Depends...

What a delightful tidbit to post as my second year of blogging draws to a close.

I recently notified a charitable organization to which I've donated in the past that it appeared I had two separate account numbers, and the address on one account number was wrong. I received a prompt reply that included these sentences:

Thank you for informing us that you have two donor accounts under your name. Please accept our sincere apologies for this error and for the incontinence that this has caused you.

Niles

Another thing you wouldn't hear at a NASCAR race, or even at your local hardware store:

Niles: "Frasier, I played the most delightful party game last night with some of Maris' friends. Tell me, if you were stranded on a desert island, what is the one meal you would want to have, the one aria, and the one bottle of wine?"

Score 1, Anesthesia!

While I could write about another glorious post-call day, instead I must make record of the amazing victory achieved overnight.

I'd worked nearly continuously from 0700 Wednesday morning until 0200 Thursday morning, with a 30-minute lunch break and a 45 minute dinner break late in the evening. My last case was a laparoscopic appendectomy which began at midnight. The same surgical team was planning to follow that case with another "lap appy", but it would be done by the other first-year anesthesia resident on call with me. I could potentially sleep from 0230 until 0800. (Our call day ends an hour later on Thursdays to allow the new call team to attend grand rounds.)

To my dismay, just as the junior surgeon was putting on bandages, I heard the surgery attending say to the senior on service, "Why don't we just go ahead and do that incarcerated hernia tonight, if we're all here? Just get it done, instead of leaving it for someone else to do." This meant two things to me: 1) It didn't seem like a true emergency if the patient could potentially have gone to the floor rather than straight from the E.D. to the O.R. The surgery team seemed to be adding it out of some bizarre sense of convenience. And 2) Unless the anesthesia team captain called the second-year anesthesia resident to do the hernia, I would get a mere 2-hours of sleep. There was also the off chance that my attending or team captain could try to block the case.

I suppose any sleep on call should be appreciated, so sleep I did. At 0415 my pager went off, summoning me to the pre-op holding area. Bother.

The patient was 77, but overall seemed realtively healthy and was not in any distress. I groggily interviewed him in Spanish, and when I examined his airway, I noted he was "Mallampati Class 4", which meant it might be difficult to place an endotracheal tube.

Turning to my anesthesia team captain (a third-year), I asked if they could do this case under sedation with local anesthesia. She hadn't thought of that, so we asked the surgery junior. "Oh, maybe so!" she said, further explaining, "We didn't even see bowel entrapped on the CT scan, so it's just going to be a little superficial operation...probably just a little omentum that we have to push back in."

This angered me. This was not a strangulated hernia; not even a real incarcerated hernia. It was a little bit of fat poking through the abdominal wall, and we were about to start this surgery at 0430. The anger had at least two facets. First of all, if the patient were my grandfather (with a difficult airway), I wouldn't want him operated on at that hour. Converting from local anesthesia to general could be dangerous, especially without support personnel around as they are during the day. The surgery team was essentially suggesting putting this man's life in danger because it was convenient for them to do the case then and leaving the case for the next day's on call team could be seen as "weak." And secondly (on a more personal level), I was losing sleep over the whole ordeal, and neither my attending nor my team captain had raised the questions that should have been asked originally. Time to take matters into into my own hands. The surgeon had given me all the ammunition I needed...

"If this is a 'little superficial operation' as you say, and there's no bowel entrapped," I asked the surgery resident, "then is this really an emergency? I feel like we could be putting this man's life in danger by attempting a difficult airway in the middle of the night." She had nothing to say. She called her attending, and 5 minutes later, the case was cancelled and instead posted on Thursday's "add-on" list.

As my head sank onto my flimsy, thin pillow at 0500 that morning, I didn't care about the sub-optimal call-room furnishings, and I didn't even mind the long, busy day. This was sleep I'd fought for and earned, and in the end we did the best thing for the patient. The sleep came sweetly.

Bowling night

So I'm on call yet again tonight. I just finished a case about 45 minutes ago, and I hear there are a couple laparoscopic appendectomies on the horizon. :-( Maybe I'll get a little sleep afterward.

Last Friday my home fellowship group went bowling at a place called Harlem Lanes in, you guessed it, Harlem. After a strong start with a couple spares, I quickly fell behind the pack. Maybe I should have gone with the 12 lb ball instead of the fourteener.

A couple pictures from the evening...

(From left to right) William, Jan, Katherine, Jonathan, Andy

Dessert afterward at W&K's. William, Andy, Jonathan, Jan, Ezer, Katherine

And to think that I saw it...

The day seemed to have an unexciting end. I finished my last case around 5:15, did a couple post-op notes, and then walked out of the hospital at 5:45. The subway station is just a block away from the main hospital building.

Once downstairs beneath the street, however, I noticed a small crowd of people. Their attention seemed focused toward the middle of the crowd...where a woman was lying on the ground and others were performing CPR.

I worked my way into the circle, set down my bag, and said I was a physician and offered to help. Turns out the fellow doing chest compressions was a medicine attending, and there was a GYN fellow there too. The girl giving breaths had witnessed the entire episode: the patient had said she didn't feel so well before passing out. The girl eased her to the ground, and they weren't able to find a pulse.

I asked the medicine doctor to hold compressions while I felt for a carotid pulse. No pulse. "Resume compressions," I said, "no pulse." I was perplexed, however, when I realized the attending was giving five compressions for every two breaths the girl gave. The basic life-support I learned had ratios of 15:2, whereas the newer guidelines are 30:2. The thought is that since it takes several compressions to even get a blood pressure, it's better to go for longer stretches. The compressions themselves may also help with air exchange.

I felt like I should say something, but then I thought, "This is a medicine attending. Maybe he knows something I don't know." In retrospect, he was probably just rusty on basic CPR. Soon, I noticed the patient was starting to make respiratory efforts, so I reassessed the pulse (which I couldn't palpate). Soon, the EMS personnel arrived and attached monitors, started an I.V., and gave supplemental oxygen before wheeling her off to the Emergency Department less than a block away.

Thinking about the whole experience, a few things strike me...

• It all happened very suddenly. I was simply walking to catch my train, minding my own business, when all of the sudden I was caught up in this episode.
• It was more than an episode. This lady had some form of pulseless cardiac arrest. This was life or death.
• I felt very helpless without my monitoring equipment. No EKG, no pulse oximeter, no blood pressure cuff, no I.V. access, no cart full of medicines.
• Despite not having monitors, I was still able to gather a lot of information about the patient, from feeling for a pulse, to watching her respiratory efforts, to assessing her color.
• I probably should have taken charge, especially when I realized the medicine attending clearly didn't know what is the standard of care.
• It's kinda weird how the whole thing didn't rock my world more than it did. I would attribute this to the nature of anesthesiology: we take care of potentially life & death situations daily.

For someone whose heart may have stopped (she had regained a slow rhythm by the time the EMS service arrived) she didn't look too bad. She was breathing, and she didn't look too cyanotic. I hope she does okay.

Joy

Thumbing through my Van Gogh coffee table book a few months ago, I was startled to see a picture I recognized. Ordinarily it wouldn't be a surprise to recognize a painting of one of the world's most famous artists, but the painting was familiar for different reasons.


This is where the mystery begins. The picture is called "The Langlois Bridge" and was painted by Van Gogh in 1888. And it used to hang in my grandmother's back bedroom 20 years ago.

