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!

Anesthesia and Litigation 101

Another on-call day at the hospital today. I've rounded on my 6 patients, and now I just wait for the pager to go off! Once I accept the fact that I'm working the entire weekend, Saturday and Sunday really aren't bad days to be on- and post-call. With no conferences or teaching rounds, it's easier to get work done quickly. However, given that the outpatient pharmacy is closed and that social workers are harder to come by, it can be tougher to discharge patients on the weekend. I have two that I've discharged today, and two more that really should go home today, but will sit around till Monday because it's the weekend.

So the theme of this post is EKG's. This is a story from last spring as a med student which was a little embarrassing for me, but a beautifully post-able story.

The time was spring, the place: the illustrious local VA hospital. The setting: I, a fourth year medical student who had already matched and was on his very last two weeks of rotations, was spending some time doing cardiac anesthesia.

Now, a word about cardiac anesthesia. If I were to ever drop dead with ventricular fibrillation arrest, I can think of no one I'd rather have around than a cardiac anesthesiologist. They take care of sick patients daily. They manage airways. They pharmacologically cradle and caress fragile hearts during procedures in which the heart is chilled, poked, prodded, torn apart, sewn together, or transplanted. They're quick on their feet and are good with trans-esophageal echocardiogram too.

Yes, trauma surgeons get their share of glory. And I would be remiss if I didn't mention OMFS. But still, we would do well to remember who keeps the patients alive while the surgeons do their work.

In any case, there I was, learning a lot of cardiac physiology but actually doing very little in this rather acute setting. Sure, an intubation here, an arterial line there. But the resident was eager to practice central lines, and thus I watched quite a few being put in.

Placing an internal-jugular central line begins with a well-placed needle jabbed into the neck. Avoid the carotids!

One particular day, the resident had to be gone. Because it really takes two anesthesiologists to start a cardiac case (and I didn't and still don't count), there were two attendings there that day. They were both women in their 40's, laid back, good natured, and very skilled at what they did. With such a high attending-to-med-student ratio, I was feeling just a shade nervous but still happy to be there.

With the usually flurry of activity, the patient was brought into the room, moved to the operating table, and hooked up to monitors. One must understand that in the OR, time is money. It's often cheaper in the long run to use a more expensive drug if it means a faster turnover time in the OR, or if it gets the patient out of the PACU (peri-anesthesia care unit) faster and without respiratory or cardiovascular compromise. And with that mindset, I swiftly aided, attaching the blood pressure cuff around the patient's arm and locking the pulse-oximeter probe onto his index finger.

You may wonder where our theme of EKG's comes in. Right about here. In basic OR cases, all that's needed to monitor a patient's heart is a three-lead EKG. One lead on the right shoulder (white), one lead on the left shoulder (black), and one on the patient's left flank (red). But in these cardiac cases, we need a couple more leads checking the heart from front to back, called "precordial leads," labeled V1-V6 in the diagram below.

I attached the three basic leads, and there I was left with an orange and brown lead. "Which one went where???" I thought to myself. I felt like people were waiting on me, as both attendings had finished their work and were ready to induce anesthesia as soon as I got the leads hooked up. I seemed to remember orange went on the right of the sternum, so I hurredly placed a sticker there and clipped the lead onto the metal snap-like piece protruding from the center of the sticker. "That leaves me with brown," quickly moving the lead toward the spot labeled V4 above.

Only there wasn't a sticker there already. What the metal pincher was headed for was not a carefully positioned sticker, but the poor patient's nipple. I suppose it technically would have still worked. But I am forever thankful that I stopped one centimeter away when a little voice in my head said, "Wait, something's not right!" Both attendings had seen my near-blunder, and I'm sure the story will be told and re-told about that lanky med student who nearly pinched the EKG lead onto a man's nipple. But I didn't. And it makes for a good story. And maybe, because I've posted this, someone, somewhere down the line, will avoid the same mistake!

A hard-fought battle

This was not a battle fought with troops and shells, mortar and tanks. There would be no blood shed, no treasures usurped, no kings toppled.

And yet, it was fought boldly and with purpose, driven by principle. Evil forces at work call on the noble and the brave to risk all for Truth. And fight I did. The enemy? Far richer than African war-lords, more cunning than al Queda, this fiend, this bastion of darkness was none other than Southwestern Bell.

Southwestern Bell's Fortress of Deceit

I readied myself for the fight which would be a war of words, full of tactical rhetoric and verbal maneuvers of wit, stealth, and cunning. The slightest hesitation, a subtle uncertainty in tone, a misstep into an unseen snare of double-entendre...any of these could be the deciding factor, the straw--so to speak--that broke the camel's metaphorical back.

