, and this is what I would like to do." I think attendings like this, and it's good for me to think through problems myself.

Turns out my attending was totally on board with my plan to transfer the patient to the unit, add a stronger antibiotic, and consult pulmonary in case the patient needed intubated later. It was exciting to make an intra-hospital diagnosis and therapeutic plan virtually all by myself, especially since in-hospital complications can sometimes be more challenging than evaluating someone off the street. And I know I'm still young in my training, and can and will miss important subtleties at time, but I know I'm starting to get a feel for how to be an independent physician.

"Please not yet! I'm scared!!!"

Those were the last words my patient spoke before we induced her and intubated her. The first patient of my call day last Sunday, she was a transfer from a small rural hospital. Like other unfortunate transfers I've received from this hospital, this one was in a state of "crumping." Her worsening repiratory distress and acidosis meant we didn't have long to get the breathing tube in her. But she was emotionally distraught and just wanted us to wait for her daughters to arrive. In this situation, emotional distance from the patient allowed us to save her life while we could: within seconds, the sedating medicine coursed through her veins and she drifted off to a peaceful sleep.

But the intubation wasn't to be that simple. After another intern tried twice unsuccessfully, the pulmonary attending stepped in with an armament of fiberobtic equipment and years of experience. I knew we were in trouble fifteen minutes later when he stepped back, looked at me, and said, "Hey Jonathan, do you want to try this?" Sure, he knew I was going into anesthesia and had slipped a breathing tube down many a patient's trachea, but this was an attending stepping aside to let the low man on the medical totem pole try! Despite my best attempts at laryngoscopy, all I could find was swollen soft tissue, bloody secretions, and a floppy epiglottis. An hour after we induced the patient, we finally secured the airway by using a device called a "fast-track laryngeal mask airway" which allowed us to blindly place the breathing tube.

I quickly slipped in a central line, and around the time we were going to check the patient's central venous pressures, she went into a pulseless ventricular tachyarrhythmia. Four shocks and an amiodarone bolus later, we had a rhythm and a pulse. Not quite what you see on E.R., but close.

The nice thing about a private hospital is the ease of recruiting specialists' expertise. In addition to the primary team, within a couple hours we had the assistance of pulmonary, cardiology, and renal services. Within a day, thoracic surgery and hematology/oncology were lending a hand.

The problem with the patient? It was a football-sized mass growing next to her heart. After we'd stabilized the patient, I went out to visit with the ten or twelve family members in the ICU waiting area. I stressed that at this point, we were doing everything we could just to help her live through the night. We could make no guarantees. This was their mother, their sister, their wife, and with tears in their eyes they accepted that she might die that very night. A niece caught me by the hand as I turned to leave the room. She looked into my eyes, and then studied the floor as she spoke, "Excuse me, doctor, but are you, um, a believer?"

"Yes, I am a Christian," I told her. Realizing that this family was teetering with their loved one on the precipice at the edge of life itself, I stepped back into the room. I told them I believed in a God who is both loving and who is in control. And holding hands as we formed a circle, I prayed with them. I could offer little hope, but I could point them to Him who could. I could make no promises and offer very little assurances, but I could turn them to the source of peace in the valley of shadows.

* * * * * *

Today, two days later, I found out the tumor is an aggressive cancer. The pulmonologist called me at home to let me know. I don't know what the coming days or weeks hold, but I suspect she may never get off the ventilator. And I think back to those first moments when the patient was alone without her family and frightened. Her last words still echo in my memory: "Please not yet! I'm scared!!!"

For my sister...

Happy birthday, Charity!

Saturday, December 10th, 2005. 26 years old!!!

My 'hood

A Q4 schedule really isn't bad. Sure, there's a long stretch of work, but then you get to enjoy a few evenings in a row. Especially after a good, deep nap on the couch, post-call days are deleriously satisfying.

I rolled off the sofa after hitting "snooze" once or twice, threw on a cap, khaki shorts, and shoes, and went out for a walk in the neighborhood, armed with my clunky yet definitely adequate digital camera. (Yes, my Canadian and Midwestern readers, you read that right: I wore shorts and a tee-shirt out in December.) Here's what I saw...


My apartment complex. My apartment faces one of the inner courtyards.

The entrance-way to a small nearby art gallery.

A four-foot bronze turtle a couple blocks down the street.

Four blocks away, I discovered this little Italian restaurant. My roommate David tells me it's one of the best in town.

A wall I liked.

Turning the corner to head back toward home, I was surprised to see this Rolls parked nearby.

I've entered a new era of blogging

That's right. I now have the unprecedented--not to mention eerily uncanny--ability to post pictures from my digital camera right here on the blog. This photo should really go with my recent post, When the weather outside is frightful.... It's a picture of my call room. I especially appreciate the work-center, complete with phone and a flat-display computer in close proximity to the bed. The art work above the bed is a thoughtful touch, though I can't say it's one I would pick.

Overheard at the hospital...

My attending: "And did you see any changes on repeat EKG?"
Heather, my teammate: "Well, we didn't repeat the EKG, so no, we didn't see any changes."

(Do I need to explain why this is so hilarious that it took every last ounce of willpower not to crack up during teaching rounds? She's answering two questions. Her first answer makes the second one unnecessary. But since he asked two questions in one, she dutifully answers the other question, which, by itself, would be technically honest but essentially a lie.)

An oncology attending in the ER, addressing me after I'd completed a pulmonary consult with my then-departed pulmonary attending: "Well, your boss may know a lot about the lungs, but I don't think he's totally correct on this one. Maybe 75% correct."
Me, after an awkward silence during which I thought about what he wanted me to say, and whether I still had any of those sweet, juicy oranges that I could eat after I got home: "I guess I try to learn a little from everyone I work with."
Oncology MD: "Are you going into politics?"

The picture above is an old stone bridge in Princeton, New Jersey, taken on one of those amazing afternoons when you're not sure whether to bring your jacket with you on your stroll, or leave it in the car.

When the weather outside is frightful...

'Tis better to be on call at the hospital!!! Well, not quite, but I guess that's thinking positively. Weather.com informs me that it is 25 degrees here, and it feels like 13. I hear the nurses complaining about the bad traffic and slick roads on their drive in for the night shift, and other nurses getting ready to leave are all bundling up for the blustery outdoors weather. Which makes me feel warm and cozy, now that I've changed into my scrubs and am sitting in my lamp-lit call room, the drapes drawn and the bed ready to crawl into!

It's been a busier call day, and I realize the thing I hate is not being busy, but being pulled in multiple directions at once. Returning pages in the midst of trying to write a History and Physical while I present to attendings and try to juggle that with the interns checking out to me! I shouldn't have this problem so much in anesthesia. There I sit, with one patient to focus on!

So it's 9:00 PM, my evening rounds are done on my new patients, I've stamped out a few cross-cover issues, and I'm not sure if I'm up next or my co-intern. It's nice being caught up! A productive use of the next hour would be updating my check-out list and finding a good article about one of my patients.