Now, either Joy was the proud owner of a million-dollar painting, or it was a reproduction of sorts. The former seems rather implausible. If it were the case, how did she buy it? Why did she hang it in the back bedroom, rather than in a place of honor? And where is it now? So perhaps it was indeed a replica, and not an original Van Gogh.

And yet, there's a nagging sense that the work in my memory was not a print but actual oil on canvas. Could it be a painted reproduction? Perhaps even Joy herself, who is known to have painted a ship on rough waters, was the copycat artist?

Even more significant than these musings and vexations, however, is something new I've learned about my grandmother who died nearly four years ago. She must have liked Van Gogh, either to buy a reproduction of his painting, or to spend hours doing one herself. Because Van Gogh is one of my favorite artists, the discovery of a new little connection with Joy makes me happy. (See these posts which mention her.) By the time I had reached adulthood, Joy was beginning to develop dementia; she would later progress to Alzheimers Disease. My relationship with her was, and will always be, that of child and grandmother.

And although I won't have the chance to ride the L with her, or discuss her favorite Van Gogh paintings over a cup of hot tea, or stroll through the mall with her again, I have the sense that in the same place & time, we would have been friends.

Jonathan recommends...

While trying to research the origins of the word duplicitous, I discovered this website. I haven't had time to really explore it, but after a matter of seconds I knew it was a website I'd love!

Midnight post

It's been a while since I used to post late at night when on call. Not that I'm too eager to revive the tradition, but it's 1:30 AM and I'm on a break with nothing else to do.

I've learned not to expect a light call day when I'm on "long call" on Saturday. Owing to one of the urologist's special dispensation to schedule up to three robotic prostatectomies on Saturdays, we're pretty sure to stay busy.

My day thus far has consisted of one robotic prostatectomy, one craniotomy for an intracranial aneurysm clipping (why yes, brain surgery), and one laparoscopic appendectomy which we're in the middle of. With any luck, I should get 3 or 4 hours' sleep after this is over.

Columbia^2

Yesterday found me walking home at 0730 in the frosty sunshine of a cold December day. I had finished a laparoscopic appendectomy around 0130, and wasn't called again after that.

My lazy morning consisted of a nap on the couch, an episode of Frasier, and a bowel of oat bran with honey and raisins, not necessarily in that order.

My main goal for the day was to purchase a couple "Angel Tree" gifts for two kids whose fathers are are in prison. When selecting my "angels", I'd steered clear of the kids asking for an MP3 player. For one, an MP3 player is hard to find when one tries to stay within the $20 limits. And when I saw a couple other children asking for a warm coat and long underwear, those were hard to pass up.

I thought Target would be a good place to find such items. Unfortunately their paltry kids' clothing section meant I would soon wander next door to Marshall's after an unsuccessful hunt. The girls' underwear section of the store was a new and strange place for me; I can't say I felt entirely comfortable there.

Alas, Marshall's did not have long underwear, either. In a bind since this was the only day I could really get shopping done before Sunday, I settled on a set of feminine blue flannel pajamas (Liz Claiborne; ordinarily $59, mine for $19.99). I hope the thirteen-year-old likes them. She gets some little gourmet chocolates too.

There was a large selection of boy's coats, but surprisingly many had fake fur lining the hood. Is this a new trend? Polyester coats with fake fur? The boy is 9 and had asked for a black or navy coat. I found a black one for $20, but it seemed awfully thin. I pictured him trying to stay warm in the blustery New York winter as he gathered his flimsy coat around his thin body, and passed on it. It wouldn't do.

And then I found it! Navy blue. Down lined. Rugged Columbia brand. It was perfect! There was even one the right size! Only it was $40. Reminded of The Office episode where Michael buys a $200 iPod for the $20 Secret Santa gift exchange and feeling slightly guilty, I bought the coat anyway. Can't I buy a coat for a child at Christmas?

After that, it was coffee with William at Columbia, where the late afternoon sun slanted across the campus and shone radiantly on column and green copper-clad rooftop. Early morning and late afternoon sunlight is amazing. I sat in on William's undergrad "Great Texts of Western Civilization" seminar where he led the discussion that evening on the Gospel of John.

I finished the day with the anesthesia department's holiday party at an Irish pub close to the hospital. Good food, a lot of my new anesthesia friends, music that was too loud, and a glass of champagne...guess it was a success.

A few unconnected thoughts

The other day at church, I was impressed by two things. One was Reyn's appropriate use of the word comprise. "Washington Heights comprises several ethnic groups," is more or less what he said. A lesser speaker might have been tempted to say, "...is comprised of..."

Secondly, during a question and answer session, Clifford, a young man who can wear a bow tie and get away with it, rose to ask a question. There was something rather old-fashioned yet dignified in that simple gesture. And practical too--his voice projected easily without a microphone.

I like to preface adages with, "Grandmother always said..." even if it's not something my grandmother always said. I guess I do it as a nod to past generations' ideas of civility and respect. Clifford's gesture fits the model:

• "Grandmother always said to rise when you ask a question."
• "Grandmother always said to rise when a lady enters the room."
• "Mother always taught me to write thank-you notes."
• "Grandmother always said that if you haven't accomplished half of your day's goals by 10:00 AM, then you're in danger of not accomplishing any of them." (Actually, I think that one is from Wuthering Heights, but I always think of it on a lazy Saturday when I have a hard time doing anything productive before noon.)
• Any others from my readers?

And the other week, I was delighted to catch a verbal nuance when my friend William was talking about presenting a paper to some other grad students. He said--approximately-- "My perspective is both originally and ultimately different from theirs." He was speaking not of uniqueness or degree of difference, but rather was referring very precisely to the source of his ideas and their necessary conclusions. In a handful of words, he said that his ideas are different not simply in static nature, but in direction past and future. Without even trying, William is cool.

One final story. I laughed so hard I nearly cried when watching an episode from the first season of Frasier the other day. "It's funny, sophisticated, and very white, Jonathan. You'd like it," my friend Clint said of the show.

Frasier: "Well Niles, people can get set in their ways. Remember when you used to think that the 1812 Overture is a great piece of classical music?"
Niles: (dramatic pause) "Was I ever so young?"

"A place in Boston"

Have you ever noticed that when you meet someone who went to undergrad or law school or business school or medical school at Harvard University, and you ask that person where they went to school, the usual response is, "A place in Boston."

Because this answer is so common, I've put some thought into it. At first blush, it seems to show a good deal of modesty. Folks at most other universities consider Harvard to be the pinnacle of education in the United States. Instead of announcing it to the world, these alumni show a bit of discretion.

On the other hand, perhaps it's false modesty. "A place in Boston" certainly begs the question, "Which place in Boston?" Besides, it's not even Boston. Harvard is in Cambridge, which, owing to the nominal connection to that renowned English university, might add an air of haughtiness. "Oh, a place in Cambridge." Then again, "A place in Cambridge" could be MIT for that matter, but--sorry Louisa--we're just not that impressed. So naming "Boston" rather than "Cambridge" or "Harvard" adds a sense of vagueness which could be argued to be dismissive.

In further support of my false modesty theory, I wonder what these people would say if they were talking to a known Stanford or Duke or Vanderbilt grad? Would they just go ahead and say "Harvard"? If so, does that mean they are simply shielding those of us who went to State U from encountering the devastating transcendence of belonging to such an alma mater? There's nothing condescending about, "I went to Ohio State." But, "Oh, a place in Boston"... Well, to that I say, "Sorry that I had no interest in majoring in gender studies, and--oh dear--I never signed up for the lacrosse club team, but really, it's okay to tell me that you went to Harvard!"