And what was at stake, one might ask? My most recent telephone bill, with a new $2.00 monthly charge (plus taxes and fees) for my supposedly free 10-cent-per-minute long distance service. I realize it's not a lot of money, but we're talking about Principle. Multiplied by 12 months, that's $30 I'd rather not spend on a long distance service I don't use.

A moat of mind games surrounded the tower, twisted and loathe to behold. I steadfastly naviagated a maze of computer prompts, and patiently endured 13 minutes of holding music which sometimes crackled as if the connection between an SBC telephone and the motherboard were that tenuous. Deceptive, yet infinitely symbolic.

Finally, a pleasant female voice answered, "Hello, Southwestern Bell! How can I help you, one of our Valued Customers?" I knew better, for even Lucifer was called Angel of Light. And yet, I thought it better that she not know with whom she dealt. Rage would not serve me here. I mustered a tone of polite innocence, "Hi, my name is Jonathan, and I was hoping you could help me with a question about my long-distance bill."

I'm sad to say that this epic ended in defeat for our noble hero. She reminded me that the long-distance service I signed up for was free only for three months; thereafter it would cost $2.00 per month. I asked if it was possible simply to drop the long distance service. Her coup de grace was a threat cloaked as another reminder, "Just to remind you, your clustered DSL service is given at a discounted rate because you have both local and long distance with us. If you drop the long distance, the DSL service rate may increase."

I accepted defeat. After all, this is the stuff of legends: even myths have room for tragic heros. But I stood for Principle, and as I hide in retreat and nurse my wounds, I can't help but think that the Enemy is just a notch weaker. The Tower will fall.

Apartment 352

The feature of this entry is...you guessed it: my abode. This is the fifth year I've lived in this city, and the fourth apartment. Ironically, all four apartments are on Maple Avenue, which has a homey, familiar sound to it. This sense of wholesomeness belies the true flavor of this trendy complex. The gas lanterns. The tanning bed. The palm-tree-shaded court yards. The twin concrete lions overlooking the pool which on a summer weekend, as my roommate David so eloquently described, resembles a beer commercial: oiled & tanned bodies lounging in skimpy apparel at water's edge, or playfully splashing in the cool water, with plenty of alcohol around to quench one's thirst. Yes, I and my pale skinny whiteness avoid that place at all costs.

But this is my home, for my last year in this city. Multiple restaurants and pubs are within walking distance, and work is only a fifteen minute drive away. The inside of the apartment is a great source of peace in the midst of sometimes clamourous and nearly always busy days. Allow me to highlight a few features:

• That from which I can never turn back. No, I'm not talking about air-conditioning or an automatic dishwasher. You'll notice two small white squares labeled "w" and "d" in the upper portion of the diagram. They represent the in-house washer and dryer. Both a luxury and a necessity. No longer do I need to hoard quarters or worry about leaving my laundry unattended.
• The sphere of good reception. Sadly, this little circle is the only reliable spot for cell phone reception. Thank you Cingular--maybe it's about time for another tower around here! You'll notice there's a door that opens to a railing...a fake balcony of sorts.
• My room. It's small--10'x12'--but holds everything I need. It even has room for my green armchair, which, when not holding clean laundry, is an excellent place to sit and read before crawling into bed.
• The island. The place to find the scotch and the brandy. Uniquely situated between kitchen, dining room, and living room, this is the spot where Dan, David, and I sometimes breakfast on cold cereal while sitting on stools.
• And lastly, the second-story windows open out onto a landscaped courtyard featuring a cluster of nocturnally-lit palm trees and park benches.

So that, ladies and gentlemen--and my one loyal reader from Iowa--is my home. A good night's sleep and an eight-hour medicine in-service exam await me...

Somebody come!!! I think she's died!

Those were the words I heard exclaimed behind me as I sat at the nurse station, working on admit orders for a patient we were admitting today. Since all the floors look pretty similar, I was a little disoriented and didn't immediately realize that I was on the same floor as my patient on comfort care. Turning around, however, and seeing the room, I knew immediately what had happened. Before any nurse responded, I was walking into room 811, which was filled with tearful family members standing watch over their beloved mother and grandmother.

The patient's daughter looked at me with blood-shot eyes and explained, "We saw her gasp, and then she stopped breathing, and her color just now changed." Earlier in the day, I had tried to support the daughter, encouraging her in this hard time as her mother slipped from life into death. As I left the room that morning, she had said to me, "Have a nice day," and I reflexively said, "You too." And I kicked myself, wishing I could say the right thing at all the right times.

What was facing me at this moment, however, was bigger than an ill-timed nicety. I was playing the role of Doctor and was responding to the scene of a death. I had never done this before, and really had never even had a briefing on what to do in this sort of situation. I listened carefully as the family talked, realizing that I would need to examine the patient--for their sake and mine.

In times like this, I can appreciate the symbolism of medicine. Despite my youth--this patient could easily be my great grandmother--the family was looking to me for support and direction. At least that was my sense. And I was dressed in a white coat and was carrying my trusty stethescope. Four years of medical training were not as important in this small room as these two pieces of my "costume."

Leaning over, I listened to her chest for heart sounds. There were none. Wait--was that one? No, I'd just moved my stethescope. Wait, was I sure? I took the patient's wrist and palpated where the radial artery should be. To my surprise I felt rhythmic pulsations, but on a moment's reflection I realized they were too faint to be hers. In my hyper-vigilent state, I was feeling the blood coursing through my own fingertips. She had no pulse.

After a minute, I stood back, and told the family, "Her heart has stopped." Strange as it may be, I still wasn't sure enough of myself to say, "She's dead." I excused myself and explained I would notify the attending, who in turn instructed me to write a "death note" in the chart. She also mentioned various tests I could do to confirm death.

Returning to the room, I asked the family to step out so that I could do a fuller exam "for documentation purposes." Carotid pulse--negative. Apical impulse--negative. Pupillary response to light--negative. Heart sounds--negative. Respirations--none. Still not completely convinced, I decided to test the patient's response to pain. I braced myself as I did a hard sternal rub and then forcibly squeezed my pen into her nail-beds. Cruel as it may sound (which is why I asked the family to step out), these are extremely painful stimuli which will arouse a patient who will be aroused. My heart pounded as I half expected her to cry out in pain. Nothing.

I spent a few more minutes with the family. They laughed in relief, and cried. They thanked me and hugged me. Sitting down back at the nurse station, I began writing. "Time of death: 1430..."

Comfort care

"Well, she does have years of experience on me..." I thought, when I heard my attending had noticed a subtle difference on the abdominal exam and ordered a KUB (Abdominal x-ray, showing the Kidneys, Ureters, and Bladder) which showed free air under the diaphragm. In this elderly lady with severe constipation--otherwise known as fecal impaction--air under the diaphragm pointed to an unavoidable conclusion: her vicera had perforated.

That morning, I had perceived a bit more abdominal fullness than before, but it was difficult to determine how tender she was when she'd cry out just because of my "cold" hands! The afternoon KUB results, however, made the course unambiguous. A younger person could tolerate a large, challenging operation, but could a frail 95-year old survive it? And if she did, would she ever get out of the ICU? The surgeon confirmed our doubts--he wouldn't operate.

After a discussion with the patient's family, my attending put the patient on "comfort care." Antibiotics were stopped. (Though started for a simple cellulitis, these antibiotics were powerless in the face of stool spilling out into the peritoneal cavity.) Vital sign checks were discontinued. I.V. fluids were no longer needed. We began titrating morphine into this lady's veins as her family stood tearfully by. Our goal was not cure or even prolonging her life; we were simply trying to keep her comfortable.

As I related from my last call night, I was again overwhelmed by the privilege it is to walk with patients to death's door. And it's truly a precious opportunity to be a healer to the patient's family. We talked of her long, full life, and her daughter told me she wished I could have known her mother "as she was." The daughter had hope: she knew where her mother was going. At some point, I offered to pray with the family, and they practically embraced me! A long night was ahead of them...

My mellow pre-call day

Well, the day has ended somewhat serenly. I worked out and went on a four-mile run on the trail behind my apartment today after work. I think this is the first time this year to run four miles at once! It's nice to get back into the workout routine, and thirty minutes is a good length for a run.

There were a lot of people out on the trail today, and I'm pleased to say that for the entire four miles, the only people who passed me were on roller-blades or bikes! The 70-degree weather is a good change too. A slight breeze and a sky full of clouds made it quite the autumn afternoon. Here's a picture of my new running shoes:

I grilled chicken and baked potatoes for dinner tonight with my roommate Dan, as David was on call. A little anesthesia reading in my green armchair was just the thing for after dinner as I listened to Adventures in Good Music with Karl Haas...as I read, I could hear the slight drizzle of rain in the courtyard through my open windows.

As I sit here reflecting on the tranquility of the sphere of my day, I can't help but remember the recent earthquake in Pakistan which has left upwards of 30,000 dead. This dwarfs the Hurricane Katrina disaster by a scale of 30, when it comes to loss of life. Suddenly, the thought of spending billions to rebuild New Orleans becomes a lot more trivial, as do my new running shoes and my green armchair.

