A couple unconnected thoughts

After church today, Andy and I grabbed a cup of coffee before he heads back to the United Arab Emirates for several more weeks of his job. Although the temperature is just above freezing today, the sun was shining brightly so we sat on a bench on the Columbia campus to enjoy the hot coffee. When I asked if he was working for the government there, his reply was rather vague: "I cannot confirm that." Of course, he didn't deny it either. Since he's flying business class, he'll be picked up in a Lincoln Town Car and whisked to JFK airport for his nonstop flight tonight. Seems much more civilized than my usual trek on the M60 bus to LaGuardia and the economy-class cattle-car.


What caught my attention after this, however, was the elevator ride up from the subway station to the hospital where I will soon begin working on my presentation. The MTA employee who sits in the elevator to push one of two buttons (upper level or lower level) had a portable radiator for warmth situated behind the three-foot-high divider which separates him from the commuters. But more notably, he had a little boombox which was playing opera. Not just any opera, but the loud, grand finale to something that sounded Verdian. There was something very funny about the whole scene. Something that had to do with how the music was none too subtle, and noting people's reactions to the music as they stepped onto the elevator.

Ah, well, I've procrastinated long enough for the day. Time to get back to z-scores and logistic regressions. I couldn't find a picture of the subway's elevator on Google Images, so instead the photo is the interior of a circa 1949 subway car housed at the New York Transit Museum.

My head is swimming

Sorry, the formatting is kinda wacky on this post, and I can't seem to correct it.

I'm scheduled to give chief rounds this coming Friday. Although I don't procrastinate as much as, say, I did when writing papers in college, I still feel a lot of pressure to get this thing done. Being in college is one thing, but in residency one looses a bit of control over his schedule. (No skipping work to add finishing touches on the presentation!)

Chief rounds are informal lectures given by residents during the noon hour. Typically around 15 other residents attend as well as several faculty members. Recent topics have included pacemakers, acute respiratory distress syndrome, postoperative nausea and vomiting, and anesthesia in the super-obese. For some reason, I had the creative idea of doing something different: biostatistics. Yes, the whole field of biostatistics, in one 45 minute lecture. Stupid.

For one thing I don't really have a strong background in statistics. My math education was cut abruptly and tragically short after barely pulling an "A" in Dr Tidmore's Calculus III in college. (What was I, a liberal arts major, doing in there anyway?) Secondly, the topic is so broad that's it's hard to hone in on the relevant parts. And thirdly, there's great potential to pour hours into preparing a solid lecture with appropriate scope that will bore people to death.

I've overcome the first obstacle by shear force of will and also with the help of an easy-to-read primer in biostatistics lent to me by my faculty advisor. As far as the second difficulty, I plan to use a couple sample articles that present well-designed studies and use them as a launching point to discuss pertinent stastistical analyses. And for the third hurdle: yes, the topic is bone dry, but with proper preparation and a smattering of creativity, humor, and wit, I think I can hold the crowd's attention for thirty minutes.

What isn't helping, however, is paragraphs like this that I'm wading through: "Baseline medical characteristics were compared statistically (Table 1). The effect of the drugs on outcome was assessed with the use of multivariable logistic regression and propensity-score adjustment. Initially, 97 perioperative risk factors were evaluated for univariate association with outcome (two-tailed P less than 0.20) and then entered stepwise (backward and forward) into multivariable logistic models, blah blah blah..."

New paws at home

Here's a picture of my parents' new puppy. I think her name is Joy, in keeping with my parents' tradition of naming animals (livestock, cattle, etc.) after matriarchal family members. The black dog, of course, is Shacor.

My mom and the mujahedin

Reader's Digest this month featured an article by Lynn Roselli called "Cybersleuth Mom" about Shannon Rossmiller, a woman from Montana who assumes alter egos online and uses the information she gains about al Qaeda networks to tip off the FBI.