On a different note, I recently read an article in The Economist about the financial strains of Oxford University. Most interesting was the bar graph which showed top university endowments from around the world. I wish I would take the effort to scan this, because the visual compilation of data is impressive. I'll simply list the wealthiest universities and their respective estimated endowments (in British pounds, converted at $1.9 to 1 pound). Imagine the bar graph, if you will. Or plot it on a spreadsheet.

1. Harvard 13+ billion
2. Yale 8 billion
3. Stanford 6+ billion
4. University of Texas (!) 6 billion
5. Princeton 5.9 billion
6. MIT 3.5 billion
7. Cambridge 3.3 billion
8. Oxford 3 billion
9. University of California 2.7 billion
10. Columbia 2.7 billion

I was surprised that the University of Texas is so wealthy. Also surprised that the sum of the ancient giants' endowments (Oxford and Cambridge) is barely more than Stanford's or Princeton's.

And one final thought; a corollary of sorts: Are all "Ivy Leaguers" created equal, or are there various levels of credibility to membership? In my mind, Harvard, Yale, and Princeton are the triumvirate of American university education. Then there are schools like Columbia and the University of Pennsylvania which, though venerable, just don't quite have that zippy instant name recognition shared by the Massachusetts, Connecticut, and New Jersey institutions. And finally, those other Ivy League schools everyone has trouble remembering. Let's see, Brown, and...I'm going to have to think...Dartmouth! Oh yeah, Cornell. Is that it?

Well, enough said this evening. Enough toes stepped on. Good night, and study hard!

420

Four hundred twenty. That's the number you get if you multiply the age of one of my patients by the number of times I've seen her this week.

Mrs S is a 105-year-old who fractured her hip after a fall. I saw her Monday evening as part of my preoperative evaluation. Her blood on the day of surgery (Tuesday) was too thin, so she got some vitamin K intravenously, and a repeat lab showed her blood just barely met the threshhold for the surgeons to operate. (I still wasn't happy about it; the case wasn't emergent, and I didn't think we should risk excess intraoperative bleeding when she wasn't really optimized. I wasn't happy about the I.V. vitamin K either. Strangely, this can rarely cause a life-threatening anaphylactic reaction, whereas intramuscular vitamin K is pretty safe. I warned the orthopedic resident to give it I.M., but the attending internist wanted I.V. (!) And so, for a non-emergent surgery, they stood by her bed and pushed I.V. vitamin K, ready to resuscitate her if needed.)

Anyway, the case was the last one of my day, and after we'd gotten her to sleep and I placed the breathing tube, I started off by sending off some baseline labs and pumping in four units of donor plasma to help her blood clot. By the time the fourth unit was in, I noticed there had been significant blood loss, so I sent another set of labs and started transfusing. (Good thing I didn't wait for the labs to come back before transfusing; her blood count had dropped significantly.)

When it was all said and done, the orthopedic surgeons had lost nearly a liter of 105-year-old blood. However, we were able to get the patient breathing & extubate her before transferring her to the unit.

I saw her again yesterday for my post-op evaluation, and then again today since another patient of mine was in the same room. She is an adorable, if slightly demented, lady; and it's amazing to think that she was a teenager during World War I. She was in her 60's when JFK was shot. And Sept 11 happened in her 100th year of life.

The other thing that will stay with me about this case is how irritating I find some surgeons' mindset. I feel like half of what I do is protect my patients from their surgeons. Especially in situations like this, where some rather unwise decisions were made.

Surgeons can sure be annyoying...

...like when they hurry me to get a patient into the room. One would think that it wouldn't be too hard to figure out that if some patients' surgeries take longer than others, then the preoperative assessment for some patients will take longer than others, especially those with congestive heart failure, coronary artery disease, cerebrovascular disease, hypertension, diabetes, multiple past surgeries, etc. And it should also be common sense that an add-on patient (a patient I find out about immediately before the surgery) will take longer to evaluate than one whom I've known about and have read about the night before.

Any good suggestions for responses to when surgeons complain about "turnover time" given the above? Maybe I should just point blank ask them, "Are you complaining that I took too long to evaluate this patient?"

Even worse is interruptions. This has got to stop. At least three times this last week, I was interrupted by surgery residents or attendings as I'm visiting with a patient. It seems the height of rudeness to break in and start speaking while a physician is evaluating a patient. I need to have a good line ready; maybe something as simple as, "Excuse me, you just interrupted me. Could you please wait for me to finish?"

The nurse in the recovery room, however, takes the cake. A patient for whom I was to provide monitored anesthesia care was tearful even as the I.V. was being put in by another nurse! As high-strung as she was, I tried to be reassuring. At the end of my preoperative assessment, she asked me, "Have you done this before?" I smiled and said, "Many, many times."

As she was waking up from the sedation after the procedure, this patient kept saying in a cute groggy manner, "Thank you all so much for taking care of me! Thank you!" Then she looked at me and said she hoped I hadn't been insulted. I asked her what for. She explained she felt bad for asking about my experience.

Before I could answer that if I were a patient I would certainly be interested in my anesthesiologist's credentials, the recovery room nurse broke in, "It doesn't matter. He just does anesthesia."

Gems from The Economist, part 2

As I've said before, I love the writing in The Economist. Smart, witty, often quirky. Some examples follow.

From the Sept 30 issue in an article about Brazil's presidential incumbent Lula, the writer notes some issues which now face the country. "Brazil's dismal standard of public education suddenly seems intolerable, prompting the president to campaign on the clunky slogan 'development with income distibution and quality in education'."

And in same issue, the obituary for former Texas governor Ann Richards begins, "Not much about Texas is becoming or demure. The coast is muddy and malarial; the west, seen from the air, is an immense brown mat of desert; the centre is scrubland munched by cattle. The state's history is one long tale of men imposing their wills on the landscape; and, much more rarely, of big-haired weather-beaten women imposing their wills on the men."

From an Oct 7 article about the cool relationships between China, Japan, and the Koreas, "Most Chinese profess contempt for 'little Japan', and young people with no experience of the war often jeer more stridently than their parents. But few appear to let patriotism get in the way of shopping."

The Economist editors know when to use forcible and when to use forceful. And they make abundant use of the comma, as seen in this sentence: "On October 3rd, as the five permanent members of the UN Security Council steeled themselves to think about imposing sanctions on Iran for failing to suspend its uranium-enrichment programme, the Iranians proposed, out of the blue, that one of the five, France, lead a consortium to enrich uranium on Iranian soil."

And a final example of knowing eactly how to get a point across: "If the question is to secure the oil-rich Gulf against Iranian adventurism, insist America's Arab friends, a good first step would be to deny Iran and its rejectionist allies moral traction, by doing something about the festering Palestinian issue."

Gems from The Economist, part 1

I have a stack of 8 copies of The Economist beside my desk with dog-eared pages and circled quotations, saved, of course, for the blog. Without further ado...

From the Sept 9 issue, a leader entitled, "Welcome aboard." This mock speech by a flight attendant reveals how airlines are often less than forthcoming with their fliers regarding airline safety.