* * * * *
Addendum

Yes, that would have been a productive use of the last hour. Instead, I ventured outside, where I found the weather pleasantly brisk until the wind picked up and "bitterly cold" became a more apt description.

I wandered over to the "Page Operator" room in the Women's Health building, which is in a sense the communications center of the hospital. The page operators are always so friendly, and tonight was no exception. There I met Bridgette, Cocoa, and Kelon. They showed me how the software works.

I swung through the Emergency Department to get a sense 0f how busy it was. The busyness of the E.D. has an inverse relationship to my probability of getting sleep. Even though many would consider this bad luck, I was pleased to find a short patient list on the monitors. I scurried out before my presence could remind anyone that, oh yes, there is a teaching service we can admit to!

My last stop was the cafeteria for a cup of hot tea and a scone to carry back to my call room upstairs on the top floor of the hospital. Momentarily, I'll pull off my shoes, dim the lamps, and just sink into that downy feather bed...

Oh, Flannery!

My brother surprised me with a jewel from Half-Priced Books the other day. He brought me home an old edition of Flannery O'Connor's Everything that Rises Must Converge. I think this is the best kind of gift--one that's thoughtful and totally unexpected. And one that involves Flannery O'Connor's short stories.

I wanted to share a quotation from the back.

When I read Flannery O'Connor, I do not think of Hemingway, or Katherine Anne Porter, or Sartre, but rather of someone like Sophocles. What more can you say for a writer? I write her name with honor, for all the truth and all the craft with which she shows man's fall and his dishonor. --Thomas Merton, Jubilee.

I myself find her both brutal and compassionate. There, two good reasons to read her!

Speaking of recommendations from the backs of books, I've noticed books of poetry tend to have the most colorful and fun declarations. To sample a few from Billy Collins' books:

• "Collins is jazzman and Buddhist, charmer and prince." --Booklist
• "What Collins does best is turn an apparently simple phrase into a numinous moment...Collins brings to mind the elegant wit of the sorely missed William Matthews, another poet of plenitude, irony, and Augustan grace." --New Yorker
• "A typical Collins poem has a self-illuminating quality to it, or...a gratifying organic feel about it, a sense that like some splendidly blooming plant, it develops naturally from even a most inauspicious instant of germination..." --The Boston Globe
• "Collins reveals the unexpected within the ordinary. He peels back the surface of the humdrum to make the moment new." --The Christian Science Monitor
• "[Collins poetry] should be placed next to Gideon's Bible in every motel room in America." --The Providence Journal
• "I have never before feltposssessive about a poet, but I am fiercely glad that Billy Collins is ours--smart, his strings tuned and resonant, his wonderful eye looping over the things, events and ideas of the world, rueful, playful, warm-voiced, easy to love." --Annie Proulx

Egypt pictures

I wanted to share a few pictures from my trip to Egypt with my parents...

A mosque in Cairo, built in the early 1800's. The upper dome is about 45 meters high.

My parents and me at the Great Pyramids of Giza. Built around 2500 B.C. They stand just on the outskirts of Cairo.

Moses may have turned the waters of the Nile into blood, but here they're golden.

A felucca ride on the River Nile at dusk.

A temple on a hill. It's older than your grandmother.

In Luxor, waiting to travel back to Cairo.

Three weeks till Christmas

My first call night was kind to me as I eased back into wards. 7-hours-of-sleep kind, which is almost unreal. Efficient post-call rounds meant I could make it to church, and then have lunch with my family at my aunt's house.

Winter is starting to arrive, as a distinct chill greeted me as I left the hospital today.

And a delightful bumper sticker seen on the back of a small, white Korean car:

I like poetry,
Long walks on the beach,
And poking dead things with a stick.

Jonathan's week in review

Sometimes I feel compelled to blog about everything interesting that's happened in life. If I don't write it down, I may forget it! And for my readers' sake, those who follow me every step of the way, cheering me on, practically living through me, I hate to leave them hanging. (I love the scenes in The Truman Show that picture the fans watching the show, engrossed.)

So, here's my summary...

• Finished ICU on Wednesday. The last few central lines I did with minimal supervision, and it's nice to feel much more comfortable with that procedure.
• Interesting personal interactions. Attempting to get what I thought would be readily given consent for a central line, I was faced with questions such as, "Why do you need to do this procedure when he already has a line?" "Pneumothorax??? That's a pretty big risk. Is this really necessary?" With 10 minutes of sweet-talking, I finally got consent and spent about as long starting the line.
• Went to the symphony on Thursday with Dawn. Beethoven's Violin Concerto was performed by a 17-year old who was technically comfortable, but, in the words of the reviewer in the next morning's paper, left us feeling like we just listened to a "very careful rehearsal." I would have preferred a few mistakes in exchange for a more carefree, extroverted, or at least unselfconscious performance. The Mahler First Symphony more than made up for what was lacking in the first half. Tucked away in every movement are soaring melodies marked by an intensity and richness that can only be Mahler. Winter decorations adorned the symphony center for this early December concert.
• Had my car broken into, in broad daylight, in a good part of town. The would-be thief was after my CD player, which he did not get after attempting to wedge out my dashboard. In the midst of the shattered glass on the passenger seat, I found a red toboggan. The police didn't seem to interested in obtaining this to document DNA evidence from a stray hair.
• Had a conversation with a patient about lymphangioleiomyomatosis. It's almost as much fun to write as to say.
• Found myself, once again, on call at the hospital. Today, a friend from college named John who's doing surgery at a nearby hospital, is on call tonight too as he's rotating through for the month.

Another pint of beer...

with my roommate David. Faced with a Friday night with no plans and call looming on Saturday, we decided to go to a local German restaurant. Standing in line, waiting to be seated, I was thinking of the various times and locations that David and I have eaten together. Behind us, a couple of older gentlemen joined us in waiting for a table. Suddenly I was struck by the potential similarities: two friends, out for dinner on an otherwise quiet, cool night in early December. Take David and me, fast-forward 45 years, and you have these other two. One even was taller and wore a jacket like mine, the other, like David, wore a flannel shirt.

The small dining area was an unauthentic yet charming interpretation of Bavarian pub. Families with children filled the room. A musician with a feathered hat in the corner performed on a keyboard and occasionally an accordian. Over schnitzel and spatzl, and of course a cold pint in a chilled mug, David and I caught up on life and relaxed.

Tomorrow is my first call back on the wards for the month of December...

Autumn has come...

and it's about time! The weather has finally turned consistently and pleasantly cool. Despite the dreary and overcast weekend, the sky today was bright blue, and the trees outside below my window offered a palette of reds and yellows.

