If you're a close reader of the comments here, you'll have noticed that the tests turned out as I hoped, not as I feared. And another scary chapter of my life is finished. But the pessimist in me mutters as I write that "the book is not yet finished." The good thing, I guess, is that I'm fairly aware of the different ways you can get a needlestick.

And as I noted yesterday, I am away from the hospital until the new year. Probably the last break I'll have before internship, so I intend to enjoy it. Posting will probably be light over that time, but I'll be starting up with neurosurgery in January, and that should be fairly story-rich. No, this is not out of a new-found desire to be a neurosurgeon, it is simply a relic of the fact that my school assigns lottery numbers to students as we pick our required neurology rotations, and, as is already evident, I'm not particularly lucky.

An oddly bright moment today was opening my mail. On my last ward medicine month, I had really clicked with a patient, who then proceeded to offer me a week at his beachhouse out of thanks. I never took him up on that, but I did get a Christmas card from him, addressed to "Dr."

Almost, almost. And it is wonderful to know he's still doing well.

Choosing a doctor, finding patients

I'm on my winter break, hence the dearth of posting lately. But yesterday, I was in a music store, asking for a specific and (I guess) rarely requested piece of music for my guitar, Spencer Doige's Fingerpicking Joplin. Check it out here, but give the guy 22 seconds to start the real piece. And here. I digress.

Anyway, the woman helping me find this piece said "I assume you're a professional then, getting this book," which started a bit of a discussion about my job and what I'm going to do. And as we ranged over my theories on accupunture and osteopathic manipulations (I'm an allopath), she was evidently impressed. She stated finally that "when you get out of your residency, come back by, because I need a new doctor, and it's so hard to find good ones."

Which got me thinking down the road. I don't really know much of how someone in private practice goes about getting a panel of patients. We aren't taught a whole lot of that in school, and as an internist, most of my time for the immediate future will be in the hospital, out of clinic. But eventually, I'll be out in private practice, and I'm not sure I want to be a hospitalist, so I'll be doing clinic and needing patients. So I guess I'll start with the guitar stores to drum up business, eh?

Blogger Beta

I upgraded to the new version, and the first thing I noticed that changed was that it deleted all the authors to the comments, replacing them with "annonymous." Not an auspicious beginning. Anyway, I can't go back now, spilt milk and all, so I'll try to make it work.

Trepidation

I've just had the last, one year later, make sure we didn't miss anything, blood test drawn to follow up my needle stick injuries from last year. And I'm actually fairly worried it will be positive for HIV. About six weeks after the one stick that concerned me, I got a febrile illness with night sweats and lymphadenopathy, and though the next test was negative, I've remained unconvinced. The next test was too soon after the illness, I think. And it is odd, maybe specific to medical students, that they worry about the diseases they study so much. It is harder here because with something so serious, your best friends and family aren't willing to entertain the idea, and no one knows what to say. Being met with either awkwardness or hearty, but not heartfelt, denial.

We are separated from one another by an unbridgeable gulf of otherness and strangeness which resists all our attempts to overcome it by means of natural association or emotional or spiritual unions. There is no way from one person to another.

Worry is a tricky thing. Though I philosophize a great deal, I'm not very philosophical, and though I know worrying about something I can't change and will know in a week anyway won't do anything positive, I worry anyway. "These are the times that try men's souls" Thomas Paine wrote, and though he was dicussing the acid test of patriotism, I think a similar case could be made for the slightly justifible hypochondriasis of the typical medical student. "The summer student, and the springtime physician..." or something, "will in this crisis" find if they are truly capable of handling the stress. So I will see. I will see if I can take a week of concern, thinking about the family I'll never have, the life which will revolve around the treatment for an incurable, fatal disease. Something my patients deal with every day. Certainly, even hypochondriasis gives perspective.

And now for some light entertainment

Part of this Intersession was to sit in small groups and discuss our views on medicine and how they've changed. Some of my more recent posts were written with these upcoming discussions in mind and I feel it's probably ok to quote yourself, on occasion, even if you aren't yet 30. Right?

Anyway, one of my classmates paid me a rather humorous compliment. We were discussing the aging process, and the discussion leader, a more experienced doctor, said "you know, we're all going to get old and need a physician there to help us."

Without more than a second's pause, my classmate quipped "I call Nathan."

Nice to know I've got at least one vote of confidence.

What are people for?

Against conventional theodicies, and above all against a culture that has lost its way, where its answer to the question, "What are people for?" is, “For autonomy and control, for health and beauty, for performance and productivity,” Professor Young has lodged a considerable critique. Human beings, she says, are made for friendship, and human communities are made for hospitality. And it would seem to be the vocation of so-called disabled people to take this gospel to so-called indepedent, fit, and achieving folk.
- Kim Fabricus

The always thought-provoking Kim Fabricus recently posted this here. And it got me thinking, obviously. I've written on the idea of disability before, as it pertains to abortion, and I've commented on it at Truth or Vanity as it pertains to the passive euthanasia of children. And I realized that, beneath what I flatter myself is an eloquent veneer is really the clash of ideologies. And I have been allowing myself to be convinced of the essential utility of a Darwinist perspective as it relates to ethics. The veneer of rhetoric allowed me to ignore the essentials of what I was saying.

Darwinism may well explain some things as biology, but as a philosophy, it is pernicious. It may indeed be the best case for the existence of God that we are still here, since left to our own devices, we tend to extend survival of the fittest to an all consuming selfishness that will destroy us. I am leaving aside the question of biology for now, because my subject, medicine, is really the spiritual side of biology. And if Darwinism is carried to its logical conclusion, there is no spiritual side to anything, except in the abstract complexity equals spirit formulations of Ursula Goodenough and her ilk. (A good friend of mine pretends to buy into this, but I think deep down he doesn't believe it.) Medicine deals with biology, but the best physicians are at least partly, if not primarily concerned with what effect biology has on the person as a person, not as a collection of homeostatic reactions.

What I'm driving at is what I've written at the top of my sidebar: "Without faith, without poetry, without music, medicine is pointless, for why save a life which is not special, and why dedicate so much effort to a cosmic accident? It would be worse than pointless, it would be cruel." In considering that life, which is so much more than a cosmic accident, the question that titles this post arises: what are people for? And relying on Darwinism, we have no answers that allow us to simultaneously affirm our rarified convictions and disapprove of mass murder of weaker individuals. Unfortunately, Darwin and Bentham are behind most of medical ethical reasoning. It is simply not possible to consistently affirm an empiricist, evolutionary perspective and also affirm the existence of evil as anything more than an opinion.

It seems to me then, to effectively function in a medical environment without becoming jaded or cynical, one must have a strong perception of "what people are for" underlying every action. And though I have assumed that my Christianity undergirded my reasoning, it seems I have been allowing some degree of Darwinism as well. This is worked into our training surreptitiously, and probably not intentionally in most cases. Since doctors play god, they become used to making value judgments about life and death which may not properly be the sphere of their control.

The problem is that, in the big picture, we need Bentham in medicine. There are a finite amount of medical resources, and those resources must be rationed. The question of how best to do that occupies numerous graduate theses and pet theories around the world. And I'm not sure what the answer is. Some of my more detail-oriented professors have stated that medical policy is not the purview of the physician, and we instead ought to solely be advocates for our patients, working to the get the most effective treatment for them at all times. Others insist we need to be mindful of the costs of the procedures we order, and the lives we expend effort in saving, because of the need for rationing. While I do not want to address the macro-scale subject of rationing now, the consideration of life and advocacy properly belongs here.

My conviction is that yes, Prof. Young is right. Humans are created, at least partly, for friendship and hospitality, not for some naturally selected drive to reproduce and leave as many beautiful, strong, autonomous descendants behind as possible. But if we approach medicine from that latter perspective, we will be unable to maintain hope in the face of despair. After all, if your life and work are merely prolonging the inevitable for the sake of the unworthy, it would be impossible to fend off despondency. If Prof. Young's perspective is true, then every action within that life and work serves the purpose of your life and work, making every moment and gesture meaningful, and every life precious. I don't think this perspective is possible to maintain outside of faith. At the same time, advocacy for a patient does not, and cannot always mean working to extend the quantity of their life. A balanced perspective, and a thorough understanding of what makes life meaningful must root all medical decisions. And that understanding is impossible to achieve, in cases where the person's capabilities with life are different from your own, without a more inclusive perspective than Darwin gives us. More than simply inclusive, we need a perspective which recognizes the essentially spiritual nature of mankind, a nature which makes him above the animals, more than simple biology, and worth preserving despite disabilities.

It is done

I'm finished with the USMLE step 2 CS. If I didn't pass, I'll be very disappointed. 12 cases, all very, very simple problems, followed by a quick note on each one. Probably the funniest thing that happened on the trip was the streetside panhandler who told me I "look like Clark Gable and Clark Kent all rolled into one."

And yet, I'm still single.