It opens, "Good morning, ladies and gentlemen. We are delighted to welcome you aboard Veritas Airways, the airline that tells it like it is. Please ensure that your seat belt is fastened, your seat back is upright and your tray-table is stowed. At Veritas Airways, your safety is our first priority. Actually, that is not quite true: if it were, our seats would be rear-facing, like those in military aircraft, since they are safer in the event of an emergency landing."

It continues in witty fashion, including, "Your life-jacket can be found under your seat, but please do not remove it now. In fact, do not bother to look for it at all. In the event of a landing on water, an unprecedented miracle will have occurred, because in the history of aviation the number of wide-bodied aircraft that have made successful landings on water is zero."

The article concludes, "We appreciate that you have a choice of airlines and we thank you for choosing Veritas... Cabin crew, please make sure we have remembered to close the doors. Sorry, I mean: 'Doors to automatic and cross-check.' Thank you for flying Veritas."

From the Sept 23 issue, a brief article about the hTAS2R38 gene in humans. What this means to you and me is that different people have different types of taste buds. The research seems to suggest that broccoli really does taste bad to some people, okay to others, and good to still others--including me.

The same issue continues the food theme with a snippet about meat grown in vats rather than on animals. This meat could avoid bacterial contamination and could also be modified to include healthy omega-3 fatty acids. Eating cultured meat "would allow vegetarians to have their meatloaf and eat it too."

Stuyvesant Town

It was big news around town recently when Met Life sold Stuyvesant Town and Peter Cooper Village in the biggest residential real estate deal to date in this country (something on the order of a few billion dollars). These two apartment complexes sit on Manhattan's East Side, and they were developed on land aquired through eminent domain and given to Met Life for the purpose of providing housing to soldiers returning from World War II.

On the one hand, it seems they've served their purpose, and the real estate eventually should feel the tug of market forces. (Why should retired people pay 1/2 market rent in Stuyvesant and own a second home in Florida, while young people struggling to make it in the city pay much more for a smaller apartment?) On the other hand, I see some legitimacy to the protection of poor folks and those on fixed incomes, which is provided by rent stabilization. It's a complex social and economic issue.

My favorite part of the issue, however, is this photograph which appeared in "AM New York: Manhattan's Largest Circulation". The paper is popular only because they hand it out free at subway stations, not because of the thoughtfulness or scope of its writing, and certainly not because of its journalistic integrity.


Need I explain the humor in this picture? Clearly they wanted a shot of a Stuy resident, but why only half his face? And this is no passerby. He is Samuel Lichtenberg, 80, a long-time resident. Thanks for the smile, AM New York!

Friends in town

Nearly two weeks ago, three of my good friends from medical school clame to visit. Dave & Louisa live in Cleveland where they are in surgery, and Alison does OB/GYN with the military in Washington D.C. New York City, therefore, was a practical and fun place to meet in the middle. (The true geographical mean would have been somewhere in the countryside west of Harrisburg, Pennsylvania. I found this spot by finding the midpoint between D.C. and NYC, and then going 1/3 of the way from that point to Cleveland. As satisfying as a true "meet in the middle" weekend would have been, NYC worked quite well.)

Fort Tryon Park overlooking the Hudson River

I met Alison at the train station, and then we had some tea at my apartment while we waited for Dave & Louisa to arrive, which they did around midnight. Thankfully, 1:00 AM is not too late to get a bowl of noodles for a late dinner near Columbia. (We were, however, warned at 1:15 AM that the restauarant closes at 2:00, and then at 1:45 we were hurried to slurp up the last of the noodles since the restaurant was officially closed. I could comment on the quality of service at Asian restaurants, but will wait for another post...)

The South Street Seaport. Very Navy Pier-esque (Chicago)

On Saturday we hung out at the South Street Seaport, bought discounted tickets for a show, ate cupcakes from the Magnolia Bakery, toured and had coffee at the Time Warner Center at Columbus Circle, stopped by Rockefeller Center, and then saw The Producers. At another late dinner at the Chelsea Grill on Ninth Avenue, I had one of the best burgers I've ever had.

The big window at the Time Warner Center overlooking Columbus Circle

I ushered for the first time at church on Sunday. Fairly unremarkable, only more bulletin-folding than I expected. That, and people would look timidly at me when it was their time to go forward for communion. All I had to do was give a subtle nod and a smile, and people knew to go up! I bet one raised finger and a direct stare would slow down those attempting to go forward while the line was too long!

The cupcakes were worth the 30-minute wait at the Magnolia Bakery!

We finished the weekend with Dim Sum and then relaxed at my apartment while waiting for the appropriate time to leave for the airport. As fun as the weekend is, it was this last lazy hour or two of doing nothing at home that reminded me most of spending time with these friends in med school! It was great!

A two week hiatus

Well, I'm back. Again. These past two weeks have been good ones, though very busy. I think part of feeling busy, of course, is the long days of residency, though certainly another part is life in New York City. Its denizens become accustomed to spending 30 minutes getting to a nearby neighborhood, or up to an hour traveling to another borrough.

I will try to share some highlights of the last two weeks in posts to come. First, however, a picture of my cousin Lucia, whom I visted a month ago in Washington D.C. I thought this was a great picture!

My Lone Star Vacation, part one

Today's been a busy call day at the hospital. A craniotomy for clipping a cerebral aneurysm kept me busy from 0800 until 1715. I grabbed some food with the fellow residents in the lounge after the case, and then had some alone time on the 12th floor roof looking out over Manhattan. The skyline at dusk and a nippy 50-degree breeze (That's 11 degrees Celsius, for my down-under readers) greeted me as I walked into the open air.

That's all I have to say about that. I wanted to share some highlights and pictures from my vacation in Texas last week. Even though I felt like three months away from my home-state was a significant amount of time, when I returned it was amazing how it felt that no time had passed since I left!

Memories include:

• Working all day with my family to prepare a shower for my cousin Lauren and fiance Trevor in our backyard. About 50 people came, though I think we had food for a hundred.

My Lone Star Vacation, part two

• Breakfast with Adam Sunday morning at La Madeleine.
• Park Cities Presbyterian Church with Dawn. Phenomenal organ music.
• Lunch with medical school friends after church

• Hanging out with David O at our old apartment in the afternoon.

• Dinner with Scott, Bonnie, and Chanelle at one of my favorite casual dining establishments, Cafe Express.
• Dessert with David and Scott.
• Breakfast Monday with Nathan.
• Visiting my old hospital.
• Lunch with Mom and Charity.
• Dessert with Adam & Ashley.
• Mom and me spending the night with Aunt Sara, Uncle Ken.
• A trip to Sam's
• Visiting Clint & Kristin in Waco. I learned never to rub my eye after taking out the seeds of a jalepeno pepper. I mowed their yard to be helpful since the baby comes in just a couple weeks!
• Visiting the Arboretum with Shelley, Roman, and Bella.
• A beer at the Ginger Man with David & David.
• Dinner with Clay & Lori. Spending the night at their place and seeing their morning routine.
  
  

My Lone Star Vacation, part 3

I left the day after I got back to New York for Philadelphia and spent some time with Uncle Paul and Aunt Betty. As usual, Aunt Betty had plenty of great, homemade food waiting!

Sunday I was back at Emmanuel, and I hosted a group of eight for "Guess Who's Coming To Dinner". This is a potluck dinner where no one knows who else will be there. Two or three guests were kind enough to help me with the dishes afterward.

