Off for Christmas
Last year I wrote about
Christmas in the hospital. This year I’m home in Alaska for the first time in three years, taking advantage of my luck in having the holiday off. We get so used to working weekends and holidays in medicine, helping others to stay healthy, that having Christmas week to ourselves seems extravagant, like a special bonus. It feels good to put up the white coat for a week, to escape the wards. Too much time in the hospital, in the face of unrelenting illness, can make you forget what life is supposed to be like, what you’re fighting for in the first place.
As physicians, we stand at the intersection between the constructed world of our daily lives, which is ordered, meaningful, even protected, and the cold, impartial reality of the natural world. In Alaska the divide is particularly evident – though our lives are filled with the normal stuff of human existence – friends, family, food, films, music, plans, jobs, dreams, they are lived in the shadow of the simple reality that with one misstep – a car breakdown in mid-winter, a frozen set of water pipes, everything could come crashing down. It happens rarely; mostly we are allowed to live our lives peacefully, but on occasion the natural world forcefully collides with the quotidian one, obliterating it. A woman is diagnosed with breast cancer. A tsunami hits Thailand. What we’re fighting for is to keep our safe, purposeful, constructed worlds, of competitive sports and holiday parties, intact, shielded from nature’s unwelcome intrusions.
We’re somewhat successful. Most people live a rather insular existence, sheltered from natural disaster. The well are frustrating to care for because they think that they are impervious to illness, that they will never get sick; as a result, they tend poorly to their bodies. They feel that the world is fundamentally fair. As doctors we are fallen from this illusion. We live in the midst of the natural world’s devastation. We know that anyone can get sick, can up and die. A young man at the height of his powers, contributing greatly to society, raising a family, can collapse suddenly without warning.
The medical fight is an important one, but seeing sickness and disease every day wears on you. Being greeted a daily good morning by failing kidneys, bid good evening by an ailing heart, paid unexpected nightly visits by struggling lungs: it takes a toll. The curse of the chronically ill is to experience pain that nags just enough to constantly remind the sufferers that they are ill. The curse of the doctor is to be cognizant of his patients' sufferering. On interval, a break is needed, an escape from the hospital, a vacation.
This week I’m going to forget that disease even exists. I’m going to experience Christmas the way I hope my patients do: oblivious to hardship and suffering. People say to live each day like it’s your last, but that’s rubbish, or at least, it’s lousy advice for a vacation. How about relaxation instead? True luxury is to live as if you were going to live forever, to dally with each and every trivial pursuit. To watch movies and feel no guilt about how you could be better spending your time, to sleep in late, to indulge yourself completely: that is vacation at its best. That is how I intend to spend this Christmas.
One's own authority
One of the sobering things about the third year of residency is coming over that sophomoric high of second year, when you were finally able to start taking care of patients somewhat autonomously. Where in second year you think “yes, I nailed the management of that hypertensive urgency,” in third year you start to wonder, does hypertensive urgency even exist? Was it necessary to admit that patient to the ICU, place an arterial line, and use an iv infusion to bring down the blood pressure of a completely asymptomatic patient? You come to appreciate that you know very little, and most of what you do know is suspect.
As I transition into becoming an attending, I’ve been paying more attention to what I know and what I don’t. One of the things I’ve realized is that knowing something isn’t enough; you have to know where you learned it. A piece of information without a source is like a carton of milk without an expiration date: you don’t really know if it’s safe for consumption, and by the time you’ve found out it’s too late. Whether a pearl came from Attending A or Attending E, from a pharmaceutical rep or a published paper, it carries a vastly different weight. When you confuse where you learned something, you open yourself up to all kinds of trouble.
Ideally, knowledge in medicine is evidence based, originating from scientific studies and grounded in some type of objective, reproducible data. In reality, though, medical training is an apprenticeship; our education occurs in the work environment, at the hands of our mentors. For this to succeed, it requires our mentors to have a certain authority. We must be able to trust that when they say something, they know what they are talking about, that their input is based upon experience and knowledge of the literature. That way we don’t have to challenge every little assertion, which would be impossible to do anyway.
Even so, taking things on the authority of others only gets you so far. At some point you have to stand up and take ownership of your own body of knowledge. As an aspiring attending, that means becoming your own authority, which can entail going back and relearning everything that you know. It’s a slow and frustrating process, one that I wonder if I ever will complete; indeed, some of my current attendings still cite their own former attendings when teaching me things. