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.