This next picture is from a different evening; it's the "Asian" small group I've visited a couple times. I'm not sure if they're so warm to me because they like me, or because I make their group more multicultural.

Far Rockaway

Confronted with a one-day weekend (as I'm on call tomorrow) I made a plan for how to best utilize it. This included:

• Housecleaning. My weekly chores comprise sweeping, dusting, watering plants, and cleaning the kitchen and bathroom.
• Watching a little of the Ric Burns New York Documentary series.
• Reading some anesthesiology.
• Riding the entire length of the A train. It's approximately thirty miles from Washington Heights to Far Rockaway in Queens past JFK Airport. I felt a neat sense of connectedness with my grandmother, Joy, when Mom later told me that Joy would grab a book and ride the "L" in Chicago for an inexpensive day out, exactly as I had done today, some fifty years later.

I wish I'd set aside more time to hang out in Rockaway. It has the feel of a small community despite its being part of the largest city in the United States. Some pictures:

A main street in Rockaway.

A firehouse.

The sandy area which lies just before the beach. The plant life in this place, whether in New York or Florida, always seems rather scrubby.

Park bench in the afternoon sun. I liked the lighting effect in this picture.

A dune with grass.

Silvery waves crashing on the beach. Gulls were flying, and plenty of people were out fishing in the cold water. The salty wind was a refreshing change from the typical Manhattan air.

My superlative D.C. weekend

Still playing "catch-up", this post is a continuation of this one.

The morning was still gray and damp when I arrived in Chinatown. I hurried from the subway station at Grand Avenue along the slick streets where men unloaded fresh fish from trucks and the blue steel of the Manhattan Bridge loomed above. One of the more startling things about the Chinatown bus system that ferries budget-conscious travelers between major cities on the eastern seaboard is that there's really no station. One rounds a corner and stumbles upon a small crowd of suitcase-toting passengers and a white bus that either bears cryptic words like "Fung-Wah" or is creepily unmarked.

On my way to Washington I sat next to a Polish fellow who was studying computer science at a university in New York. This was a real-live case study where I could put my knowledge of European current events (gleaned from The Economist, naturally) to the test. We talked a few minutes about changes in Poland since joining the EU, the migratory patterns of skilled and unskilled workers in Eastern Europe, and possible government reforms in Poland. Pleased with myself for daring to enter such a conversation, though wary of getting in over my head, the conversation soon shifted to our respective plans in this nation's capital.

My good friend from college, Emily, picked me up from the bus station, and as we drove toward Georgetown pointed out interesting landmarks including where she used to work and the upscale restaurant where she and her husband recently had a $30 three-course dinner as part of the local eateries' promotion. We also drove past a huge flight of stairs near campus which was in a famous horror film, but of course I couldn't remember the name of the movie when telling the story later, and I still can't remember it. Kinda takes away some of the punch of the moment.

My cousin Lucia met up with us--she's a freshman at Georgetown--and showed us around campus, including her dorm. Here's a picture of Lucia and me on the terraced rooftop of one of the upper-classmen dorms with a great view of the river and the Washington Monument.


We dined at a local Indian restaurant, and then Emily and I met up with Seth at a "passing on the torch" Saturday afternoon get-together at their church. Emily is taking over the coordination of the church's Sunday morning coffee hour, and this was a key meeting where she could network with the various hosts. Seth and I networked with the snack buffet. Wherever there are Methodists gathered, there will also be good food.


This was my first time to see Emily & Seth's home in a smaller town in Maryland. Regrettably I didn't take pictures, but the best parts of the "split-foyer" home were the automatic apple-peeler, and the back deck where Stumpy lives. Stumpy is a little turtle who has been part of the K_____ household for several years. A student gave him to Seth back when they lived in Texas, and Stumpy is so named because his two front legs are just that. He seems to get around okay, though, and enjoys a diet of mealworms.

The remainder of my time there consisted of a great Mexican food dinner (New York sadly has a paucity of good Mexican places), and church on Sunday morning, with a home-cooked Sunday lunch. Another picture of Seth & me at the kitchen table while the pork roasted. (You can see that I'm busy working, while Seth is doing a little light reading.)

On days like today...

On days like today when nothing of note happened, it's difficult to write a post.

There's really no need to write about my awakening in the middle of the night to the crash of my white pull-down window shade falling to the floor, or the incessant "Barber of Seville" alarm tune of my cell phone as I forgot to take it off snooze while I showered. For that matter, it would bear no relevance to mention that I now shower with the bathroom door open a bit to keep the mirror from fogging and to slow mildew growth, as advised by Aunt Betty.

Clearly no one would want to read about my piping hot cup of green tea which lifts my spirits during my morning commute on the groaning subway while I thumb through my dog-eared news journal, or how I prefer to walk a block along the dawn-lit street past the carts of street vendors selling bagels and sausages, rather than trudge that block through the yell0w-lit hospital even though it's more direct.

How boring to note that I remembered Christian had told me that Thursday was "Taco Day" in the cafeteria as I walked through its doors, only to see Christian making himself tacos, piling sharp yellow cheddar over hospital-grade ground beef and crisp shells.

Of course now is not the time to say that surgeons sure can be irritating when they ask what the blood pressure is every two minutes, or how my heart soared when I was relieved at 1600, just when I was about to pre-op my final case of the day. And a blog is not the place to relate my special trip to Target today to buy a VHS tape to record The Office (not knowing the VCR would fail me), and how I bought 15-watt fluorescent bulbs there which have the same light output as 60-watt incandescent ones.

If this were a menu I might describe my pan-seared tilapia with crushed red pepper and parmesan cheese on top, or my green spinach salad with lemon juice and little Greek olives, or my small serving of special dark chocolate squares with toasted almonds. But it isn't.

It would be of no importance to dwell on the cool, gentle breeze and muted street noise wafting in my window in this moment, or the warm glow of the lamp on the cocoa walls and my soft beige comforter pulled back. Nor will I linger on how pleasantly warm my feet are when stocking-clad, or how my pillow knows just how much to give and how much to support my head as my eyelids grow just a bit heavier...as I sink into the end of yet another day.

Lions & tigers & bears...

I love it when I can link two seemingly unrelated experiences in one post, which I will now proceed to do.

A month or so ago, some friends and I were dining at the Carnegie Deli in Manhattan's Midtown. One in our party ordered a sandwhich called "The Mouth that Roared." At least 8 inches tall, this culinary offering comprised layers of pastrami, cheese, egg, and tomato. Even in the context of the generously portioned fare typical of this establishment, this sandwich was impressive.

While we were talking and laughing about it--even taking pictures--I noticed a 5 year-old girl at the next table who caught sight of the sandwich. She was already an adorable kid to start with, but when her mouth dropped open and she tapped her daddy on the shoulder in total amazement, she transcended levels of cuteness that ordinary kids achieve only on a good day.

And just the other day as I was on the train to Philadelphia, I was speaking with a 30-something woman on her way to a class reunion at Swarthmore. With her was her three-year-old half-Korean, half-Caucasion son, who at one point whispered to his mother. She then looked at me and said, "Would it be okay if Timmy showed you his roar?"

I wish I had him on video! The child squeezed his little hands into fists, arms bent at the elbow, took a deep breath, and then..."Grrrrrrr!!!" The overall effect was that of a kitten trying to imitate a lion's growl.

So there, two cute kids, two roars, one post.

Gladys' calf

My parents have pared down the herd to two cows. Our original bull, Supper, got sent to the auction along with the majority of his harem. With escalating hay prices and all-too-frequent Texas droughts, it wasn't cost-effective to keep a larger herd.

My parents did keep, however, two cows which tend to have better calves. The quality of the calf can make a big difference in the price per pound they bring at the auction. I have yet to figure out how they'll continue to have calfs, unless that new equipment under the kitchen sink is for bovine IVF.

Here's a couple pictures of Gladys' new calf. (Gladys, in the tradition of naming cows after the women in my dad's family, bears my great-grandmother's eponym.)

Catching up

Once again, the blog has been neglected. My readers cry for help from the ditch beside the road. For the last two weeks, I've simply gathered my robes and hurried about my life, looking the other way.

But I'm back. Never again will I let this happen. I have started afresh. A new leaf. An open book. The curtain rises.

Yeah, yeah. Right. Get over it, readers. I'm busy, okay? It's called residency! Yes, I know, I know, it's anesthesia, but I'm still working harder than those Wall Street traders I know. So two weeks went by. It's happened before; it'll happen again.

(To my more mild-mannered and gentle readers, I apologize for that brief tirade, but it must be understood by those nervy patrons of Mulberry Street who is the one writing this blog.)

So here we are. I wanted to share a brief synopsis--the highlight reel--of my busy September weekends.

September 1-4 Labor Day weekend. New & old friends Jessica, Michael, and Sarah in town. We strolled the Brooklyn Bridge, ate pastrami elbow-to-elbow with strangers at the Carnegie Deli, and braved the rain on our self-guided tour of Columbia. I cooked a garlic-embedded leg of lamb one evening, which we enjoyed. One particular fellow sitting ahead of us at Spamalot did not seem to enjoy the garlic during the funnier parts of the musical. And then there was the stroll through the park, sushi & sake, dim sum, and the Empire State Building. I did more tourist things that one weekend than in two full months in The City.

September 8-10 The weekend started with my birthday on Friday spent on short call. Yippee. Roommate Clay treated me to dinner that night at what is destined not to be our new neighborhood hangout, Rancho Jubilee. Dark. Candle-lit. Caribbean decor. Creepy romantic Latin music. At least the shrimp and sauces were good! The next day friends from Philadelphia--Luke, Marianne, and Lucy--came in town. We had brunch at a sports bar, I finally visted the Cloisters, and later we enjoyed Magnolia cupcakes in Washington Square Park. On Sunday I hung out with Justin after church on the "urban beach" of Columbia's steppy mall, and picnicked in Central Park with other residents. And by sheer, random chance met William, whom my sister knew in Fort Worth.

September 16, 17 Overnight call on Saturday has a way of eating up the weekend. Thankfully there was still time for church, lunch at a cheap Mexican place with Alex, and a little social activism at the Darfur rally in Central Park where I met up with my cousins Lucia (accent over the i) and Johanna (pronounced with a y). I accompanied Johanna to afternoon church at Redeemer's East Side service. And oh yes, chanced upon William--this time with wife Katherine--yet again, entirely randomly on the street.

September 22-24 Fellowship group with my church on Friday night at Andy's amazing brownstone apartment. 12 foot ceilings, and a bay window looking out onto a tree-lined street on the Upper West Side. I arose at 0500 the following morning to take a subway to Chinatown. Awaiting my connection at 59th Street, I enjoyed listening to a few jackhammers busy at work early on a Saturday morning! The Chinatown bus took me to Washington D.C., about which I'll write more in a future post.

Coming home

My original plan for my first week of vacation during anesthesia residency was to do something new and exciting: perhaps a week in London, a trip to Toronto, or a hike in the Catskills resplendent with autumn color. As the time drew closer, however, I realized that the thing I wanted most was to go home to Texas! My three months in New York City make the longest stretch of I've ever been away from my home state.

More posts will come regarding my whirlwind tour of the Lone Star State, with over 500 miles logged under the dizzying dome of the cavernous Texas sky, but I wanted to write first about what is most recent in my mind. Sure, since moving to the northeast I'd spent a night away here or there visiting family & friends in Philadelphia and Washington D.C. But this was my first real homecoming to New York City.

I'd requested a left window seat with hopes of another flightpath up the East River and phenomenal views of Manhattan. Unfortunately my boarding pass was printed with the seat assignment 12D...aisle, right side of the plane. An airborne preview of The City, however, wouldn't have prepared me for the new sensation I experienced as I stepped outside of the terminal at LaGuardia Airport.

Leaving behind October weather in the 90's in Texas, I stepped outdoors into a sunny late New York afternoon in the 60's. A breeze greeted me as I gazed at the the purple and gray clouds streaked across the sky. In the distance rose the Empire State, Chrysler, and Citicorp Buildings. And the strange thing was that...that it was familiar. This airport was my portal back to "regular" life with my apartment, job, new friends, and church. Just a few miles away lay my bridge, the little grocery on 187th that I frequent, and the Dominicans playing dominoes on the sidewalk outside my building.

The M60 bus pulled up to the curb after a couple minutes, and it was all very normal to dip my Metrocard as I boarded and simply to read a magazine to pass the 30-minute ride into The City. Walking down the block in Harlem--past the African-American hairstyle establishment Kinky Twirls, I might add--the sidewalks crawled with humanity in the long shadows of the late afternoon. But best of all was what lay beneath the streets. Dirty, dingy, damp...New York City subways! The familiar rumbling, squealing, and screeching greeted my ears as I squeezed my suitcase, carry-on, and myself onto the packed car.

Little had changed in the apartment, except for some mail stacked on the dining room table. Enjoying my first hours of alone time during my vacation, I put on a sweater and went down to the little pub nestled halfway below street level at 181st Street. I sat alone at a tall bar table in the dark paneled room and watched college football while enjoying a burger and beer. And then, of course, the familiar fifteen minute walk home down Bennet: the bike shop, the Hebrew school, the little pastoral Lutheran church, and the semicircle of park-benches where older folks feed birds in the afternoons. I was home.

A movie worth watching

Ever since college, I've found the increasing importance of stories to be a theme of my life. For one particular colloquium session in the Honors Program, we read a book called The Call of Stories. (Of note, the session was lead by the particularly warm and hospitable wife of the dean of the College of Arts and Sciences.) Although I don't remember much about the book, what I do remember is that our writing assignment following the discussion group was to write about books that have impacted us. I wrote about A Tale of Two Cities. This was one of my first instances to begin to think of stories for more than their entertainment or historical-folk value. The nature of fiction unfolded as I began to encounter the power of myth, instruction, and reflection in stories.

That said, I also appreciate a movie about stories. I had the pleasure this drizzly post-call morning to finish watching Big Fish. What a great movie! I'd seen it a few years ago in the theater, and my only regret about renting it is that for just 5 or 6 more dollars I could have bought it.

Without spoiling it, the movie is about a son who is searching to better know his dying father--a father better known for his scintillating tall tales than frankness. The stories, in a sense, become who his father is, and vice versa.

A couple moments in the film I particularly enjoyed: Thanks to Tim Burton's fantastic directing with a bent toward the fantastic, the potentially overly sentimental ending instead treated the viewer to a light-hearted and humorous moment between father and son.

Also I can't help but mention the bathtub scene. Nothing racy here; just remarkably well done. And finally, I had to laugh when Will leaned over to push the nurse "call" button at the hospital. The button was positioned on the wall, such that an ailing patient would have to reach a few feet over his shoulder to summon aid!