Tonight my friend Jim comes into town--he'll stay for a night or two. I felt both responsible and hospitable making preparations before he comes:

• Emptying the bathroom trash can. Setting out a fresh towel and washcloth.
• Putting clean sheets on the sofa, along with a couple blankets and a pillow. Turning on the lamp for ambiance.
• Moving the coffee table to the wall for extra space, and putting out an alarm clock. And a coaster.
• Hot water is ready for a cup of hot tea when he arrives, should he desire. Or a small glass of Scotch.

Confessions of an intern in the ICU

As this month in ICU draws to a close, I've had a little time to reflect on my experiences. One of the challenges of ICU care, so I've noticed, is the tendency to objectify my patients. Too often, I know them simply as beings on the ventilator with whom I've never had personal contact. Despite the "intimacy" of medical care--attending to every aspect of my patients' physiology--there is no relational intimacy or physican-patient trust. For these reasons, this month I've sensed a pronounced disconnect between being a medical care provider and being a phsyician. I've done far too much of the former (and not very well), and precious little of the latter. And the strange thing is, I'm the one who misses it!

I wonder how my attendings handle doing this for years and years. Part of me assumes that this is something they never wrestle with. Does it simply take a hardened, thick-skinned person to do well in the ICU?

Inadequacy has also been a feeling I've experienced quite a bit of. Every patient has family members who are deeply concerned...when I'm struggling just to get the work done and merely understand the complexities of critical care, I dread questions from family members. Especially if I haven't seen the patient for a day or two (as a result of the "divide and conquer" mentality to rounding), I feel like a deer in the headlights when I'm asked, "How's my father doing?" "Um, let's see, was he the one on the vent with the renal failiure and the fungemia, or is he the one on the vent with pneumonia and post-op heart valve replacement? Maybe I should check with the nurse and get back to you," is what goes through my head.

And the fact that every patient is really sick, every patient has family who needs supported makes me feel stretched thin, or worse, uncompassionate. And so even though I'm drawn to critical care as a possible subspecialty after anesthesia, these are some of my concerns about entering the field. The eternal optimist in the back of my head reminds me that the more competent I become managing ventilators and the more comfortable I feel balancing 10 medical issues at once, the easier it will be to be to step out of the role of medical provider and be the physician I desire to be.

Ping pong

I had to post this link.

Matrix ping pong

Happy Thanksgiving

Rather than my original plan of sharing the litany of things I'm thankful for this Thanksgiving Day, 2005, I thought I would simply post to say I'm back in the States and hopefully back to blogging more regularly. To my family and friends--you're at the top of that list.

I saw King Tut's underwear

It's Wednesday evening, and I've passed the "tipping point" or our vacation. One of the things a well-intentioned friend had warned me about was to expect some "culture shock." That really hasn't been the case for this vacation, except for some mild annoyance when I have to say "No, thank you, but I really don't care for a burro ride to market" for the fifteenth time.

Another thing I hate: bargaining. I'd sooner come away with no souvenirs than haggle for them. It seems I inevitably feel either that I'm taking advantage of the vendor, or being taken advantage of. Most of the cases of the former are in actuality likely the latter. Yet there's plenty of humor to be found. A typical (and real) conversation follows:

Dad: How much for the instrument?
Egyptian: Twenty pounds. (There are about 5 Egyptian pounds per dollar)
Dad: Let's see, that would be about four dollars. I could give you two dollars.
Egyptian: Deal. In pounds, that's about 15 pounds.
Jonathan, laughing: No, Dad, give him 10.

Other highlights of the trip:

• The Egyptian Museum in Cairo. The "treasures" of the museum include the burial mask, sarcophagi, and Afterlife supplies of the young King Tut. His linen underwear was also on display, hence this post's title.
• A train ride from Cairo to Aswan on a Soviet-era "first class" train. A 10-watt bulb lit my sleeper cabin, a musty smell permeated the room, and the decor seemed to be straight from the 50's. Definitely an experience to remember.
• The pyramids at Giza. At this point I would say something like, "You can't appreciate how big they are until you stand beside them," but I've heard that line so many times that it's past cliche. They are nearly 1/3 the height of the World Trade Center, and supposedly Napoleon calculated that they contain enough stone to build a three-foot wall around the perimeter of France.
• A "felucca" (small boat) ride on the Nile. Amazing gold-to-red sunsets over this great river's western bank.
• Is "EuroTrash" a politically correct term? Just wondering. Anyway, lunch on the cruise ship was a frenzy of French-speaking mayhem. We later dined with two British couples which was much more enjoyable. Another fun fact: If you were to drop the Great Pyramid at Giza onto the Eiffel Tower, the latter would be smashed flat. As would the Louvre.
• Mom has asked a couple of our guides why the different groups in Iraq (Shiite, Sunni) can't get along as well as the Muslims and Coptic Christians who peacefully coinhabit Egypt. Feeling a bit like I was in the middle of a Flannery O'Conner story, I told her the guides probably didn't have a good answer for that.
• Visiting the "High Dam" across the Nile. The first dam was built around 100 years ago (flooding the ancient Temple of Philae which was later painstakingly moved), and the High Dam completed ~30 years ago. These dams forever altered the flow of the Nile, eliminating harmful excessive flooding, but also preventing naturally fertilizing silt from reaching the farmlands of lower Egypt. The lake created behind the High Dam also displaced many Nubians. (I'm sure they all agreed to this project, knowing they'd be well-compensated for exchanging their personal property for a gigantic electricity-generating project.) The High Dam supposedly contains 17 times the amount of material as the Great Pyramid at Giza.

We sail tomorrow for Luxor. Signing off for now...(Imagine a picture of the Sphinx at the top of this entry. It wouldn't upload properly from this internet/smoking lounge's computer.)

A blogging hiatus

Just wanted to let whomever may be reading know that I won't be blogging for the next ten days or so... I'm taking a little trip with my parents to the country pictured above. We're flying different airlines tomorrow, so after seeing them briefly tonight, I bid them good-night and said, "See you in Cairo!"

It's been a busy week in the ICU, and full of many stories. Unfortunately I just haven't had the time to share them yet. Perhaps I'll gradually catch up and write more in coming weeks. Unless the snipers catch up to me in Cairo...

So good night and fare well.

A little turkey, a little Brahms

So last Thursday evening had me driving staight from the ICU to the symphony center downtown for a performance of Brahms' second symphony and Richard Strauss' Four Last Songs. My impression of these two great composers is of two men who refused to abandon a good thing while everyone else had moved on. Two giants who almost post-date their eras. Brahms carefully trod in Beethoven' footprints, his sometimes stark and sparing compositions standing in sharp contrast to the lush works of Wagner and contemporaries. And then there's Strauss who carried the torch handed off by these late Romantic German composers and pressed nearly halfway through the Twentieth Century.

I was fortunate to make it to the pre-concert lecture. While it was full of interesting facts, the nugget I wanted to share was the philosophical influences on these composers. Brahms believed firmly in the inherent beauty of music. His works are crafted to be appreciated for exactly what they are. Strauss, however, greatly influenced by Nietzsche, sided with those who explored the programmatic nature of music: Music's value can be in its depiction of something other than itself.

Certainly there are volumes written on such things, but enough with the abstract. The concert was full of magical moments, one of which was the french horn solo at the end of the second of Strauss' Four Last Songs. This solo happened to be played by a fellow I went to college with who now plays in a major symphony orchestra...He obviously has done more with his instrument than I!

The title of this entry is a quotation from this french horn player's father, who was the conductor of my college symphony. We were about to disband for Thanksgiving break, but were scheduled for a concert shortly after featuring Brahms' Tragic Overture. These were his last words to us, encouraging us to practice a bit over the break.

Amani's wedding

So now that I've been working consistent 12-hour days, I'm finding it a little harder to post regularly! I'm now on ICU which is challenging (especially learning new patients who have been here) but overall enjoyable.

Friday night was my friend Amani's wedding. Although she's out of state doing pediatrics residency, the wedding was here in _____.* It was a mini med-school reunion with 5 or 6 classmates there. It was a simple wedding--and short--but one of the best parts was seeing the close-knit families and hearing the blessings bestowed upon the new couple. Congratulations, Henry & Amani!

Another wonderful thing about the wedding was the mosaic pattern on the plaza outside the building. It was a tessellating pattern of the state of Texas. Now, it's one thing to make Colorado or Wyoming or even Vermont tessellate, but Texas!?! I scribbled a copy on a piece of scrap paper and have tried to reproduce it above. My rendition is a little distorted, but it seems to work.

The thing that intrigues me about this Texas tessellation and even more-so the intricate Escher tessalations is that there have to be some sort of rules for how patterns tessellate. I don't have the brain power right now to figure out, but would appreciate it if anyone could explain why this works...


* oops, I posted the name of this city, and it was on the World Wide Web for a good five minutes, endangering the confidentiality of my patients!!!

Life of a Hobbit

• 0625 Friday 4 November 2005 Pour a bowl of Golden Grahams, small glass of orange juice. Watch news for five minutes
• 0700 Arrive at hospital. Piddle in resident's lounge, debating between starting ICU rounds or going to "Coffee with Cardiology" residents' conference. I'd prefer going to the cardiology meeting, but I feel a little guilty because others will round on my patients if I'm slow.
• 0715 Arrive to "Coffee with Cardiology." Help myself to a biscuit, eggs, fresh fruit, and coffee.
• 0735 Start ICU rounds
• 0920 Finish ICU rounds. My co-resident on ICU, Ming, asks if I want to join her for breakfast before we start floor rounds. I oblige. I eat Third Breakfast, consisting of a bowl of oatmeal with raisins and brown sugar and a glass of skim milk.
  

My URL

Several of my loyal readers (and even more of my unfaithful readers) have wondered about the URL I've selected for my blog. Is it my life verse? If so, is it Mark 1:13 or Mark 11:3? The answer, surprising as it may be, actually has nothing to do with temptation by Satan or a donkey.

The biblical eponym is in fact my middle name, and 113 just so happens to be the street address where I lived for 16 of my first 18 years of life. I thought it would be fun to reflect on some memories from 113 Horseshoe Drive.

• The house sits on about 1/2 acre, which my brother and I would mow in the spring and summer. I remember raking up leaves in the fall (several large trees not shown) was more of a family project. We have some fun video footage of young Charity raking up leaves. Let's just say we're all glad she didn't go into lawn care...
• Bedroom A is the master bedroom. My brother and I shared B, and my sisters shared C. Since the house was built in the 1950's the rooms are generously sized, and the closets are quite large. Charity, David, and I sometimes would have meetings in our closet, under the auspices of a "secret club." We didn't get too far with that.
• The garage is a free-standing structure. (The den was the original garage, and it was converted into a room before my family moved in.) The house and garage were separated by The Conservatory, an elegant name evoking images of the board game Clue. The butler used a candlestick to kill Mr Green in the conservatory. In fact, this was a rather unsightly alley-way which had plexi-glas windows and was hid from the street with vines on a trellis. In the winter, Mom would store plants in the conservatory, and there was a little gas heater that our cats would sleep near to stay warm.
• The bathrooms had affectionate color-coded names, which they retained even after being repainted a different color. The large hall bathroom was always The Yellow Bathroom even after being painted a dark red. The name of the bathroom off the den had a way of rolling off the tongue: The Blue Bathroom. This is the one I would shower in and use from middle through high school.
• The ceremonial curved planting of gladiolas around the pine tree. This arch ended in a 100-lb boulder. I'm not sure, but I believe they were there when we moved in the house in 1981.
• The three bars of color in the top-right illustrate the outdoor color scheme. It's a little difficult to coordinate with orange bricks, but I think the house looked great when we re-painted the shutters a subtle yellow and roofed with brown shingles.
• Some other time I'll have to write about the creek behind the house, as well as the neighborhood.

LIfe in the ICU

My new rotation this month is Intensive Care Unit (hereforth, ICU). The other resident and I have the responsibility of rounding on all of the ICU patients with pulmonary issues (about 12-20 patients), rounding on the "floor" patients who have continued pulmonary issues (another 15), and seeing new consults. The hours aren't bad: 7AM--7PM, Monday through Friday, plus one weekend this month.

It can be a little tough to "learn" new patients who I haven't seen before and wade through pages of poorly-scribbled doctors' notes to figure out what's going on! It should get easier as I get into it. One such patient has a sternal wound infection after a heart valve replacement. When I saw her yesterday, there was a VAC (Vacuum-Assisted-Closure) dressing in place. This is basically a black sponge covered by plastic with suction. The sponge distributes the negative pressure evenly, stimulating better wound healing.

This morning, however, it was Dressing-change Time when I walked in her room...the wound care nurse was there, and I was more than a little horrified when I turned to look at the patient. With every inhalation, her rib cage expanded and the two halves of her sternum (breastbone) separated. And there was her beating heart! I could see the aorta and pulmonary arteries to boot. It was easy to hear heart sounds as I placed my stethescope on her chest, since I had a visual cue for each heart beat!

Today I lost a few style points on my central line technique. An attending was overseeing me as I placed a line in the Peri-Anesthesia Care Unit. Having been a couple months since I'd done it, I was hoping I'd remember all the right steps... Essentially, a wire is introduced into the vein (as illustrated above), the skin is dilated with a small cone-tipped plastic tube that fits over the wire, and then the catheter is inserted over the wire. I introduced the wire into the vein, then dilated the skin. The next step would be to slide the dilator off the wire, leaving the wire in place. Unfortunately, the dilator looks deceptively like another device called a cordis which a Swann-Ganz catherer can be put through. Being a little confused, and much to my attending's dismay, I pulled the wire out with the dilator still in! It was back to squre one...but fortunately the second attempt went smoothly, and we finished the central line without any more (mis)-adventures.

Halloween at the hospital

Today the rain blew into town. Watching from the tenth floor of the hospital, sheets of precipitation crept closer as headlights glinted off the slick street pavement and the wind whipped the trees below. Soon, the hospital floated on a turbulent gray sea of clouds, and the rain billowed about on gusts of wind. One of the more impressive storms I've seen this year. By sunset, however, the trees glowed in rich beams of sunlight and streaked purple clouds danced across the blue-gray sky.

So here I am, biding my time in the call room as kids are out knocking on doors and trick-or-treating. This year, I guess I work most holidays: July 4th, Halloween (on call), Thanksgiving, Christmas, New Year's Eve (again, on call). But life isn't bad here at ___________ . One holiday gone by is another holiday closer to anesthesia!

My only bit of excitement so far was dealing with another intern's ICU patient who wanted to leave AMA (Against Medical Advice). She'd had a cardiac catherization today after her heart briefly stopped yesterday. She insisted on going out to smoke, which I refused to grant. At this point she demanded to sign the paperwork to leave. I had a little chat with Risk Management as well as the patient's attending before getting out the AMA paperwork.

I decided to try one last time to sweet-talk the patient. I halfway felt like it wasn't worth the effort to plead with a patient who was so uncooperative with medical care. But I tried one more time...and it worked! I emphasized that we wanted to do our best to take care of her, and that it absolutely was not in her best interests to smoke or to leave the hospital, but that we could not force her to stay against her will. If she stayed, we would do everything we could to make her comfortable (from "relaxing" medication to nicotine patches).

Again, she asked if she could smoke, and--I was pleased with myself for coming up with this--I told her that smoking was not up for discussion. What we were discussing was whether she would stay and let her doctors take care of her, or whether she was going to refuse our advice and leave the hospital. No in-betweens. Two more times I needed to remind her that I was not willing to discuss smoking, and she finally acquiesced.

My weekend

At the risk of boring my new readers and offending my faithful readers, I'll avoid lapsing into an uninspired and ponderous narrative detailing the offerings of this weekend. It was a good weekend, to be sure, but one that doesn't easily render itself blogable. Hence, I present another bulleted summary.

• Friday, October 28 David and I journeyed to the northernmost reaches of this city to dine with Clay and Lori. A few fajitas and a margarita later, we spent the rest of the evening playing Trivial Pursuit: Pop Culture Version. One of the two questions I actually knew was What position does Harry Potter play in the game Quidditch? Ten points for whoever leaves the correct answer first as a comment.
• Saturday, October 29 Far from being a "get-in and get-out" sort of day at the hospital, I nobly overcame two sabotaged discharges. Constipation is no match for the pen that orders a Fleets Enema with the threat of a larger-volume tap-water enema to follow, and a little run of asymptomatic second degree heart block can be addressed with "curb-side" cardiology consult, a medication change, and close follow-up.
• David and I finished the evening by dining with Adam at a neighborhood cafe. The UT-OSU game played in the background, and Adam, being an Aggie, cheered not so much for the Cowboys as against the Longhorns. However, I'm sure Clay appreciated his alma mater's second-half come-from-behind 47-28 victory. Three years and running...
• Sunday, October 30 After rounding, I joined the rest of my immediate family (minus Charity's husband J.T.) at church for Shelley and Chris's new membership. We ate as a family afterward and then relaxed at my apartment with coffee and scones. Later, Roman, Isabella, Shelley, Chris, and I wandered down to the nearby park so the kids could play. It was a thoroughly relaxing Sabbath afternoon, and it made me realize how much I'll miss my family next year when I'm farther away.

Trivia question: 50 points goes to whomever can name the location (city and state) of the house pictured above, or the school of thought co-founded by its famous architect.

Life's ups and downs

The elevator rides here can be tedious. Doors take about 5 seconds too long to close. People ride to go up (or even worse, down) one floor. Long waits for the elevator to even come are standard. I'll often take the stairs for anything less than 6 flights...or use the visitor elevators which are speedier and less crowded.

However, today I found myself on the Lower Level (two floors below 1) needing to go to the ninth floor. After a several minute wait during which quite a few people congregated at the elevator's closed doors, the car finally arrived.

On boarding, I pushed the "9" button. Also lit were "G", "1", "2", "3", and "7". By the fourth stop, we were to the third floor, with only one more stop before I got to nine.

At this point, the unthinkable happened. A nurse in blue scrubs announced to the remaining two of us, "Everybody off. We're here to get a patient." I immediately sensed a "power play" vibe when the other rider hesitated and the nurse addressed her directly, "You have to get off. Patients take priority." With that, she took a key and locked the elevator door open. I peeked outside and saw no patient. Evidently, she was here to retrieve a patient and bring him down to the O.R.

Sure I had the white coat, but I had no key. In this psychological power struggle, I was defenseless, emasculated. Was it worth reasoning with this demigod? Pointing out that we could ride to 7 and 9 and the car could be back to 3 by the time she'd retrieved the patient would be useless. Would there be any hope of evoking pity? Not in a brute like this. Suggesting that she could have informed us at the lower level of her intent to commandeer the elevator would be sure to provoke contempt, not reform. I gathered my white cloak around me and quickly swished out of the elevator, cradling my fragile-yet-still-intact dignity.

My next ride was more pleasant. At one stop going down, two jovial scrub-clad nurses pushing a cart full of candy boarded. Their smiles and cheer were difficult to ignore. Noticing that they both wore clear protective goggles in the elevator, I was reminded that this is Protective Eyewear Week. (I can't wait till Foley Catheter Week in April!) One asked me, "When do you were protective goggles?" At a loss to come up with a clever-yet-sassy reply, I answered, "Well, I would wear protective goggles when I put in a central line." "Thank you for answering correctly!" the other said, "Help yourself to some candy." And just like that, they were gone.

So there I was, having come full circle, back on the Lower Level, battered and bruised by some rather poor elevator etiquette, yet now contentedly munching on a Reese's Peanut Butter Cup. My day's karma appeared balanced. Maybe in my next day, I'll wake up to have the elevator key...

The Iraqi constitution

My friend, Doctor J, recently posted a link to the blog of an "independent informed observer" of the war in Iraq. This journalist is named Michael Yon. I encourage you to read the post entitled "Purple Fingers." It'll take just a couple minutes.

While I've stayed up with current events lately mainly via the local newspaper, cnn.com, and NPR radio, I found this perspective both startling and refreshing. "Purple Fingers" has evidently been recently published in The Weekly Standard.

Did Michael Yon go to journalism school? Probably not. Does his personal story encompass the full essence and scope of the work in Iraq? Is it conservative propaganda? No, it's simply a story. A story that is highly personal and captures the thoughts and emotions of one caught up in the swirl of history-in-the-making. And it exudes a sense of hope that I really haven't seen in traditional media.

Yet it's a realistic hope. One that recognizes that 2,000 American soldiers have lost their lives in Iraq. One that knows the price of freedom. This was a price the colonial Americans knew well, and one that the Tennessee Volunteers nobly helped to pay in the fight for Texas Independence.

I guess the thing I appreciated was the overarching meaning that Yon's post gave to the suffering and death that we're all well aware of. He puts himself in harm's way to tell his story. But being there in the midst of danger, he witnesses first-hand the snaking lines at the polls and the purple fingers of Iraqi voters casting their ballot for freedom.

A little Thai food

John Knox's house in Edinburgh, Scotland

Well, another call day gone by. (My friends at rigorous academic programs: please skip to the next paragraph at this juncture.) Now that it's just us, Sunday proved to be a relatively easy call. We admitted only four patients to the team; two went to me. Of those two, I sent one home on the post-call day. And then there was the sleep...magnificent sleep...seven wonderful hours, interrupted by only 4 cross-cover calls!

And so that's why private residencies are actually tougher than the traditional academic programs. A good friend of mine from college, Emily, was in town this weekend for a wedding, and the highlight of my week was joining her and her parents for dinner last night at a local Thai establishment. We had fun reminiscing about college memories--many of which have become quite fuzzy--and catching up on the general events of life. Since Emily and her husband live in Maryland, I hope to see them a bit more often in coming years!

Another off day today had many things in store:

• Sleeping in till 8:00. I'd left my bedroom windows open last night, so the room was nippy and conducive to rolling over and staying under the covers!
• Leisurely reading the morning paper.
• Working out
• Dictating up at the hospital. I'm still behind by three discharge summaries! But the charts are still in coding, so that's a good enough reason to procrastinate.
• Buying a couple C.D.'s (certificate of deposit) through ING. This is a great bank. Right now they offer 4.4% interest on an 18-month CD.
• Picking up a wedding gift for Amani.
• Taking a luxurious one-hour nap.
• An afternoon stroll to a nearby Starbucks; reading my anesthesia text outdoors. Roommate David met me there, and we walked to a local burger place for dinner.
• Adventures in Good Music with Karl Haas
• Balancing the checkbook.
• Organizing my room.
• Waiting for inspiration for an insightful and creative post. It didn't come. By the way, the picture above represents my Scotland calendar's October photo.

Toward a more serene life...

Clutter is anything we don't need, want, or use that takes our time, energy or space, and destroys our serenity. -from www.cluttersanonymous.net

Are you a clutterer? Take a look at this 20-question quiz. Most clutterers will answer in the affirmative to at least three questions. I answered "yes" to four.

I became interested in this topic after reading this article on msn.com today. There seem to be 12 steps involved, and I wonder how much of this organization's philosophy is adapted from Alcoholics Anonymous.

My roommate David will be pleased to see me publicly admit I have some clutterer tendencies. Most notably, I save containers. Shoeboxes, Altoid tins, cardboard mailing tubes...all of these things are undoubtedly useful. I keep quarters in an Altoid tin in the car. My shoe-polish and buffing brush goes in a shoebox in the closet, and the mailing tube....well, that is still propped up in a corner of my room--but I know I'll find a use for it!

Maybe my problem isn't that I find useful purposes for old containers. It's when I keep containers that I still haven't found a use for. After all, my friends started teasing me only when there were ten empty Altoid tins stacked on the shelf. I can still hear Jenni's voice playfully mocking me, "But, but...I can use them to store buttons!"

On the other hand, people like my brother-in-law J.T. inspire me. A rigorous sense of neatness and order permeates J.T. and Charity's house. And there's my cousin Robby, now a sophomore in college, whose desk is always neat and well-stocked with an arsenal of freshly-sharpened pencils.

Is this unattainable for regular people like me? Perhaps not. Perhaps a first step would be throwing out that mailing tube. Properly disposing of or filing my mail the day I get it. And yes, parting with those Altoid tins squirreled away from David's probing eye.

Just when I was getting some sleep...

Sleep is precious on call. Yet sometimes it's interrupted for the dumbest reasons: "Doctor, Mrs. Jones is constipated. Will you order some Milk of Magnesia?" This befuddles me in a number of ways. First of all, why would a patient wake up at 0200 and call the nurse because she's constipated? And why is this something that the nurse believes needs to be addressed at this hour? I have so much appreciation for the job nurses do, but sometimes I wonder when I get calls like this.

A number of such calls were in store for me my last call night, ranging from the above to correcting electrolyte abnormalities. Another patient I went to see had lupus, rheumatoid arthritis, and major cellulitis with abscesses. The primary team had stopped the i.v. morphine and i.v. Dilaudid because the patient was over-sedated that day--she'd fallen asleep while eating! (Good move.) Her still-potent-yet-orally-taken Norco just wasn't doing the trick controlling her pain. So after getting the story, reviewing the chart, and examining the patient, I said, "I'll ask the nurse to bring you a little morphine." I felt sorry for her with all these ailments, and I believed she was in pain.

"Actually, morphine doesn't work for me, Doctor," the patient replied. "That i.v. Dilaudid is much better. I need you to write for that. And besides, I would hate to have that morphine just go to waste, because it really does nothing for me."

I paused. Something was amiss. The "drug-seeking" vibes had nearly knocked me off my feet. As I gathered my wits together again, I took control of the encounter. "Hmmm...I understand what you're saying, but your primary team was concerned you were over-sedated today, and that Dilaudid is pretty strong stuff. I think morphine is a reasonable step up from Norco. We'll go with that." By commanding a "this is what we're going to do" tone, I staved off any protests. No more calls from that patient that night!

My final call of the night came at 0300 and with a definite Indian accent. "Doctor, we need your help. Patient has died. Can you please pronounce him?" I pulled on my scrub shirt, wrapped myself in my white coat, and with my eyes still bleary, made my way down to 3-west. "Which room?" I asked, stumbling by the nurse station. They pointed down the hall.

The hospital is quiet at night, but this night was stiller yet. Upon entering the chamber, I closed the door for privacy. The body lay motionless, the morphine infusion still pumping into the the pooling veins. "End-stage AIDS, on hospice care," is what somebody had murmured as I passed the nurse station. I donned a gown and gloves and performed several objective tests to tell me that yes, this corpse really is dead. Around the time I got to the corneal reflex, I started to feel weirded out. Quickly I finished this patient's last medical examination and scribbled a death note.

Maybe it was the quietness of the room interrupted only by the humming of the morphine pump, or maybe it was the speed with which I fell back to sleep, but the whole memory still has an eerie, dream-like quality to it. Unlike my last pronouncement, this one was totally isolated from any sense of suffering. I had seen no family, and my entire time with this patient was after he had died. This is what you get when you distill out the art of comforting and of walking with a patient though his final days and hours. This was plain science: Doctor and cadaver, scientist and object. A few straight-forward tests, a simple experiment. And then back to the call room for a couple more hours' sleep.

October 22, 2005

Today was my first day off in more than two weeks. I know that's nothing compared with The Old Days of residency training, but still it makes me appreciate the time a lot more!