C'est la vie. Actually, I would have given him the dollar he asked for because of that line, but I had no cash. Felt a bit bad about that.

After the test, some of the local testees took a few of the travellers out for drinks. I'm struck more and more by the fact that physicians and physicians to be tend to hang out together a lot, even when they don't have to. At the last few parties I've been to, all the med students cluster together. At this test, we all naturally went out together and had a great time. My theory is that, despite all the complaining we do about the hell that is medical training, it acts as a kind of standardized fraternity hazing ritual, albeit one with a grander point than being considered part of Gamma Delta Beta, or whatever. This is also borne out by the point that the socializing tends to be congregation between training levels. Interns and fourth years have a large gap between them, and the fourth years look down, almost condescendingly, on the first years. Probably most professions are somewhat similar, though I doubt if many have the institutionalized beatings to pass from one rung of the ladder to the next.

But today, the sun is shining, the air is crisp, and I find it very difficult to be down about any of this. And I just found this quote, which shows so well what I ought to be aiming for, beyond this "place of wrath and tears."

There are men and classes of men that stand above the common herd: the soldier, the sailor and the shepherd not unfrequently; the artist rarely; rarelier still, the clergyman; the physician almost as a rule. He is the flower (such as it is) of our civilisation; and when that stage of man is done with, and only remembered to be marvelled at in history, be will be thought to have shared as little as any in the defects of the period, and most notably exhibited the virtues of the race. Generosity he has, such as is possible to those who practise an art, never to those who drive a trade; discretion, tested by a hundred secrets; tact, iried in a thousand embarrassments; and what are more important, Heraclean cheerfulness and courage. So it is that be brings air and cheer into the sickroom, and often enough, though not so often as he wishes, brings healing.
-Robert Louis Stevenson

So here's hoping all that pain guides the development of Hereclean cheerfulness and courage. Right now, I'm going to enjoy the day.

USMLE Step 2 CS

I'm going to take the last major test of my fourth year, and of my medical school career. After this, there are no examinations worth troubling about between me and graduation. (I have some intra-departmental exams remaining, but as they are written by amateurs, they are not tough, at least to someone like me, who has pretty much one practical skill: taking standardized exams)

This exam has become a graduation requirement only in the past few years. It was originally designed for foreign medical graduates, to ensure they had the requisite command of English to embark upon a residency here in the States. I guess even British and Canadian graduates had to take it, which is actually funny. Anyway, the exam is the same now as it was then, and consists of eleven (I think) simulated clinic encounters, with actors of varying degrees of capacity playing the patient. The student goes in, asks some questions, does a basic exam, and then comes out of the room and writes up a short note.

Since the exam was designed to see if you speak English and can understand English clinical conversation, it isn't tough. 96% of American medical school graduates pass, and about 80% of foreign graduates pass. I'm not worried. (I'm sure Medstudentitis and Angry Medic won't have any problems either, should they need to write this exam) Unfortunately, it is both expensive and inconvenient to get to, as it is offered in only five places in the country: Houston, Chicago, Philadelphia, Atlanta, and Los Angeles. So I get to ride Amtrak for the first time in my life to the closest of those cities and get a hotel so I can wake up early tomorrow and take this thing. So I guess the exercise for today will be comparing the American and British rail systems. I think I know who's going to come out on top.

One year later

So my blog is now one year old. I'm pleasantly surprised that it has been so much fun, and that I've been relatively consistent with it. 204 posts according to blogger, but there are a few unpublished drafts, mostly fragments that were worked into other posts, lying about and figuring into that count. Still, that averages out to a post every other day or so.

Thanks to all you regular readers. I started this thing partly to connect with people, and partly, way back then, on psychiatry, I felt I needed some kind of outlet to maintain sanity. I did not expect to have regular visitors from five continents just a few months later. Knowing my thoughts are read, my experiences shared, and my stories enjoyed by others motivates the effort. The title of this blog comes, as some of you have guessed, from a poem with a rather bleak view of human contact, but I'm glad the picture isn't as bad as all that. Not quite anyway.

So thanks, keep dropping by and I'll try to make the next year at least interesting as the first.

Year after year
The leaf and the shoot;
The babe and the nestling,
The worm at the root;
The bride at the altar,
The corpse on the bier—
The Earth and its story,
Year after year.

Another Intersession

My school has decided that the best way to standardize the education of its students, who rotate through different hospitals and *gasp* might learn different things during those rotations, is to bring the whole class back together for more classroom experience before letting us have a winter break.

It has been, for all my complaining, an illuminating experience. I sat at lunch today with six of my most successful classmates, the kind of people who already know where they are matching, because the residency director took one look at their scores, saw them on the wards, and accepted them on the spot. Among this group of luminaries, I posed the question: looking back at all this, would you come to medical school again? Not a single person said yes.

The afternoon was a series of three classes on "Shared Decision Making" which is a fancy way of saying "be nice, and don't pretend you're a god." I figure if you haven't figured that out, you're going into surgery, and if you have, you're not going to learn anything from it. The last thing I need is to hear some know-it-all tell a moving story and then follow it up with a threat to "sue a doctor I doesn't[sic] like." I felt all the compassion they were trying to bolster draining out of me as she droned on with her poor grammar and utter inability to face the fact that her medical problems were largely due to choices she had made, and that the projection wasn't becoming.

That's not very compassionate, I know. Chameleon-like, I can take such attitudes from my surroundings. And when I think back to first year, contrasting the classes then with the one today, I'm struck with the memory of people actually smiling then. People excited to become doctors. Now it seems we're just exhausted and angry. Sam Shem in The House of God says something about being able to tell, just by looking at them, the difference between a student just starting their third year and one just starting their fourth, because the fourth year is the one with the cynicism about the entire enterprise. I don't think the cynicism really abates until after residency, and sometimes, not even then. But I can definitely feel the pull towards it I was warned against while starting med school. People say "don't let them change you," but like Vader said: "you don't understand the power of the Dark Side of the Force."

Quotes

This is priceless:

"The medical student is likely to be the one son of the family too weak to labor on the farm, too indolent to do any exercise, too stupid for the bar and too immoral for the pulpit."
- Johns Hopkins University President Daniel Coit Gilman

And then, to confirm, in more concise language, the essence of my last post, we have the British Journal of Medical Psychology, saying the desire to become a physician goes from "helping the needy" to "needing the helpless." Later, in the same article:

Knowing that one is a physician allows people with a very shaky self-esteem to find a niche...it becomes a crutch to their self-esteem....Being needed by their patients may reinforce a sense of grandiosity, but it is [an extremely fragile mechanism,] a process which has to be endlessly repeated, and being so dependent on one's patients to maintain a sense of self may generate feelings of anger and resentment towards them.*

And I am six and twenty, and oh tis true, tis true. (apologies to Housman)

*Johnson, WDK British Journal of Medical Psychology 64(1991):317-329.

Reevaluation

It is isn't difficult to find the pain in life. It may even be easier in the world of blogging, since I think there's a remarkable tendency in people to be more open about the tragedy they experience in an online forum than in person. So today I wasn't particularly surprised when, following some links from another person's blog, I randomly found a blog that deals almost entirely with the pain the writer has experienced. What makes this even remotely relevant is the fact that her theme is infertility and she writes extensively about her relationship with physicians and midwives.

Obviously, if you've read any of my posts, I'm not going into OB/Gyn, but I was reminded in reading her words of two things. One, that medicine, to me, to the practicioner, is a job, albeit a very fulfilling one, but one that can easily be seen as just a job. It is entirely possible, and probably common, to drift into autopilot and see patients as nothing more than a set of problems to resolve.

Two, that this withdrawal into oneself, leads to very poor writing. People are interesting as people, and interesting to write about only as people. Unfortunately, the best writing comes from difficult circumstances. There is a reason stories end with "and they lived happily ever after": it's a great close if you like that kind of story, but it's a rotten opener. We want tension, dragon-slaying and damsel-rescuing first.

So this explains to me a few things. The reason I've had difficulty writing anything interesting (to me anyway) lately is that I've fallen into that tired, withdrawn state that regards patients as problems, for despite the fact that it sounds cliche (and really is, within medical writing) it is, oddly, true. And that to write anything interesting I need to be assisting people who are dealing with stress. When I'm writing, I'm generally happy, or at least fulfilled. So, where I am most happy is with patient contact in stressful situations. It's also where I find it easiest to see patients as people and be the kind of doctor I would want to have.

That's a lot of threads of reasoning left untied. If I may be indulged a general resolution paragraph, I'm trying to say that I've been writing poorly lately, due to the fact that I've not been enjoying my job, and I've been acting as the kind of doctor people love to hate, the kind that sees only the problem and not the person. It took reading a patient's perspective to return me to this healthier view of my profession. It is not my desire to be this kind of physician, and I realize to avoid being that type of physician, I need to deal with people who are sick, and I need to deal with them in a longer-term setting than consult cardiology.