My book list

In spite of staying (relatively) busy with residency, I'm trying to make a habit of reading more. Who needs television? (Except, of course, for my two official shows, The Office and Lost, returning this fall on September 21 and October 4, respectively.)

I have a few novels to recommend from this spring and summer. Actually, I'm just going to list all of them, and a few highlights from each.

Old School by Tobias Wolff. A Jewish boy's senior year at a northeast boarding-prep school in the early 1960's. In itself, a "celebration of literature," according to the first editorial reviewer on Amazon.com. And one of my favorite lines from the book, appropriately captured by a spotlight reviewer, is in reference to the narrator's dream of rubbing shoulders with the likes of Frost and Hemingway: "My aspirations were mystical...I wanted to receive the laying on of hands that had written living stories and poems." I enjoyed the compact, elegant prose in the book; a sort of spare writing style. I thought, however, that the last forty pages or so were an odd-fitting ending to the book.

Extremely Loud and Incredibly Close by Jonathan Safran. A tale of a nine-year-old's loss & recovery in the aftermath of September 11. I most enjoyed the quirky perspective of a kid and the tender father-son relationship portrayed in the book. Drawbacks, for me at least, included the book's toeing the gimmicky line with its use of color, illustration, and text-art. The parallel narrative of the grandparents was also strangely disjointed and disturbingly sensual.

In the Lake of the Woods by Tim O'Brien. A rising political star is haunted by secrets from the Vietnam era. Part murder mystery, part modern commentary. Rather dark, but if you like Tim O'Brien... The Amazon.com editorial review notes that the use of quotations from fictional newspapers mixed with actual reports create "a mélange that lends the novel an eerie sense of verisimilitude." Does this guy take himself seriously?

Pride and Prejudice by Jane Austen. I bought a pocket-sized copy several months ago at Half-Priced Books for a dollar or two. It became my subway reading material for a few weeks this summer. Years ago I'd picked up the book, but quit reading after 20 or 30 pages, because--this is hard to believe now--it was boring...the pages were filled with women talking about balls and the like. After my second encounter, however, I consider it one of the funniest classics I have read! And Elizabeth almost became a friend, so to speak, on my daily subway rides. Amazingly sharp & quick to see ironies and pretense, she is at the same time consistently polite. This book will probably garner its own post in the near future.

A Short History of Nearly Everything by Bill Bryson. I'm only 100 pages in to this book my brother gave me, but it's proving to be a quick and interesting read on the history of, well, nearly everything. I enjoy the way Bryson puts "common" scientific knowledge into the historical context of the discoveries as they were made. Already I've read about origins of the universe, the construction of the solar system {"...with Earth reduced to [the size of] a pea, Jupiter would be over a thousand feet away and Pluto would be a mile and a half distant (and about the size of a bacterium...)}, and the British Geological Society.

In remembrance: 9/11/2001

New York City, September 11, 2006

This day began as beautiful as that day five years ago. Cool, clear, amazing September day.

From the papers, I knew that throughout the city there were observances. Names read. Moments of silence. Somber music in the parks. Visits by dignitaries.

For me, however, it was another work day--a Monday--as usual. Busy enough, nothing too stressful. It wasn't until my late afternoon run across the George Washington Bridge that I had some time to reflect on this city and the world that are different places than they were five years ago. As big as the events were that day, and as big as the events are that have taken place since, I couldn't help but wonder how we will look back on these years ten, twenty, thirty years hence. In what way will they shape that history that has yet to be written? Will those 3,000 lives lost fit into some larger meaningful picture, of what we hope will be sacrifices for freedom?

On the Hudson River, a tugboat guided a gargantuan barge far beneath the bridge on which I ran. I noticed the hues of the sky's blue as it faded into the clear horizon miles and miles to the north. Gray and purple clouds floated in a smattering across the sky. I saw the Jersey shore with its steep tree-filled banks. To the south, the densest part of the most crowded city in America lay in distant rest. Manhattan, quietly basking in the afternoon sun, balanced around the Empire State Building.

But most memorable, as cable after cable raced behind me, was the flag hanging in the arch of the western tower of the bridge. I'd seen it from a distance; it could easily be spotted from miles away. But as I jogged closer, the size of it was what pressed onto my mind's eye. Easily 60 feet wide and 100 feet long, I imagined how many eighteen-wheelers it could cover. It billowed over the bridge in the cool eastern wind.

As I came closer, a helicopter circled far above. I wondered if the pilot could spot me--a solitary runner--dwarfed beneath the American flag. And this is the picture I will carry as I remember this day. Yes, the world changed shape on September 11, 2001. Yes, an narrative is forming as the rudder of history swung a new direction. But I'd like to take a moment this day not to simply solemnly remember the number 3,000, but to think that beneath the vast banner of American freedom are individuals who died that day...from this vantage point, each is not much more than a speck beneath that unfurled flag, but every one is far from forgotten.

A new sleeker Mulberry Street

My regular readers will probably notice the subtle change to my blog. It was time for something fresh.

Ah, autumn

My favorite season has definitely arrived to the northeast! September marks the beginning of this great time of the year, and my birthday just so happens to be today.

I was assigned to a genito-urinary room today where we did three robotic radical prostatectomies. (see sample pictures below) Ironically, the urology resident's birthday was also today! She was turning thirty, I, twenty-eight.

A picture of a robot-assisted operation. This is not a prostatectomy, since that would be a very high-riding prostate. Also, given that the patient's arm is over the sterile drapes, I suspect this is a staged photo.


This is what the surgeon looks like during the case.

Rising to preeminence

Type in saw, mulberry, and street into Google's search engine. The blog of yours truly is number seven on the list. Unfortunately I'm competing directly against Dr Seuss's book.

How to contact me

Mulberry Street Public Service Announcement

I've added an e-mail address, MulberryStreetBlog@gmail.com, to my profile so that readers who may not know my regular e-mail address can still contact me.

I'm a new fan...

...of the musical Sweeney Todd. My roommate Clay had seen it 3 times, counting the time we went together a couple weeks ago to see it, purchasing affordable last-minute tickets. For the second half we stole down to some empty orchestra seats which gave us an incredible view of the actors'/singers'/musicians' expressions and audience interaction. We also had to crawl over a grouchy, arthritic older lady who asked, richly in sarcasm, if we had any more coming.

In brief, the show is about a barber who kills people with his razors for revenge. The music is fun and full of rich and varied textures, and this production, which originated in England's regional theater before making it in London's West End and then coming Broadway, is unusual since the ten actors also perform all the music. The scaled back, deconstructionist* approach encourages use of the imagination, and the simple set and props turn the focus onto the actors' expressions and movements. The Lion King had phenomenal costumes, but as a musical I enjoyed this one much more.

So, for Clay's birthday coming soon, I took him to see our second showing of Sweeney Todd in as many weeks! Here are a few pictures to give an idea of the show. It closes on Sunday, but there may be a national tour next summer.


* Deconstruction is a philosophical or critical method which asserts that meanings, metaphysical constructs, and hierarchical oppositions (as between key terms in a philosophical or literary work) are always rendered unstable by their dependence on ultimately arbitrary signifiers. (www.m-w.com)

Apartment 7G, amended

I realized my scanned page in the 7G post didn't have the best resolution. I tried increasing the size, tried changing file types, tried uploading from My Documents rather than My Scans. All to no avail. I don't know what I'm doing wrong.