The weekend began with a little quartet work Friday evening with Dawn, Erin, and David. We had a potluck dinner and then spent an hour playing works of Barber, Corelli, and Mozart. I can't speak for the others, but my sense of rhythm and my ability to play anything faster than an eighth note have disappeared along with my ability to study for more than an hour and memorize anything.

My faithful readers will also note that I've learned how to place pictures in a position other than "center."

"Sleeping in" till 7:30 (yes, I know it's sad) was a great start to the day today! My brother--who had spent the night--and I drove over to the city where he lives, and he showed me his classroom. I treated David, Charity, and myself to lunch, and then we hung out at the local Botanic Gardens in the refreshing Texas October weather! It was the sort of day that started and ended with cool 60-ish weather. By the time we made it to the gardens, it was pleasantly warm in the sunlight yet still cool in the shade. This, I feel, is the essence of autumn in Texas. It lasts for a few days here and a week there.

A train ride back into town and a picnic with the folks from the residency program with volleyball and Mexican food closed the day.

Today on CNN.com

Cunning rat outsmarts scientists


I liked the proposition of this experiment: set a mouse loose on a 20-acre island, and then see how hard he is to catch! (See story.)

A favorite quote: "Our findings confirm that eliminating a single invading rat is disproportionately difficult," James Russell and his colleagues said in a report in the science journal Nature.

Allocation of scarce resources

Today in conference, a case was presented of a previously healthy young woman (26 years old) who presented to the hopsital with abdominal pain for two weeks. She was found to have Wilson's disease, a genetic/hereditary condition, and died from fulminant liver failure in a very short time.

Prior to death, arrangements were attempted for a liver transplant; but these efforts, the presenter noted, were unfortunately unsuccessful as she was an illegal immigrant.

The subtle word choice, "unfortunately," prompted a bit of informal discussion afterward. Of course anyone caring for a sick patient would want a potentially curative transplant. But when livers are few and the transplant list is long, how should "Who gets the liver?" be decided?

There's the very personal, intuitive answer: This was a young patient. She had done nothing to cause or exacerbate her disease. She had a very steep downhill course and desperately needed a liver. Who wouldn't want to give this girl a transplant?

On the other hand, there's a political perspective. The patient was an illegal immigrant. Some people might balk that this even be considered. "We're in the here and now! Where is your compassion?!?" I can hear them saying. But should a foreigner (and one here against the law, at that) receive a liver courtesy of Uncle Sam before an American who needs the same liver? Remember, these resources are scarce.

And then, there's the socio-medical perspective. This patient was young and had an inherited disease. There was nothing she could have done to prevent this. Perhaps the American mentioned in the previous paragraph is a 55 year old alcoholic who has destroyed his liver with his frequent bouts of intoxication. Are age or lifestyle or preventability reasonable factors to consider?

In this post, I have only asked questions and provided no answers. Situations like this, which have obvious emotional overtones, spark me to re-think this classic quandary. And add a few questions of my own: Who should be in charge of allocating scarce resources--in this case, a liver? What criteria should be used? What can I learn from extraordinary circumstances like this to apply to my day-to-day practice?

Random thoughts as I run, part 4

Note: My last hour of posting has resulted in a quadri-segmented entry. Please begin at the post Random thoughts as I run for a chronological read and for maximum enjoyment of my carefully crafted narrative thread.

Sometimes true opposites aren't what you always assumed. I've heard my pastor say that hate is not the opposite of love; fear is. Or how about this one, for you science-y people (ahem, Clay): cold is not the opposite of heat. Absolute stillness is.

Now these ideas, admittedly, can be a bit abstract. What about this tangible world? A schoolchild might be tempted to say that an apple is the opposite of an orange. Many adults would find this prepostorous, but I would encourage you adults out there to think again. With one fruit you eat the skin, and with the other, you don't.

Okay, that last one is a big arguable. But here's one I've thought about for quite some time: What's the opposite of NPR (National Public Radio)? The answer, in a moment of great clairvoyance, came to me as I ran: Blue Collar TV. This was a show I happened to see on the television the other night as I exercised in my complex's work-out room. I cannot begin to describe it, except to say it involves camouflage caps, plenty of overalls, and three lead actors who delight in being the biggest offensive idiots I could imagine. They make Homer Simpson seem qualified to teach at butler school, and in comparison Dumb and Dumber achieves a stance of elegant poise and restraint. (That Blue Collar TV is the opposite of a symphony orchestra could also be argued, but that can wait for another post.)

NPR, however, was my companion for the last half of my run. I listened to an interview with Zadie Smith, young author of the recent best-seller On Beauty, a work of fiction exploring how situations shape one's identity. This is a radio channel where it's not uncommon to hear people who would spell epitomise with an "s", and who pronounce can't like "Kant" and ought somewhere in between "oat" and "aht."

Aside from the fictional novel's plot, I was intrigued by Smith's ruminations on identity. Although she is black and British, she argues that these factors do not shape her identy unless she pursues them. By pursuing her African heritage, and by relishing things British--be they Shakespeare's Henry V or Prince William fever--she embraces the very things that mold her identity. So an identity has less to do with who a person is, as what those person's passions may be.

Aside from the obvious implications on the meaning of joining, say, the National NeedleArts Association, I had to wonder if this might be why it could be difficult for Americans of opposing viewpoints to engage in meaningful dialogue. To have someone challenge a passionately-held belief could be to have one's own identity threatened.

Somewhere around this point, my thighs started to burn, and my lungs were nearly saturated with thick mucous. I was on the home stretch when the unthinkable happened. A red-head, about my age, passed me. The event-horizon trailing in the wake of my fundamental pace was instantly compressed into the size of a quasar. Or was it a quark? In any case, with time still at a standstill, I had plenty of it to re-think some presuppositions of the thermodynamic arrow of time. This Irishman clearly must have been traveling in a reverse vector which happened to still coincide with my psychological arrow of time. Comforted, I trotted of the trail, entered the gate, and began to stretch...

Random thoughts as I run, part 3

By this time, dusk was creeping into twilight. The downtown lights shone against a deep blue sky, as approaching figures slowly morphed from faces into silhouettes. It crossed my mind that my run, though rather linear in nature, existed in not two, but four diminsions. This was space-time. The change in the lighting of the horizon was just as intrinisic to my run as the scenery I passed. A graph of my run through space-time could be charted. My stopwatch and the milemarkers told me the same thing: where am I on this run?

I'm reminded of Stephen Hawking's book I read not too long ago. In this case, I would be a beam of light. (A fitting comparison, given that nothing travels faster than light.) The diagram above represents time verses space. The diagram below shows what a person on the very cusp of the event horizon would see. My ovoid head results from the curved lines in space-time when one travels at approximately light speeds.

Random thoughts as I run, part 2

I've decided to break up this post, for fear of losing readers who get bogged down in arithmatic and geometrical theorems. We now move on to my next random thoughts.