While her actions are valient, to be sure, and patriotic, there was still an inherent comedy in picturing what this woman has done. A couple sample paragraphs illustrate the point:

"One night, she dared herself to post a message on a Saudi Arabian Internet forum known for its violent anti-American content. Within a few months, Rossmiller had begun to establish contacts among the mujahedin, the brotherhood fighting for jihad. She could entice would-be terrorists into e-mail "conversations," she realized, by promising money and weapons to support jihad. Maybe her efforts could even foil their plans and lead to their capture.

"In August 2002, she convinced a Pakistani arms dealer that she was interested in buying weapons. When he offered to sell her U.S. Stinger missiles, she turned the information over to the FBI."

Savvy as my own mother is with things like eBay and internet research, I still have a hard time picturing her brokering a black-market arms deal with terrorists from Pakistan. Then again, she has been lobbying for a faster internet connection lately...

A slushy day in NYC

This year, evidently, has been unusual for very little snowfall in New York City. Last night as I walked to the fitness center at Columbia (of which I'm a new "guest" member), a "wintry mix" fell lightly from the sky. This continued through the night and during the day, so by the time I left work today at 5:30, snow was piled on the sidewalks and the streets were full of a wet, brown slush. I thought it was fun to wade across the small drifts.

On the agenda for Valentine's Day evening were a couple possibilities: a violin recital at Juilliard, or laundry. Sexy though it is not, laundry won out. However, it is hard to beat padding around the apartment in scrub-pants, socks, and tee-shirt with a cup of hot tea.

I found the picture above recently. It's an aerial view of Union Theological Seminary in New York City (where Dietrich Bonhoeffer taught last century) with Riverside Church in the background. My church meets in a chapel at the seminary.

One more thing of note: I bought "Loving shepherd of thy sheep" on iTunes. Highly recommended.

Bigger isn't always better

Last night my roommate Clay and his friend from out of town and I made a trek to the East Side's famed Serendipity restaurant. Evidently there was a movie that involved the restaurant. I'm not clear if it was famous before the movie, though from the quality of the food and waitstaff I would be surprised.

Most famous for desserts, it's not uncommon to wait a couple hours for a table at this restaurant. We put our name in and then slipped down the street to share a pizza at California Pizza Kitchen. On returning to the crowded and dark Serendipity, the three of us shared two gigantic sundaes.

The peanut butter humble pie was, to be sure, good, and the bananas and vanilla ice cream complemented it well. But the chocolate cake sundae was just so-so in my opinion. At $13.50 apiece they weren't cheap, but there was definitely plenty: I think one sundae would have been plenty for three people.

We had one somewhat rude encounter with the host (whatever happened to "the customer is always right"?) and evidently we weren't the only ones. See this review I found. So, bottom line is that if you want to pay a lot of money for an oversized dessert that isn't great, Serendipity is the restaurant for you. Otherwise, I think a pint of Haagen-Dasz offers better value. And it won't be rude to you.

My specialty at war

The other week I was on "short call" at the hospital. I was reassigned to another room after my room finished, and I wrapped up that other case around 7:00 PM. The team captain was on the verge of telling me I could go home, when he received a call from a resident who was in a "triple A" case.

An AAA is an abdominal aortic aneurysm; a bulging of the largest artery of the body. The danger of the bulging is that the bigger it is, the more susceptible the artery is to rupture, which translates into instant death when the blood pressure drops precipitously to the brain and the heart. This gentleman's AAA was special, not only because it was huge at nearly 8 centimeters, but also because it was partially in the thoracic cavity. The higher it is, the more difficult to operate.

So this resident was calling because she was having trouble running an Activated Clotting Time on one of the little machines in the operating room. I knew how to properly calibrate the machine, so I offered to help her with it.

I knew that the case was more complex than those I typically do as a first-year resident, but I wasn't really prepared for everything in the room. The case had started nearly 12 hours earlier; the surgeons had clamped and unclamped the aorta multiple times, and the patient had died in the middle of the case (going into ventricular fibrillation arrest) and was rescucitated.