This may also mean that cardiology isn't for me. Cardiology attracts a set of people who act more like surgeons towards their patients than any other medical subspecialty. They are great, and manage to maintain their humanity and compassion in that environment, but since I'm more the handholding type, that may not be my niche. We'll have to see.

Divertimento

So, what do medical students enjoying a holiday do, besides sleep in? Make coffee to stave off withdrawal headaches, and then watch silly videos online, that's what. Check this out:

Music for one apartment and six drummers
Uploaded by naly

Handholding, or why I love internal medicine

Shortly before ending my cardiology rotation, I saw a patient in consult whose diagnosis I figured out as soon as she started talking.

This woman, Mrs. Hickory, suffers from fibromyalgia, which disease is quite possibly the source of more frustration in physicians than almost any other. It is a disease of unknown cause which causes debilitating chronic pain, without any anatomical basis. The disease is often referred to, in a slightly deprecating fashion, as "supratentorial," which is the medical professional way of saying "it's all in your head," referring to the tentorium, a membrane which roughly divides higher from lower brain function. (Feel free to clarify, S. Lee) Anyway, I've seen enough of these patients to be able to pick them out across the room. Generally female, 30s to 50s, and usually with a constant facial expression of someone who has been wronged. They usually talk with a bit of a whine in their voices as well.

So you have a combination of a mysterious disease, a large proportion of physicians who don't believe it is real, coupled with a personality which is not, to put it mildly, endearing. You can see why people avoid rheumatology.

But I actually like fibromyalgia patients. They do whine sometimes, and some of them have an almost amusing inability to talk about anything but their pain for more than 30 seconds or so, but I think part of why they have the expression and manner they do is the fact that no one believes them. It's a maladaptive response to the fact that their disease pushes them to the sidelines of life.

What is it I see in them? They are, for one, the absolute best test and best encouragement of bedside manner I have yet to experience. A patient who is in pain no matter what you do to examine them, wincing even at the stethoscope being placed on their chest, is a challenge, surely. But I feel that if I can connect with and gain the trust of someone hard wired to distrust and feel threatened, I can gain anyone's trust, right?

There are a couple of key points in interacting with these patients that are not intuitive, but they transfer well to other patients too. First, I have to remember that the pain they feel is real, even if I can't discover the source. It's like Morpheus in the Matrix: "[What is real is] electrical signals interpreted by your brain." That's horrible metaphysics, and I'm not an empiricist, but it is where you need to start with these patients. I suppose, though, a deeper point could be made that the essence of understanding is the recognizance of a person outside yourself, so that the interaction, from the first, proves a reality outside oneself. But fibromyalgia sufferers are rarely so philosophical.

To return, accepting the patient's perspective on events is necessary to start. Secondly, I have to let them talk. This can be challenging, but more than a lot of other patients, these need to be heard. That's what I'm there for, so I let them talk. Third, when I start making plans, I have to engage the patient and make sure they understand what we are doing fully. Making sure they have a voice, that they do not feel as marginalized as their disease can make them, is vital here. And fourth, sometimes a little handholding goes a long way.

I'm not a real big physical contact kind of person. I don't generally hug friends, etc. Probably because I'm male, but the point is, medicine has taught me that you have to have physical contact. It's part of the interaction. Hospitals are rather antiseptic, and it is possible to do a large part of the typical exam and workday without actually touching a patient. Even a stethoscope allows some distance, and was actually designed for that purpose. (True story: The stethoscope was invented to allow physicians to hear heart sounds without placing their ear directly to the patient's chest, as it offered some young ladies offense. Not to mention the expense saved on ear-cleanings. I made that last part up) So when a physician, or physician to be (176 days!) like me actually touches a patient, holds their hand while speaking with them, places a hand on their shoulder while using the stethoscope, it makes a difference. At least, that's what my patients have told me.

All of these points can profitably be applied to any patient, but it is toughest with patients who force me to be intentional about all this. Anyone can be nice to someone sweet. It takes real grace (or long practice) to be nice to someone who is not sweet at all.

So from fibromyalgia patients like Mrs. Hickory, I am taught patience and compassion. More important, I'm taught how to be both patient and compassionate professionally. And as I sat on Mrs. Hickory's bedside, holding her hand as she cried out her story of pain and misunderstanding, I remembered why I came to medical school.

But leave me a little love,
A voice to speak to me in the day end,
A hand to touch me in the dark room
Breaking the long loneliness.

Jacta Alea Est!

I've finished my cardiology rotation, and now all that is left to wrap up my long odyssey is to drive home to the metropolis. I think I've accomplished my purpose of networking and impressing the requisite people here, and now I just have to await match day and enjoy the last bit of my fourth year.

I'm excited to see the results of the match actually. I'm fairly certain I'll get either my first or second choice, and of the two, I like different aspects of each. It will be fun to await a surprise with almost no downside.

It's all out of my hands now.

The Decemberists - The Crane Wife

Have you ever listened to an album that expressed, with almost every chord change, exactly your mood? I have recently listened to two albums which have done this for me, and one of them is this, the latest by the Decemberists. When I first tried to listen to this one a month or so ago, I wasn't real impressed, and I had bought another one along with it. So this was relegated to a drawer and I only pulled it out today while I was packing to leave my last away rotation and head back to what will only be home for a few more months.

I was blown away. The first track is still not a barnburner, but I should have left the CD playing. Track two is epic, rising from standard Decemberists ethereal guitars and drums to a sythesizer solo that probably makes Keith Emerson jealous, winding down to a beautiful guitar piece. That is followed by a duet with Laura Viers, and the hits keep coming. Great packing music, with energy and variation enough to keep this obsessive complusive medical student at least mostly engaged in his task.

And I was pleasantly surprised with the lyricism. Colin Meloy often has catchy lyrics, but often they are more than a little shocking. At least on Picaresque, but I should have expected it from an album with a song title Odalisque.

This one's going to be keeping me company on my long drive back to the metropolis. I have yet to make up my mind entirely about the lyrics, but there is nothing like a long car trip for close listening to an album.

Potpourri

Some random things that have made me laugh recently.

One of my residents is given to rather odd, often vulgar, but usually hilarious phrases. Some of his latest gems include:

"They" and "them" are spirits of darkness. When someone tells you "they" all do it, run the other way.

Don't give him heparin, ambulate the motherf@#%&r.

Giving this guy predisone is Kosher as Christmas.

Overheard in the waiting room, from a very obviously newly married couple:

"Kix? You put sugar on your Kix?! I thought I knew you!"

Shortened contacts, deadened feelings

I have struggled these past few weeks to write anything. Nothing comes, and certainly nothing poignant or meaningful. Not that I have not enjoyed myself, indeed, much of what I've been up to has been fascinating, but not in a sense it is easy to relate. As I said in an earlier post, I'm not sure I like not having much contact with my patient, seeing them for an hour, tops, before going to write a note and wash my hands of them, in essence.

And I regret it. One of my patients was in WWII, and is quite excited to relate the fact that he was in the Pacific campaign for 36 months. He fought his way from Australia towards Japan for three years, but even now, I don't have to try and make up a pseudonym for him, because I don't remember his name. He's the guy with a probable pulmonary embolism.

So I'm left reconsidering whether specialty medicine is for me. Specialists do have better hours, fewer headaches, and more interesting cases, not to mention more knowledge and more respect, but they also see only a narrow piece of their patients lives. At least on a consult service.

The good news is, I have two years to make up my mind about a specialty. And the better news is that in less than six months, I'll be Nathan, MD.

Worthwhile purusal

Joel has an interesting post here, discussing where to draw the line in deciding how strenuous an intervention should be made to preseve the life of a child born with disabilities. My most recent response, which I'm posting here for the double reason that I have little else to say at present and that I want to preserve it here as well, is as follows. I've disabled comments on this post, since Joel kicked off this discussion, I'd like to continue it there.

Drawing that line is complicated. I think, in general terms, that if the person in question (for except in some very, very extreme cases, I think all these children are persons) will be able to live with minimal to moderate assistance, or even if there is a question of them being able to live with minimal to moderate assistance, then all reasonable measures to sustain their lives should be taken. If, and only if, there is no question that the person involved will require exceptional measures to sustain their life for the entire duration thereof, I would have very little problem not taking those exceptional measures at the start. I do not think, with this Anglican declation (as far as I can tell) that the ability of the parents to care for the child should affect the decision. Isn't it the role of the Church, from Acts onwards, to assist those in such straits?

I think the right decsion was made in the Terry Schiavo case, for the record. The clip that got so much air time, of her apparently responding to her mother, was just that, a clip, not more than a few seconds long, taken from over 4 hours of video. In that amount of time, any random action could be taken as proof of ability to communicate. She had been in that same state for years. I think her husband's incription on her tombstone said it best: "departed this earth 1990, at peace 2005."

