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.