As I ran, I came up behind someone who strangely looked familiar. By the skin color and dark hair, he looked like an Asian friend of mine named Dale. As I got closer, I entertained the thought that perhaps this was Dale, and wondered why on earth I would think this guy from behind looked more like Dale than any other Asian guy I knew.

Just as I was passing him, I subtly glanced at his face...it was Dale! We ran together a mile or so, and I realize how much more fun (and less tiring) it is to run with someone. When I got to my two-mile mark, I turned back toward home, but Dale continued. This brings up the question: Am I really that good with people's backsides? This surprises me, but also disturbs me. My suspicion, however, is that I could recognize most of my friends and family from behind. Maybe I've said too much... Any thoughts? (Keep your snide remarks to yourself, please, unless they're really clever.)

Random thoughts as I run

If you've read yesterday's post, you'll know that I was in the mood for a good run yesterday. It would sound good to tell you that I do my best thinking as I run, but in honesty, the opposite is probably true. At least it was relaxing, in a tiring, sweaty, choking-on-my-own-airway-secretions sort of way. For you, my readers', edification, I've assembled a rather haphazard collection of thoughts from the run.

• It piqued my curiosity that I tend to pass many people going the opposite direction, and I pass several walkers going the same direction as me, but the former is always much more than the latter. Theorem: If I run 8 mph one direction and I assume that people are stationary and peppered evenly along the length of the trail, then for a given distance, say two miles (= 15 minutes of running), I pass X number of people. There are X people headed in a certain direction evenly spread along two miles of the trail. However, if you assume this conveyor belt of people moves toward me at their walking pace of 4 mph, then I would pass 1.5X number of people.
• Corollary: If I run the same 8mph for two miles (15 minutes of running) but I consider the people walking in the same direction, then it's as if I'm only running 4 miles per hour. In that same stretch, I would only pass 0.5X number of people. The obvious conclusion is that I will pass three times as many people walking opposite me as the number I pass walking in the same direction as I run.
• Corollary number 2: If we add the total number of those I pass (going with and against me) then we get 2X. Ironically, or shall I say mystically, this is the same number I would pass if everyone else were frozen in time. In two miles, I would pass X people facing me, and X with their backs toward me.
• Foundational Postulate: It is not necessary to factor in the number of people who pass me. This would be like teaching elementary school children about the square root of a negative number. Imaginary numbers needlessly complicate the main point.

Lessons learned

Days like today make me glad I have a blog--an avenue to write down thoughts. It started as a way for family and friends to keep up with what I do, as well as for me to remember fun or interesting things in life. Another secondary purpose which developed is simply to entertain people (even strangers) with interesting stories. However, today I take advantage of writing as a way to reflect.

In a previous post entitled I hate this part of the job, I recognized how difficult it is to break bad news to a patient. Today, however, I deal with the fact that I AM bad news to the patient. At least I can be.

It all began when I walked into the residents' lounge today. The resident on call informed me a patient I'd discharged on Saturday was back--with angioedema, a life-threatening condition. Angioedema is swelling in non-dependent places; in other words, swelling not affected by gravity. I generally think of it as an allergic/immune response, and it's dangerous because the airway can swell, essentially suffocating the patient.

In the ABC's of medical emergencies, the A is for airway. It's the most essential thing for maintaining that fragile balance we call life. In this patient with a recent heart attack, the admitting team was reluctant to use epinephrine to counteract the angioedema because it could stimulate the heart and precipatate another massive heart attack. Fiberoptic nasotracheal intubation was attempted in the emergency department, with the result that the patient developed a life-threatening cardiac arrhythmia. She was eventually stabilized and brought to the ICU, where she remains.

The problem began a week or so ago. This pleasant 80-something patient had a list of 10 medicines she took, and 10 she was allergic to. One of the meds, labeled by its proper name, I jotted down with the comment, "face swelling." I wasn't familiar with the name of the medicine (not too uncommon a situation, as there are many thousands of medicines), but I didn't take the time to look it up.

To make an unfortunate story short, we started her on an ACE-inhibitor, a great blood pressure medicine, which just so happened to be one of the two drugs in the name of the tablet I wrote down on my admitting H&P. While there were multiple layers of protection against this sort of thing that should have been in place (my attending, my resident, the pharmacy--which knew of her allergy), the fact is that I was practicing medicine and I neglected to investigate a key piece of information, to this patient's detriment. She was on this medicine for several days before discharge, but the side effect began the day after going home. (The graphic at the top has a mnemonic we learned as second-year medical students with the side effects of ACE-inhibitors.)

I can't help but remember some of the last words she spoke to me before I discharged her, "Thank you for taking such good care of me!" Little did she know we were poisoning her. She didn't have the medical training. We did.

I don't know what will become of this situation in the legal sense (and hence it may not be the wisest to post this entry), but I know that I have a much greater respect for the power of medicines, both to heal and to harm. And my prayer is that she survives this second hospitalization without a permanent mark on her life of my mistake.

Code blue--2-ICU

"Code blue, MET, 2-ICU" blared through the overhead speakers at 0100 this morning. My resident and I were sitting in one of the doctors' workstations in the E.R., reviewing a patient's old records before going in to interview him. Glancing at each other, we dropped the things we were working on, and half speed-walked, half jogged out of the E.R. and up the stairs to the ICU.

As the second code of the day, I'd already seen my resident in action. An all-around excellent resident, I was thoroughly impressed with her calm manner, clear thinking, and swift directives in the first code. She rapidly assessed the situation, got report from the nurse, evaluated IV access, and was palpating a pulse while keeping an eye on the cardiac monitors, all while I was still trying to pull gloves over my sweaty palms!

This second, early morning code was a patient with delirium tremens from alcohol withdrawal who had respiratory arrest. He was holding his blood pressure okay, and simply needed ventilatory support. I was up to intubate.

But this large man with a small jaw and huge neck wasn't making it easy for us! I attempted laryngoscopy with the tool as pictured above, but his jaw was too tight. We pushed 10mg Etomidate (an inducing agent), and I attempted again. This time, he gagged and coughed every time I advanced the tube. Unfortunately, I hadn't put on a mask, but no secretions came my way. Another 10mg of Etomidate, 2mg Versed, and 100mg Succinylcholine (a paralytic) did the trick. Still barely being able to visualize the posterior aspect of the vocal chords, I advanced the tube. The respiratory therapists inflated the cuff, withdrew the stylet, and attached oxygen. CO2 return, mist in the tube, bilateral breathsounds, and chest rise were all good signs that the tube was in the right place!

Just as I had begun my third attempt, an ER attending who had been summoned arrived. I was vaguely aware of this fact, and was happy I was able to do get the job done without his having to step in. I feel like after all the OR intubations I've done, code intubations should be a little easier by now. At least it's one more under my belt! And the other good news is that by the time we returned to the ER, the attending had already seen the patient we were starting to admit, and told us just to go to bed! The patient wasn't going to the teaching service!