An overarching theme in medicine, reflected from our culture today, is the worship of life, specifically long life. There is, in medicine at least, some reaction against that lately, and like most things, it can be taken too far. But I think a healthy appraisal of the value of a life, and respect for its owner's wishes, where possible, is necessary. Some people want to be kept alive at all costs, others don't want anything done. When the person can't communicate, as in Schiavo or a child, a balance must be found. Detractors might say we don't have the right to "play god" but that's an overly simplistic view. In the hospital we're working against Genesis 3 as a way of life. Sometimes I think we need to realize that in the end, the curse is still in place.

Coffee, post 2

I love coffee. It pretty much keeps me alive, as I've said before. So today, in lieu of writing anything deeply moving or insightful, I'm going to post a comic strip I found hilarious, and perhaps a little close to home. Also, I want that backpack.

Competition

Why does the way of the wicked prosper? why are all they at ease who deal very treacherously?

I've recently lived exactly the kind of competition I find so distasteful and referred to in an earlier post. I'm working in the same department with a classmate of mine, and a week and a half ago, I saw a fantastically interesting case. Fantastically interesting, by the way, coming from a doctor or doctor-to-be generally means the patient is screwed. Fret not, this guy will live.

But his case isn't the point. The point is, this case is really rare, in that the condition itself is about 1 in 200 000 or so, and to have the right combination of enivronmental factors to bring out the manifestation we saw...suffice to say it's never been written up before and will undoubtably be published now in a major medical journal.

I saw this of course, and asked my fellow (the cardiologist I'm working with) if I could write the case up for publication. He said yes, and I started writing. Meanwhile, as we were only the consult team, we transferred the patient to the inpatient team. The inpatient team happens to contain my classmate, and as we made the transfer, I told him that I was writing the patient up. So, what did my classmate do? He talked to his fellow, and three or four staff cardiologists, and started writing his own article. And since the staff heard about it from him first, he gets the article.

I have only rarely been this displeased with another human being. He completely exemplifies the backstabbing, look out for number one attitude I despise in the ultra competitive medical student type. And though I very much doubt I'll have a say in his life in the future, right now, I'm fairly certain if I did, it wouldn't be a positive one.

Which is of course unhealthy and unchristian. And though I'm not going to actively work to undermine him, I don't think I'll have to. Surely karma will catch up with him. But even wanting him to fail is probably wrong. Big picture, this isn't going to matter a lot, and I should try to remain on good terms with him. But that's not a level of strength I have in and of myself.

Consult Cards

I'm doing consult cardiology right now, and overall, I love it. Cardiology, or "cards" as it is referred to occasionally, is an amazing specialty. If you liked physics, or math, because "it just made sense," you'd love cardiology. It is far and away the most scientific of the branches of medicine, in that it takes evidence based medicine very seriously. Every point has to be proved. For example, even knowing nothing about physiology, you'd probably guess that someone with "inducible arrhythmias and heart failure" is worse off than someone with "heart failure alone", right? Well, cardiologists felt compelled to prove that, in a trial called MADIT 1. That's the other quirk of this specialty, all the important studies seem to be named. MADIT, CONSENSUS, AFFIRM, ISIS... the list goes on for ever. There are over 2000 named trials.

But I am being sidetracked. The intricacies of cardiology are not my point here, interesting as they may be. What I wanted to say was the oddity I've noticed with consult medicine. As a specialist, you are consulted to see patients you don't need to follow closely. You are concerned with one problem, or at least, one organ system. And so the connection with the patient is not as strong as from the primary team. So I see dozens of patients, but have difficulty remembering names. I see a slice of who they are, but I'm being forced to consider only one organ system, and the others only as they relate to that system. It keeps the patient at arms length in a sense. I'm fairly sure I don't like that.

The good news is that no specialty is entirely consults, as far as I know. It is also possible to see clinic, and have your own patients, in all of the medicine subspecialties. So, while cards remains at the top of my list of favorites, sober judgement (and review of my grades) is causing me to keep my options open. We'll see.

As long as you both shall live

Behold another dream is even now turned into mist.

It is easy, I suppose, to look on tragedy and hope for ease. It is easy to see the pain I do, and while longing to and working to ease it, nevertheless not wish it upon oneself. My previous post grows out of this easy route. But, in the fresh light of a new day, having seen not only fresh instances of the general curse laid upon humanity, but also the recently captured images of my three month old niece, I amend my thoughts.

It is true that Mrs. Walmswood is in great pain, and that her life, such as it remains, will be, in Hobbes' (the human, not feline, philosopher) words "nasty, brutish and short". But it will not be solitary or poor, the other qualities that singularly gloomy man ascribed to human existence. And that I think is the key to understanding here.

Humanity, with rare exceptions, exists in its most complete form only in concert. Life is a communal activity, and is meant to be lived as such. And though in isolation we can avoid certain kinds of pain, there are others we cannot avoid, and in the balance, it is better to be in company.

Shared joy is double joy, shared sorrow is half sorrow

And seeing Mrs. Walmswood, I recognize that even in my prior thoughts, I touched on the reason her husband is still with her. Despite the irritating, monotonous quality her voice has, it is still possible to see the humanity in her, the humor, the wit, the soul. She told me a joke that I still chuckle at, hearing it again in my head.

None of us know the future, though it is easy, watching the parade of sickness while in the health of youth, to assume immortality for myself. And the decision Mr. Walmsood made not so many years ago could just as easily have turned out the other way, with him on the bed, and a bright, jovial Mrs. W by his ailing side. Life, it seems, is a bit of a lottery.

And since none of us know the future, and most all of us desire companionship, it seems we must be willing to "take the bitter with the sweet" and promise to remain "in sickness and in health," trusting that the other, also not knowing the future, is making the same committment. I guess there is more wisdom in those words than I suspected.

So, did you hear the one about the dyslexic devil worshipper? He pledged his soul to Santa.

Thank you Mrs. Walmswood. L'chayim, l'ahava.

...in sickness and in health...

Visiting a dying patient is nothing new to me. Seeing someone sick isn't either. Exposure to both over the past two years has slowly changed my perspective on life and love. I've been to more than a few weddings over the years, and at most of them the traditional vows are exchanged, almost a magic formula, the significance of which few, if any of those parties truly understand. I doubt many of those parties envision Mrs. Walmswood.

This woman is dying, but she has not been given a swift departure from the world. She is suffering from a very slowly progressive form of ALS, also known as Lou Gehrig's disease. And as her body's functions have been slowly taken from her, she has lost along the way the ability to inflect her voice, or speak at more than about 30 words per minute. Walking into her room for the first time, I was set on edge almost immediately. I tend to size up a person quickly, and my initial impression of this woman was that she was a bit mentally slow, and in general the typical obese diabetic with two or three psychiatric issues. As I got her history, I found that she has been suffering from her disease for over ten years.

What struck me was the fact that her husband was in the room, and he was smiling and upbeat. Actually, more striking even than his presence and attitude was the discovery that this woman had been a teacher in a nursing school, a very highly functioning individual. And as I tried to get past the irritation I felt waiting for her to finish sentences, I discovered that preserved within her was a wry sense of humor and a still-facile mind.

I guess what awed me was the fact that this man had made a commitment to this woman, and even as sickness has taken most of what, to an outsider, is attractive, he has stayed with her, and I imagine most days manages to see within the decaying mortal remnants that soul he married not so many years ago. But I must wonder if he ever regrets his choices.

In faith, I do not love thee with mine eyes,
For they in thee a thousand errors note;
But 'tis my heart that loves what they despise,
Who in despite of view is pleased to dote.

I don't doubt the ability of humans to make and keep promises. But the single guy in me questions the utility, marvels at the commitment, and ponders the components of those promises. Just as I wouldn't want to end up a patient on a medicine ward, I especially wouldn't want to have my wife (should I ever have one) end up a patient on one. It almost seems that it would be more worthwhile to live singly than live with that pain. I respect the strength I see in my patient's families, but I wonder if I even possess the ability to have that kind of commitment. Judging from success rate of marriage in this country, I think many of my fellow citizens suffer from the same weakness.

On me can Time no happier state bestow
Than to be left unconscious of the woe.
Ah then, lest you awaken me, speak low.

Nurses

I wrote, for the first time, an order which made a nurse angry with me. The good thing about the situation is that the order was necessary for patient care, but I still felt bad doing it. I even apologized to the guy, but hey, if a patient needs an enema, she needs an enema, right?

I'll admit though, with this guy, I felt less bad than I might have with another nurse. He was the reason I started a morphine PCA on my patient. She didn't really need a PCA, but she kept getting him as her nurse, and he would take two hours to get her the morphine shot I had written for. So I gave her the PCA, with some hesitation, and though her morphine use is about the same, her mood and outlook on life is miles better.

Most nurses are amazing. Even the ones I'm not flirting with. Seriously, though physicians (and budding physicians) are great at figuring out the long term plan for a host of patients, performing complicated procedures and interventions or surgery and guiding a patient towards recovery, none of that would take place without good nursing. But like most things done well, good nursing is difficult to notice unless you are looking for it. Bad nursing sticks out like that ghastly Millenium Wheel on the Thames.