This is all remedied, however, thanks to a suggestion from my friend Scott. I took a digital picture of my original sketch, uploaded that to the computer, and uploaded that to Blogger. There has to be a better way.

This may be the appropriate place for a general question regarding the nature of the verbs upload and download. Of course I upload a picture to my blog, and I download music from iTunes. But what about camera to computer? Does uploading always refer to transferring from the simpler to the more complex? Or does downloading always indicate a direction toward my personal computer, whether that be from the internet or a digital camera?

Anyway, here's the picture. I forgot to write "bike" next to the funny-shaped thing locked to the railing of the staircase. "Jonathan's bike" is now in the hall outside the apartment, rather than in the living room.

A couple days of misfortune

After days like Thursday and Friday, it would be easy to come home discouraged. I think I generally try to think optimistically, but these days were stretching. A quick summary:

Thursday, patient 1: The I.V. I started in the patient's arm infiltrated* at some point. She was nearly completely covered by warmers and drapes, so I didn't realize until I took down the drapes at the end of the case. The entire arm, up to the shoulder, was swollen! I (and she) were fortunate in that she still had a good pulse (in other words, the pressure in the arm did not exceed the arterial pressure, so blood and oxygen was still delivered to that limb), and I had given no "vasopressors" in that I.V. which could have potentially compromised her blood flow.

Thursday, patient 2: During the second case, which was a laparoscopic case done in lithotomy and steep trendelenberg*, I noticed the patient had regained her twitches, which was a sign to re-paralyze her. (It's important to keep patients paralyzed during laparoscopic cases so that the movement of their diaphragm doesn't interfere with the surgery.) I gave an appropriate dose of medicine and waited a few minutes. She still had twitches! Around this time, the circulating nurse noticed a large puddle of fluid on the floor! Given the trouble with the last case's I.V., I immediately became concerned that my I.V. had slipped out and produced the puddle. This would explain why the patient wasn't paralyzed! I called my attending who came to assist. We pulled out the patient's arm (with difficulty, given the position) and realized the I.V. was fine. Meanwhile the surgeon is getting frustrated because the patient is breathing on her own and we're having trouble re-paralyzing her. It got to the point where my attending and the gynecologist were nearly yelling at each other! Turns out that for some reason or another, this patient needs whopping doses of paralytic agents. And then after my attending left, the gynecologist continued to be snippy to me. Between cases, I think she felt bad, and so she tried to joke with me that from now on I would be called "Mr Paralysis." Not funny.

Thursday, patient 3: With the same gynecologist. Case is going smoothly, except again in steep trendelenberg, I notice the patient's CO2 levels increasing. (Laparoscopic cases are done by insufflating the abdomen with CO2 since it's quickly absorbed, and trendelenberg makes it difficult to effectively ventilate patients.) I increased the patient's breathing rate a little, and switched the ventilator over to pressure control in order to keep her peak airway pressures down. Not a problem. CO2 is 40, everything's fine. Well, a colleague came to relieve me around 8:45, and I "checked out" to him by telling him the patient's medical history, where I have I.V. access, and how the case was going. Quietly I told him that the CO2 had been creeping up and that I'd switched to pressure control.

The gynecologist heard me, and said, "What's creeping up?" I told her the CO2 had increased, but that I'd compensated for it by increasing the patient's ventilation. Still frustrated, I think, from the last case, she began lecturing me that I have to let her know when this happens so that she can take the patient out of trendelenberg, blah, blah, blah. It wasn't so much what she said as the tone with which she said it! I didn't really say anything in reply, but in retrospect, even though I would be talking to my superior, I should have said something along the lines of, "As I already said, I've compensated by increasing the patient's ventilation. If I were to run into difficulty and couldn't control the CO2, I would certainly let you know."

Friday, patient 1: Older lady with multiple medical problems (hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, asthma, stage IV lung cancer) getting a simple procedure--venous port under her collar bone for chemotherapy. Everything was fine, except I just felt on edge the whole time given her fragile physiology. (If you're not a doctor or nurse, just skip to the next paragraph now.) That, and when the surgeon placed an intravenous wire, I realized it's really hard to differentiate atrial fibrillation with LBBB from PVC's! I had fun authoritatively telling the surgeon to please pull back the wire.

Friday, patient 2: A very high strung patient undergoing a large procedure involving a urology, general surgery, and gynecology tag-team approach. She nearly refused the procedure last minute when the surgery resident briefly went over benefits and risks of the procedure in order to get the consent form signed! The difficulty from our end was that her two front teeth were actually caps held on with temporary cement. We warned her that in the process of intubation, the caps might be knocked off.

I intubated, and my attending was hawkishly watching the teeth the entire time. After I placed the tube, she congratulated me, "Good job." I turned to get tape to secure the tube, and when I looked back, a front tooth was missing! I saw it on the tongue! I tapped my attending on the shoulder, and her blood pressure immediately skyrocketed when she realized what had happened! (She was not upset at me, just suddenly under a lot of stress to get the tooth.) As she manipulated long forceps trying to retrieve the tooth which kept slipping farther down the throat, she bumped the other front tooth which also fell out!

All ended well. She retrieved both teeth, and we called an intra-op dental consult. The patient knew this was a risk of the procedure. And I felt better knowing that a simple tap by the forceps was enough to dislodge a tooth. Everything was going to be okay. When stress levels were back to normal, I started to mention to my attending that these mitigating factors certainly helped. We did what we could, but it still happened. Part of a day's work. Before I could say much, though, she patted me on the shoulder and said, "It's going to be okay. I mean, you will think about this every night for the next two weeks, but you'll get through it. It could have happened to anybody. Don't beat yourself up. It'll be hard, but things will be alright." Yikes. I simply nodded and told her I appreciated her encouragement!

Friday, patient 1 from Thursday: I went to write a post-op note on yesterday's patient. I explained (again) to her that the swelling in her arm would go down over the next couple of days. I was thankful that she had no pain in that arm. She did complain of significant pain in her abdomen, where the incision was. She also asked me what all the I.V. fluids were hanging above her bed. I leaned to my left to look at the fluids, and wouldn't you know it, my stethescope slipped off my shoulder and right onto my patient's belly. She cried out and cringed in pain for what seemed like 5 minutes. All I could do was apologize profusely. Maybe that's why surgeons always carry their stethescopes in their white-coat pocket.

* Infiltration is when the catheter slips out of the vein, so that any fluids or medicines given simply collect in the surrounding soft tissue rather than going to the circulation.

* Lithotomy position--think women's exam. Trendelenberg is a fancy word for head of the table down.

Apartment 7G

This is my new apartment. First, a sketch of the floorplan. I rearranged today to make better use of the space. Our previous arrangement made the living room feel extremely long. Instead, I've tried to create two smaller rooms within the room.

My new dining table from Target.com. It's great! The design on the wall is something I'm working on. It's a design I copied from a Frank Lloyd Wright prism window. My thumb is numb as I type from all the cutting.


The other dining table. It has a clever design which allows it to fold and become a small side table.


The poetry corner.


The living room. My mom bought me the Iranian hand-woven rug for $1.35 on eBay. (Shipping was another $30).

Brooklyn Bridge

Or "Budweiser can framed by Empire State and Chrysler Buildings."