It was amazing just to count the number of catheters and devices entering and leaving his body: breathing tube, urinary catheter, a couple I.V.s, pulse oximeter, ECG leads, central line, arterial line, temperature probe, nerve stimulator, trans-esophageal echocardiagram probe. The room looked like a battlefield: bags of transfused blood littered the floor close to the anesthesia area. An instant lab hand-held device was on the anesthesia cart, and multiple infusion pumps were pumping in vasopression, epinephrine, and norepinephrine at times; nitroglycerin and nitroprusside at other times.

Most noticible, however, was the air of subdued panic. I exagerrate, of course, but it was clear that this case was not a controlled situation. The anesthesiologist, aided by one of the attendings, was essentially doing everything in her power to keep this patient alive. In addition to monitoring and treating his circulatory arrest, his labile blood pressure, his crummy oxygenation, his worsening acid-base status, and his calcium deficiencies, she'd had to transfuse about 48 units of blood. Imagine six 2-liter bottles. That's how much blood, or more than twice the amount of blood that someone usually has circulating through their vessels. In addition there was albumin and plasma transfused as well.

After his arrest, the anesthestics were essentially discontinued, as everything possible was being done to help support his blood pressure. He was given intermittent boluses of scopolamine and midazolam, which, instead of anesthetizing, were meant to provide amnesia and prevent new memory formation.

I stuck around and helped as a I could with the case; transporting the patient to the ICU was nearly as difficult as the case itself. I understand the patient lived a day or two, but then died in the ICU.

Frankly, I think we would have all been surprised it he lived to get out of the unit. The other weird thing is that the patient was very much an object from my perspective. I don't mean to sound cold or uncaring, but I was introduced to him as an interesting physiologic project and left him as such. I didn't meet him preoperatively (he walked into the hospital on the day of surgery), I didn't see the family gathered around his bedside in the ICU afterward. For better or worse, perhaps objectification is part of medicine, especially surgery and anesthesiology. We can't do our jobs well if, when things go poorly, all we can thing about is how the patient (or Jim or Nancy) is awaiting the birth of his first grandchild, or how he's going to surprise his wife with a trip to Hawaii soon, etc. Objectification is part of detachment, which is good.

But clearly there is a lot lacking if there is only objectification, as I experienced with "the triple A case". No one looks forward to telling family members that their loved one is dead, as I've had to do many times before. But it's part of being a physician, and part of being human.

Brought to you by the MTA

I used to think it strange when I noticed the Poetry Moment (my name, not theirs) placards posted above the seats in the subway. An ad for the Bronx Zoo, sure...a call for action in Darfur, why not? But I wonder how many of the 7.7 million people that daily ride the Metropolitan Transit Authority's gargantuan subway system stop to appreciate the short poems posted for their edification?

One of my favorites is posted in both French and English. Even if you know no French, try to get a feel for the rhythm, the meter, the rhyme scheme, the tone. The first stanza follows:

Chanson D'Automne

Les sanglots longs
Des violons
De l'automne
Blessent mon coeur
D'une langueur
Monotone.

-Paul Verlaine


In researching the poem, I found a great website (http://billknott.typepad.com/billknott/2007/01/05/index.html) that offers a multitude of English translations. The subway's translation is by Arthur Symons. In reviewing all of them (from the website), it's also one of my favorites:

Song of Autumn

When a sighing begins
In the violins
Of the autumn-song,
My heart is drowned
In the slow sound
Languorous and long.

It's very interesting to read how various poets translated it. I think this one is effective for a number of reasons. The rhyme scheme is kept exactly the same. Although I don't like the "ins" sound of the first two lines, the "o's" of the final four are pleasingly long. I also appreciate the liberties Symons took, branching away from literalism. For example, the addition of "song", creating the fresh "autumn-song" pairs with "langorous and long." Also, I'm fascinated by the change from "blessent mon coeur" to "My heart is drowned." Fantastic.

CFA, I'm expecting a comment from you on this post!