So good nurses, (which includes all those who read this blog, I'm sure) thank you. It is people like you who keep us from going completely insane when your colleagues let my patient sit with a heart rate of 160 for two solid hours before calling me.

I don't want to end this on a negative note though. With this same patient, Mrs. Dalrymple I'll call her, I have dealt with three other nurses who were absolutely amazing. Nurses who are good enough not to demand a cosignature on my orders for Tylenol. Who have the patient's vital signs ready when they page me. Who know how to draw blood from a PICC line without causing a lab error by drawing TPN into the blood tube. I'm sure there are a thousand additional thankless things you do that I never see, without which my job would become infinitely harder. You guys rule.

Odd rewards

I guess I'm doing a pretty good job being friendly with my patients. One of them, whom we recently discharged, was so pleased with my care that he and his wife offered me a free weekend at his rental property on the coast. He told me "anytime you want it, call us up, and we'll figure out a time that works. Bring beer, bring girls, bring whatever." "Um, ok, thanks" was my response. I don't know that it is ethical to take him up on his offer, but still, it's nice to know he approved of my work that much.

So weird.

In other news, my posting has slacked off lately because I have been sicker than many of my patients. Listerine, cough drops, and orange juice are all that's gotten me through the last three days. And I'm on call again tomorrow. Hooray!

The good news is, this is my last week. If I can survive, and still make a good impression through the end of Friday, I'm free, and the easy part of fourth year starts with cardiology clinic.

Mr. Montoya

I see the rainbow in the sky
The dew upon the grass;
I see them and I ask not why
They glimmer or they pass.

I met Mr. Montoya in the Emergency room. He was concerned about some indigestion he'd been having, and my diagnosis was an ulcer. He had some concerning factors in his history though, so we admitted him overnight for a EGD in the morning. He is a great patient, easy going, upbeat, nice to the medical student who presumes to act as liason between the real doctors and him, and with an interesting, bread and butter problem.

So I got him up to his room, checked in on him, and then went on about my business. I came and went a few more times, met his wife, his son, son-in-law, and two grandchildren. The next morning he went down for his scope, and in all likelihood, his life changed forever.

See the scope found ulcers, so I was right about that. What it also found was that the ulcers are likely cancerous. Gastric adenocarcinoma allows only about half of its victims another five years.

The tell us in med school that patients often know what is wrong with them, if you just ask. So when I gave the news to Mr. Montoya, I wasn't surprised that he wasn't surprised. He just asked me some intelligent questions about prognosis, prefacing his comments with "assuming the worst here doc..." I've told him I'm not a doctor, and he has repeatedly said "you're a doctor as far as I'm concerned." At the time, I didn't know much, as I hadn't done a lot of reading on this type of cancer. But now, having done my reading on the subject, I will talk to him tomorrow about the hard facts. This is not a conversation to look forward to.

He's been a wonderful patient. He asked me today to give him my home address so that he and his family could send a Christmas card to me. I'm praying he lives to send many of them.

But I understand why he's staring out the window at the horizon praying the rosary when I come by.

The autumn wind's
Icy morning breath
Is on the hill of Sanu.
I wish, to you about to cross,
I could lend my coat.

The moral of the story is...

...don't try to die in radiology.

One of the patients my team has needed a paracentesis this morning. This involves, basically, sticking a needle into someone's belly and pulling out excess fluid. Despite what you might think from the title of my post, this went quite well. I pumped about 2 liters of fluid out of Mr. Block, and he felt better immediately.

Then, we started ending the procedure. This involves pulling the needle out and putting a band-aid over the hole. Seriously. But we also packed gauze under the band-aid to absorb some fluid. So, thinking one band-aid was not enough, I asked the tech for another. But we were in the radiology department. And the tech wasn't able to find one.

Now I have heard that the two toughest things to find in a hospital are aspirin and band-aids, so I tried again.

"Have you any tape?"
[tech leaves
[tech enters
"No, we don't."

I was a bit surprised, but perhaps naively so. A procedure clinic without dressing tape? What is up with that?

Also, I came up with a few witticisms which are probably way funnier since I've spent the last thirty-four hours without sleep:

A hospital is a lot like a casino, because in both a)time has no meaning, and b)the only people doing well are the ones working there.

Also, you might be a med student if...you've ever needed to check your cell phone to tell what day it is. Apparently it's Tuesday.

Interview

So my interviews for this residency site are complete. As usual, I find it difficult to judge how well or poorly I did. Fortunately, I didn't get the worst question ever: "Tell me what you see as your greatest weakness?" I did, however, get a difficult question which, though better from the point of view of the interviewer, can be awkward and off-putting: "Tell me about yourself."

What do you say when pressed with such a question? I've often thought how I would try to define myself in a few words or phrases, but I'm not concise enough to do so. I don't know that anyone really could. And when it's asked as the first question in an interview, I'm not nearly warmed up to the interviewer enough to give an answer I'm happy with. What is it that defines a person? Where you're from? What you do? How you spend your spare time? Do you answer honestly, even if that means "I've been so tired lately my spare time when I'm not asleep has been spent sitting on the bed in the hotel room thinking I should just turn off the TV and go to sleep?"

For I have known them all already, known them all:
Have known the evenings, mornings, afternoons,
I have measured out my life with coffee spoons;

Probably I'm just frustrated. I was recently discussing my situation with a classmate, also in the midst of applications to residency, and we were both remarking upon how it has taken a lot of effort and drive to get where we are in life. But the end is not in sight, and if anything, it is harder work to move ahead now than it ever was before.

Which is why I don't know that I'd recommend a medical career to anyone asking me for advice. Fewer than ten percent of applicants to medical school are accepted, nation-wide. But that's not the end of the bottle-neck. The competition you see and participate in before medical school only gets worse. Before medical school, you can pretend that it's only a facade, it's not really you, the competition is just a phase.

But it's not. You become that person, and if you don't, you fail. Two of my classmates actually dropped out of school, because they saw that. One is now a weatherman, and the other drives an armored truck. Mad props to them both. (Sorry, dated reference)

So, who am I? I'm a guy who doesn't mind working hard, but is tired of making life about a competition, who wants to help people, but doesn't want his life completely subsumed in others. Maybe that means I won't be a great doctor. But if being a great doctor is defined by the number of textbooks I've authored, I don't think I want that. At least, I didn't back when I was sane. I don't know.

Dang, that's what I should have said.

Worth checking out

Regina Spektor
I just got this album. I had to. Two separate people recommended it to me within a week. I've not been disappointed. I'm tempted to write a review, but I'll just say I recommend clicking on the link above, listening to the track and then buying the album.

Because I'm too tired to write anything serious...

I think it should be illegal to ride an elevator down one floor if you are able to walk and aren't pushing a gurney or cart.

Especially in a hospital. Come on people. Take the stairs and work off that plastic packaged 1000 calorie, 22 gram of fat cinnamon roll you're munching.

This is odd

Apparently, if you are making an offering to a heathen wight, you should use whole milk, never 2% or skim. Seriously. Scroll down to section V, "Calling and Speaking with the Wights."

I guess Thor doesn't like Jenny Craig.

Back to work...

First page...and second.

I've gotten paged before. But never before have I been expected to act as the intern and decide what to do about a patient at 2am. I still remember the conversation, which is good. I had just laid down to sleep (how typical, I'm thinking) when I got the page, and calling the phone number, I rang a nurse who told me that "Mrs. Wright has a diastolic blood pressure of 109, and I rechecked it manually and got 101, and though she's asymptomatic, I'm worried about her."

At this point, I was probably sweating. All of a sudden, I didn't know anything. What the heck is blood pressure anyway? Luckily, I managed to keep my head a little, and asked the question "she's asymptomatic?" despite the fact that the nurse had just answered it. Then I said "I'll come see her."

This has a double purpose. One, it's what we're trained to do, as it's the right thing to do, since you can't make a decision about someone without seeing them. At my level anyway. Two, it allows you the time it takes to walk to the patient's room to think about what you might do.

In my case, it didn't matter. I still had no clue when I reached the bedside, so I gathered some information and paged my resident. Of course, while talking to him on the phone, I felt like a complete idiot, as he rattled off questions I hadn't asked, including basic ones like "what is the ranger her blood pressure has been running?" Mortified, I set the phone down and ran over to grab the patient's chart, and we figured out what to do.

I returned to bed about ten minutes later very angry with myself. I had completely failed to add anything substantive, and had needed to page my resident over a really simple problem.

Half an hour later, I got a chance to redeem myself. I was paged again, on another patient. This time the question was simpler, but I hurried downstairs and clarified medication orders, wrote telemetry orders, and had, in general, a minor success. Very minor.

An hour later, I seriously redeemed myself. I got another page on Mrs. Wright, and this time, I asked the nurse the questions my resident had asked me, then went and saw the patient, and then made a treatment decision on my own. I decided not to page the resident, as I was now comfortable with handling the problem.

