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...