My, what a nice eye you have!

So I've sacrificed two hours of sleep just now to go admit a patient in the E.D. (Emergency Department is supposedly the more correct term, as most E.D.'s are more than one room. As for the apostrophe in the previous sentence, discussion will have to wait.) This elderly 95 year-old lady, who moaned every time we touched her with our icy-cold hands, presented with obstipation and a gigantic abdomen. She'd already had two enemas, so we're sending her down in the morning for a hypaque enema...this should do the trick! In the course of the interview, however, I made the faux pas of referring to the white-haired man in the room with us as her husband. It was her son!

Well, the payback for missing sleep is what awaited me in room 3. One of the attendings told me to go do an eye exam. I'd already caught wind of a fake eye, so I was expecting the usual well-made prosthetic globe that looked and moved like a real eye, only with no response to light. This model, however, was a little different. The prosthetic included the eyelid, eyelashes, and skin around the eye in the distribution of the orbicularis oculi. And it was attached to her glasses, coming off when she removed the lenses! This is more or less what the prosthetic looked like:

A little morphine along the way...

So I guess I'm getting back into the swing of wards... Today was filled with conferences: EKG/Cardiology conference, 1 1/2 hour teaching conference, and then noon conference. Somewhere in between I rounded, and then from 1:00 PM until 11:00 PM was spent admitting patients and fielding multiple cross cover calls.

One of my patients--who happens to be deaf and hispanic--only speaks in Spanish sign language. (And here I'd thought it was an international language! Maybe not when you have to spell words.) He also has cerebral palsy. Anyway, a good part of my history was obtained by guessing his miming and my writing Spanish phrases on a note-pad to have him point to what he wanted to say. This was challenging!

I trooped over the cancer building with my resident to check in on a patient with metastatic breast cancer, placed on hospice today. This was by far the most meaningful part of my day, as the family was all in the room to say goodbye to their mother & grandmother. My resident doesn't expect this patient to live through the night, but she's being kept comfortable--though somewhat sedated--with morphine.

It's been said that sometimes easing suffering hastens death. I used to not understand this, until I saw situations like this one. Rather than have this patient be in pain, she is kept comfortable with morphine, which depresses her respiratory drive and keeps her more sedated and hypoxic. While her organs shut down, her drive to breathe becomes less and less...

This is a good side of medicine to see, the side that walks with the person to the very end, whether or not the disease has been conquered. This is practicing the art of medicine, when healing is a higher goal than cure.

Hilarious story!

Okay, so I've already piddled away a good 30 minutes since my last post. But I did discover a well-written blog written by a medical student. In one post from this summer, he relates this story which has me laughing still!

A glorious October day

Autumn in New Hampshire

Autumn has finally come to this corner of Texas! Although I'm back on the internal medicine wards for the month of October, I happen to be off today. (I'm particularly happy about this, as I especially enjoy Thursdays.) Mixed with my aspirations to make the most of the day was my desire to sleep, and so my day began lazily at 0730. A quick trip downstairs to pick up a newspaper was my first taste of the refreshingly cool autumn air that crept into town overnight. I opened all the windows to the apartment to let in the 61-degree air and spent the next hour purusing the paper at the breakfast table.

What to do with the day?!? So many possibilities! Here are a few:

• Vacuum the apartment, tidy up my room--these chores will help me feel productive and enjoy my room more, though I've gotten pretty good at ignoring the small pile of paperwork hidden behind the armchair in my room.
• Buy new running shoes. My old ones were purchased in September 2004, and I'm sure have traveled well over the recommended 200 miles for a good pair of running shoes.
• Go running on the trail near my apartment.
• Read a chapter or two in my anesthesia book.
• Read an issue of the New England Journal of Medicine.
• Purchase and pot some fall plants for my balcony planter-box.
• Consider going to the symphony tonight (which is performing the Copland Clarinet Concerto--a great blend of jazz and classical music)

Walter Mondale would have been a good guess...

Here's another anecdote from my brother's experience in the middle school classroom. He was teaching logic to seventh graders and gave an example of Ronald Reagan's using a red herring to his advantage. When asked in a presidential debate if his age might be seen as a disadvantage, Reagan responded that he certainly wouldn't, for political purposes, take advantage of his opponent's youth and inexperience. (see interview)

Around that time, my brother paused and asked the class, "Wait, do you all remember Ronald Reagan? What year were you born?" These kids were born in the early nineties. And then he asked, "And whom did Reagan defeat in 1980?"

After a pause, one girl timidly raised her hand. "Adolph Hitler?"