It struck me, as I decided it was now too late to go back to bed and I started my morning rounds, that this is probably how most learning takes place as a resident. Seeing an example, and next time, not needing to call.

The end of the story is that my resident was impressed at rounds this morning. I hadn't realized, but I admitted more patients last night than either of the real interns, and I only needed to page the resident once. I feel almost like a doctor.

Sub-Intern

The rotation I'm doing now is an official "subinternship," which means I am to act as much like a real doctor as possible, clearing all my decisions with my resident, but writing all the orders, all the notes, and in general "carrying" the patient. I get paged by the nurses with questions and requests for clarification of orders. I talk to the subspecialists for consults.

I love it, I think. In part, what I do is just glorified secretarial work. I file papers, review papers, summarize papers. The fact that three years of med school is necessary to file these papers doesn't really seem to matter. It is here, in the headaches of paperwork, that the dehumanization begins. Patients become numbers, become diagnoses, because we see a stack of thirty pages about them more than we see them in person. In "The House Of God" the Fat Man comments that it is never necessary to actually see a patient, and in modern medicine, that's probably true. There are so many notes about the patient that it is possible to write about them, make decisions about them, and even cure them, without setting foot in their room.

That's the part I don't like.

So today, getting bogged down in phone calls and the elaborate system of documentation necessary to comply with the often whimsical requirements of HIPAA and JCAHO, I took a break and actually went to see my patient.

She's a wonderful woman, unfortunately without a bright future ahead of her. But she's come to terms with her poor prognosis and speaks quite frankly about her decisions. She doesn't want resuscitation, doesn't want surgery, and (a bit frustrating to the medical team) she doesn't even want a surgical biopsy of what we think is cancer, because she doesn't want to go through the treatment. She realizes she's old(er) and probably dying. Unlike Mr. Ashman, she doesn't have a family to support her, and after seeing her husband die of cancer a few years ago, doesn't want to go through treatment without support. All in all, a wise decision, if not an uplifting one. But we still managed to chat amicably for a half hour or so. She's from England originally, so (working from past experience) I got her talking about tea. Brits love talking tea, and she's no exception. It is a bittersweet conversation, since she has a nasogastric tube and can't drink tea right now. She may never again. For reasons much more aesthetic than mine her one wish now is to be able to drink coffee once more, "because though I do like tea, I fancy a spot of coffee now and then." It's maybe a bit odd that such a phrase can bring tears to my eyes listening, and now again while writing.

So then I went back to my papers, back to the headaches, back to the phone and pager. But now I'm not just trying to get my work done. I'm trying to help an old lady return to drinking tea, with a spot of coffee now and then.

Extreme, but he has a point

The New York Crank: Necessary and urgent, but political poison: Why the United States needs to restore the draft

One of the great things about fourth year is being able to read and write non-medical stuff. In the former of those categories fell this blog, whose author has an excellent point. One I can't agree to without caveat, but something worth considering.

I love this place

Another day, another hospital. I'm now in my rotation at my number one choice for residency, and I am reminded regularly of why. Everyone is happy here. The patients are similar, the workload is, if anything, greater, but the people are uniformly happier to be here. I don't really have a great explanation for the difference. I just really like it here.

Saints of all Sizes

I'm thinking about Mr. Ashman. More particularly, I've been thinking about his wife. We've admitted him for a very severe pneumonia, but the reason he stands out is more serious. See Mr. Ashman suffers from ALS, a debilitating disease which will slowly remove every muscular function of his body, leaving only his ability to think and be aware of his surroundings. This is oddly helpful if you are Steven Hawking, and your job involves sitting and thinking. But Mr. Ashman is just a regular guy, who found out 5 years ago that his tremors and weakness were a sign that very soon, he would be utterly helpless.

He was 35.

Now he is unable to breathe on his own, as the disease has affected his diaphragm, he is unable to walk, move his arms, or speak. Aside from turning his head, he can only move his right index finger.

But his wife is the reason he is still alive. She takes care of his ventilator, attends to his needs, and when necessary translates the cryptic gasping sounds that remain of his voice. On its own, this would be touching. What is almost staggering is the fact that she is one of the most upbeat people I've ever met. It is cheering to everyone in the ICU to see her.

Cheering and instructive. Through my past few months, I have so rarely seen happy stories that I'm tempted to slide into depression. But here is someone who lives the saddest story of all and is coping magnificently. My hope is that anyone so unfortunate to be in Mr. Ashman's condition could have someone like Mrs. Ashman around. For everyone else, there's just me.

The paths of pain are thine. Go forth
With patience, trust, and hope;
The sufferings of a sin-sick earth
Shall give thee ample scope.

Crazy

So Mr. Brook, who didn't need to be admitted, is gone, but not before bringing some much needed hilarity to the ward. In the first place, he is a raging alcoholic, telling me he has cut down to a six pack of beer a night. Pretty impressive, so we were watching closely to ensure he didn't enter withdrawal while under our care. Amazingly, he didn't. In fact, we didn't notice any signs of withdrawal at all, which had us wondering.

Until one of the nurses surprised him by walking in unannounced and discovering he had actually smuggled alcohol up to the floor. How he managed to hide this for four days straight is beyond me. I never even saw his door closed, and I was on call for 36 hours of that time.

Overall, a wonderful patient, funny and charming despite his intractable health issues. He had a snappy answer to every question. "Do you snore?" met with "none of the ladies complain." "How are you doing?" met with "I want to get out. I bet the ladies at the senior center already miss me."

Maybe oddly lecherous old men are just amusing. I'd be tempted to say it's only because I'm a guy that I found him so, but my resident, a woman, was cracking up at him too.

Camera Obscura - Let's Get Out of This Country

When a guy wearing a plastic sword-shaped cocktail skewer as an earring, with the fingernails on one hand painted black and the those on the other natural colored, tells you an album is worth a listen, it's worth the try, right?

In my book anyway. What's more interesting is that this guy and NPR agree.

So do I. The album is definitely worth a listen.

When I first listen to a band I know nothing about, I tend to make comparisons to other bands. So when I first popped this one, I thought "the Shins, but with a female vocalist." On the next track however, I was thinking "the Beach Boys?" And I went through the Strokes, Over the Rhine...nothing fit. Because these guys are unique. Sure, they have elements of all those bands, but it's always a "not quite...ooooh, I like what they did there, how unexpected" kind of reaction. The summary I keep coming back to is that of 50's pop instruments (organ, guitar with that era of amplification, etc.) with a modern melody and edge. By the way, it probably shows that I'm not a real music critic in that I have no idea what "that era of amplification" means, hardware-wise. Gibson? Les Paul? No idea. Anyone who does, please, let me know.

Though I wouldn't describe the songs as "anthemic," they are largely melody driven, something I like because it is fun to listen to. The lyrics are fitting, but not stand out. But everyone can identify with songs about heartbreak and partings. "The first track here states over and over "Hey Lloyd, I'm ready to be heartbroken" which is a response to a pop song from twenty years ago asking (go figure) "are you ready to be heartbroken?" Tracy's voice is perfect here, quavering but still earnest. Though I can't pick favorites here, a counterpoint to that track is "Country Miles" with the refrain "I won't be seeing you for a long while/but I hope it's not as long as these country miles" where the earnestness in Tracyann's voice lends a poignant air to the song. No real downside to the album, in that I don't notice myself skipping tracks as I listen.

A fun listen, one I'll be keeping around for a while. Recommended.

Residency application

Mine is complete, but I wish it were more stellar. I'd like a medical version of this if you will.

ER docs

I know there are good ER docs. There must be. Unfortunately, it has not been my good fortune to run into many. What got me thinking about this most recently was an encounter from my last night on call.

So my team is down in the ER, seeing a patient. We want the guy to come in, because he has had chest pain which is a bit concerning, but the enzyme levels we look at to detect a heart attack are not demonstrating any damage. So we lay out the story exactly like it is, telling him he needs a stress test, but he'll have to wait until Monday to get it. So he'll be camped out in the hospital over the weekend.

Mr. Brooks (the patient) decides he'd rather spend the weekend at home. Not smart, but it is his right, and we told him about the risk for death, etc., if he checked out.

Enter Dr. Oaks.

He's the ER doc who had been seeing Mr. Brooks, and upon hearing that the patient was going to leave, he swung into the room and said "oh, that's a bad idea sir, one of your cardiac enzymes is elevated, which means there is muscle damage to your heart, you know, that you're probably having a heart attack, so we'd like to watch you here."

This is both true and false, and the result means that Dr. Oaks is a)a liar or b)an idiot.

Let me explain. The enzyme we are talking about is called CK-MB, and it is part of the CK group of enzymes. We worry about it, because one of the places it is released from is the heart, and so if it is elevated, it can mean that a person is having a heart attack. However, we measure two more things as part of this test. One, we compare the total elevation of CK enzymes to the CK-MB elevation, and get a ratio. If the total level of enzymes is high, then the CK-MB part will be high only if you measure the number, but the percentage doesn't change. Put more vividly, if you have a set of marbles, with 10 red and 1 blue, and you combine it with another set of 10 red and 1 blue, now you have two blue marbles, but the ratio of blue to red is still 1/10. Mr. Brooks' CK ratio was normal, and the elevation in total CK (total marbles) is probably just a normal variation.

The other enzyme we measure is called troponin, and it is much more specific to the heart. It's almost 100% specific (but nothing in medicine is 100%) so if the troponin goes up, you can tell someone's probably having a heart attack. If it isn't up, they probably aren't. (Though that has more to do with sensitivity. Nevermind. If you wanted a lecture on EBM, you wouldn't be reading my blog)

So the options: Dr. Oaks didn't know enough about cardiac enzyme tests to be able to tell Mr. Brooks was not, in fact, positive, or he intentionally violated his medical ethics and lied to patient. It doesn't matter that he intended it for good.

My resident was, shall we say, vexed. She called out Dr. Oaks right there, and when he didn't respond favorably, she wrote up a report on the incident and filed it with the hospital.

We'll see if that helps his practice (or his ethics), but it probably won't improve relations between the medicine and ER teams.

C'est la vie.

Full Code

Mr. Grainger is going to die.

Not now, but the time for him is more imminently on the horizon that it is for me or you. He has cancer throughout his body, spreading into his brain. And as with any seriously ill patient, when we brought him into the hospital, we talked with his family about his "code status."

Code status refers to how aggressive the patient wants his caretakers to be in resuscitation. "Full Code" means that if his heart stops, we'll do CPR, and defibrillation as necessary, if his breathing stops we'll put a tube down his throat, etc. A "full code" on a patient is a violent occasion. CPR, if done properly, can break ribs, especially 80 year-old osteoporotic ones. A 30 year old might survive a code. An 80 year old almost certainly won't.

Which is what we tried to convey to Mr Grainger's family. But they were incensed that we would even ask about this and insisted he be "Full Code." So that was entered into the chart, though we didn't agree with the decision.

So this morning, my attending gave us a long talk about the ethics involved, insisting that in a patient like this, where a code has zero apparent chance of success, it is within our power as physicians to simply refuse to perform the code. His exact words were "if they want to sue, let them. There is no way a court can hold you liable for not performing a procedure that is against your medical judgment."

Leaving aside for the moment the fact that he turned, without thinking, an ethical debate into a legal one, the point is that we are to do the best for our patients, and sometimes that means doing nothing. I think I'm on board with that.

What bothered me about the way he defended it was by turning the discussion into a legal one. I'm concerned that so many derive their morality, at least in ambiguous situations, from the law. The reverse should be true, no?

...

I've also noticed, throughout my time at this hospital, that my concern for my patients has been somewhat lower than previously. My team, and indeed, most of the residents at this place seem to hate their jobs, hate the program, and hate their patients. I know that's not true completely, but the contrast with other hospitals, including my Number One Choice, is stark. I'll be ranking this one pretty far down my list when it comes to the match.

What this means for my blog is that I've realized my tiredness more, I've had a harder time finding touching stories and fun patients to write about, though I've been reluctant to join in the cynicism of my team. So I'm going to try to swim against this tide of negativism.

Hem - Rabbit Songs

This isn't a new album. It isn't even the first time I've listened to the band. But I hadn't paid too close attention to them until I realized that this ad uses Hem's song "Half Acre." I thought the ad was rather touching, and it stands out from the crowd in that it doesn't appeal to prurient interests to sell you something. For that reason, I don't know if it will be effective, but that isn't really the point here.

The point is, I bought the album this song comes from today because of this reminder. And I've had it on repeat ever since. From the opening bars of the lullaby "Lord, Blow the Moon Out Please" through the beautiful "Half Acre" to the closing notes of "Horsey," I was entranced. Very few albums will hold my attention so well that I'm unable to do anything but listen as they play the first time. This is one of them. I don't pretend to understand all of the songs, but it's hard not to connect with lines like "Think of every town you've lived in/Every room you lay your head/And what is it that you remember?" when you're sitting in a hotel room far from home. And if you're given to pensive reflection, as most of the posts here demonstrate I am, it's hard not to agree with lines like "So we carry every sadness with us/Every hour our hearts were broken." And for those interested in the meanings of the songs, this website is a bunch of quotes from the band explaining them.

But the words are far from the only high point of this album. The music is well crafted, and well executed. Between the filigreed mandolin, piano and clarinet of "Half Acre" and the bluegrass-ish "Cuckoo" is wide variety of styles, bound together by the ethereal voice of Sally Ellyson.

The band tried with this album to write something quintessentially American. They've succeeded admirably. Highly recommended.

Patients that make you say grrr

Mrs. Starbuck
Mrs. Starbuck has made a series of phenomally poor choices in her life. She has decided to smoke, two packs a day, for the past 20 years. The second poor choice she has made is deciding, after being diagnosed with asthma, to continue smoking. Her husband, perhaps considering "till death do us part" as incentive to hasten that event, has continued smoking as well.

So it wasn't exactly surprising to get that history from the pale woman sitting in the ER on continuous albuterol nebs, with an oxygen saturation of about 88%. For the non-medical reader, albuterol (in a nebulized form, aka "nebs") is something we give patients to dilate their airways in asthma attacks. Usually, it is administered once every few hours, every two in pretty bad disease, but even every half hour if someone is about to die from airway closure. So continuous nebs means someone is really worried. In point of fact, continuous nebs aren't shown to be much more beneficial than 30 minutes apart, but the exasperation of internal medicine with ER docs will have to wait for another post.

Anyway, Mrs. Starbuck was speaking only 3 words at a time before taking big gasps of the nebs, so we admitted her to the ICU, where she is on a BIPAP machine, something between full out intubation and nasal cannula oxygen.

Why people smoke, I have no idea. Why people with asthma smoke is so far beyond me I get angry with their stupidity just thinking about it.

Mrs. Solson
Real, live, Munchausen's syndrome. This marks the second time I've seen something similar. This patient came in and requested a central line. I've only ever seen that in drug abusers. Sure enough, about ten minutes after she was brought up to the ward, she threatened to leave AMA if she wasn't given IV morphine.

I would probably have stayed strong on this one, and offered Tylenol instead, especially since she didn't complain of any pain at all in the ER. But my resident is nice (or just fed up) and wrote an order for morphine. She didn't completely cave in though, and wrote the order for 2mg q4 hours, which is about enough morphine to cover really bad hangnail pain.

I did enjoy one aspect of this admission though: making the phone call to psychiatry.

Life

The part of life we really live is small. For all the rest of existence is not life, but merely time.

So today was my day off this week, and I spent part of the morning watching ER. I don't actually have TV at home, so when I'm away, living out of a hotel room, the novelty gets the better of me sometimes. Anyway, so I'm watching ER, and the thought came to me that yes, the heart wrenching decisions you see on a show like that are made, every day, in a hospital. But what they don't show you is the fact that sometimes, you don't even notice they are being made. There is humor and tragedy all around, but like the rest of life, if you aren't paying attention, it will pass right by you.

I think the most important moments of our lives often occur without a second thought. We don't always see them coming, and we don't necessarily notice while they are happening. It is only afterward, looking back, that we notice, and either exult or regret. Families don't think about living wills until after their loved one is comatose, and then they argue in the ICU over what is to be done. Mothers think two children is enough, and then, five years later with a new husband, listen with tears in their eyes as they are told the tubal ligation reversal didn't work, and that is all the children of their own they'll ever have.

I used to think (and maybe still do, in my conceit) that working where I do throws life into harsh perspective. That it makes each decision about life or death, and therefore more meaningful. But I'm becoming convinced, oddly enough sitting on a cheap mattress in a hotel room watching a mass market drama, that this is just life, and the perspective is what makes it meaningful.

September 11

I wasn't going to write about this day here. I don't know still that I have anything unique to add, that anything about my experience of a clear autumn day five years ago is much different than what 250 million of my fellow Americans experienced.

But I've reconsidered. I do think it is important to remember September 11, 2001. On that day, civilization itself recieved a blow from the barbarians, and just as those who sacked Rome in 476 AD, these barbarians want nothing less than the destruction of our way of life. It is important we never forget, for if civilization is to stand against barbarism, we must remember what makes us different.

I had here written a lengthy description of what I did that day. That really doesn't matter though. What matters, as I wrote for my school paper the next week, is how we respond. Yes, preservation of civilization is necessary. And yes, to defend a flock of sheep, wolves must sometimes be killed. It is important that we do not allow that killing to make us killers, and that we remember why and what we defend.

Though I wrote a poem on that day, like most poems attempted by amateurs, it isn't any good, so I'm going to close instead with some lines by a real poet, who saw the world change nearly one hundred years ago, and similarly, he recognized theat things would never be the same. He could have written this yesterday.

Never before such innocence,
Never before or since,
As changed itself to past
Without a word - the men
Leaving the gardens tidy,
The thousands of marriages
Lasting a little while longer:
Never such innocence again.

From MCMXIV, by Philip Larkin


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Medical antagonism

Another of my residents told me a story I'm not sure I believe, which I was reminded of by writing my last post.

Some patients no one likes. But most of the time, the way you deal with this is by doing your job, taking care of the patient, and realizing that your reaction to the patient can tell you something about them too. It's called countertransferrence. Ok, maybe I should have been a psychiatrist. The point is, this unfortunately doesn't always happen.

So one of the residents in the program I'm checking out right now was at the local county hospital, and he was completely fed up with a patient. I don't know all the details, but I know that patients can be aggravating. This resident made a highly unprofessional decision though, and wrote an order for "Fleet's enema, q1hr, until AMA."

What this means is that the patient was to be subjected to an enema every hour until he signed out AMA. Completely uncalled for, but what is more sad is that when this story was told, almost everyone in the room laughed. Yes, it was a long day, and yes, even the best of doctors has probably had a similar thought cross his mind transiently, but to actually write the order is malpractice. To laugh at the story is is bit inhuman too. Isn't it?

I'll admit, I laughed.

Maybe I'm becoming more jaded than I thought.

AMA

Today, for the first time, one of my patients left against medical advice, or "AMA." It was tough, because I had really developed rapport with him and I could see his side of the reasoning. He's 40, but as I told my resident, "doesn't look a day over 65." He's been smoking two packs a day since before he can remember. He drinks a half case of beer a day. And he has cavitary lesions (massive, rotting holes) in his lungs that need to be treated. Finally though, his exasperation with "being poked" got to be too much, and he signed out.

Like I said, it's tough. Part of me really wanted him to stay and get the further tests we need to treat him effectively. But part of me was fed up with his behavior, and wasn't sad to see him go. It was, by our count, the third time he changed his mind about leaving AMA, and we were all as tired of the paperwork as he was.

But I had to force myself to step back and consider, not what would make me feel better in the short term, which would be to stop writing notes on someone who is so inconsiderate and self-centered, but what is best foor the patient. And so I tried my best to get him to stay. My resident pretty much surrendered to (understandable) jaded feelings and though she tried to convince him to stay, it wasn't done very emphatically. I could read between the lines. I sincerely hope I don't ever reach that point of disillusionment.

Now the hope is he'll actually survive to make it to follow-up appointments.

On Call...

I just finished my second work day here. My second work day here was 31 hours long. Believe it or not, I'm still upbeat. I realized a few things. One, MS-IV (medical student, fourth year) is almost as magic as MD when it comes to writing orders. Also, I still love internal medicine. My two patients are pretty typical of the range you see on the wards.

Mr. Wish has CHF, and as part of that disease, he is supposed to watch his salt intake, keeping it to an absolute minumum, I think off the top of my head, it's supposed to be less than 2 grams per day. A can of pop has about a fourth of that. So it takes some discipline.

Discipline he lacks.

Mr. Wish informed me that "yes, doc, I'm keeping a real low salt diet. I don't put salt on anything at all anymore."

I should state before going further than the reason he is in the hospital is because he gained about 15 pounds over the past three weeks, solely from the salt he "isn't eating."

So I asked him what he had for dinner, say, the night before he came to the hospital.

His answer was "we went out for Chinese." In case you were wondering, the average single dinner, without sides, at a Chinese resturant, has well over 2 grams of salt in it (not to mention upwards of 50 grams of fat)

He also firmly belives, despite taking diabetic medications including insulin, that he is only "pre-diabetic."

Some patient education is in order, I think.

The next patient...will have to wait for another post. It has been 31 hours since I've slept, and I'm going to enjoy this.

Back to the Fluorescent Tomb

I'm quite excited. On Tuesday I start back doing what I love to do: seeing patients in the hospital. It will also be a new city, and a hospital I've never worked in, so some sense of adventure as well.

It is one of two hospitals I'm considering for residency, so there will be an element of tension, but on the plus side, I know what I'm doing, and I'm pretty well prepared for it. Now if I could only find my stethoscope, I'd be done packing...

The interview with the program director is going to be the most stressful part of this. They always ask "do you have any questions" and I never have a good answer. What percentage of graduates go on to fellowship, what percent of graduates pass their boards on the first attempt...once those are answered, I've got nothing. Any brilliant ideas anyone?

Delicate conversations

One of the new experiences every medical student knows is that of having his friends and family members ask for medical advice. On a certain level, this is entirely understandable, we are, after all, studying medicine in order to relate our knowledge to others (probably wiser) who haven't given ten years of their life to its study.

But on another level, this is an intensely difficult situation. Medicine deals with the most intimate secrets of a person's physical existence, and, (not being a dualist) with their most intimate spiritual secrets as well. There is a certain level of secrecy which decorum demands we keep in our interpersonal interactions, and while it is jarring enough to see beyond that veil in a stranger, with friends and relations it can be staggering. The other side of this is that, as we get more used to knowing about people, and to reading the small details which betray so much about them, a comfort with that greater level of familiarity grows. Probably this explains the propensity of physicians and other health care workers towards crude humor.

But I am being sidetracked. I was reminded of this today, but only in passing. More important than any level of personal discomfort with medical knowledge is understanding the impact medicine has on others. Most people in medical school are young, and generally healthy. To practice medicine we have to have some level of health, and sometimes we forget how important that is. It is easy to forget how scary the unknown is.

Combining the two thoughts above, today I was asked by someone I know relatively well about a fairly involved medical issue. I've long gotten used to this sort of question, and I'm not far enough in my training to have tired of it. The second point about came to mind as I did some reading before getting back to my interlocutor. With any medical problem, from hang-nails to amputations, there is a range of severity in outcome. And this range is apparent in the medical literature. It is easy, when dealing with a person about whom you did not care one way or the other before they walked into your office, to rattle off percentages, and follow them with concern and cooperation in forging a treatment plan.

When you actually know and care for the person before the serious conversation, it puts a different perspective on things. You question how frank to be, how best to couch what you say, and what effect every single word will have on their perception of the problem.

Fortunately, the problem I was being asked about has an excellent prognosis. But even that phrase "excellent prognosis" can sound like medical evasion. And in explaining it, the necessity arises of discussing worst case scenarios along with best case ones. I suddenly understood, better than ever before, the paternalistic attitude of previous generations of physicians.

But the nervousness I experienced was instructive. For I realized that I should be that concerned with every patient. I think I am empathatic, to at least some degree, but I've never been so careful to relate pro and con, positive and negative. I very much wanted to convey exactly what I knew, without causing undue concern, but without hiding anything either.

This is why medicine is the art of science.

K. C. Groves - Can You Hear It

K. C. Groves is the one of the members of Uncle Earl, an all female bluegrass/old music band. Abigail Washburn, whose album I previously reviewed, is also a member of this group. I bought this CD at their concert, because out of all the very talented members, I was most impressed with Miss Groves. (As a side note, I now have a huge crush on her, so if you're reading this K.C., the contact info for the tall handsome guy at the back table is in my profile.)

Just kidding.

Anyway, live, Miss Groves sounds like Patsy Cline reincarnate. On her album she's a bit closer to Alison Krauss without the "I'm three years old" quality to her voice, but still really good. And she's a talented musician. On this album, she plays guitar and mandolin, and sings all the songs, which she wrote. Guest musicians include Tim O'Brien and Peter Rowan, so she's got some pretty good friends helping her out too.

The title track is a paean to old time music, with the repeating refrain "can you hear it, or is it just me?" She follows this with a few pensive ballads. Though by no means the most innovative lyricist, I was impressed with some of her poetry in these songs too. "You Think We're Friends" is rather clever at times, with the hook of the song being "you think we're friends/but I'm in love with you."

After several listens, the only song I'm not a huge fan of is "Pony Days" which is just a bit too cutsey. "I traded my ponies for new clothes and boys/and now that I'm older, I question that choice" is her theme here. What? No, thanks. Fortunately, the album picks up again from here and finishes strongly. The final track is a wistful reflection, with the best poetry on the album: "And the world turns around/The sun comes up and the sun goes down/questions abound/still the world turns around."

Like most albums, it is easy to find some fault with it. Unlike many, it rises above those faults to be a solid piece of work. Recommended.

The concert, as a whole, was amazing. Solid instrumentals, tight harmonies, Kristin Andreasson doing some clogging, and exceptional fiddle playing by Rayna Gellert. Abigail Washburn, whom I compared favorably to Emmylou Harris, has a bit of Mahalia Jackson in her as well. Most times, when a band is encored, they'll play a real rousing send-off to get everyone out on a high. But this one was different. Miss Washburn led an a capella call-and-response gospel tune titled "Keys to the Kingdom" and got the entire crowd singing the chorus. It was simply beautiful.

So if you're in an area where Uncle Earl is touring, go out and see them. You won't regret it.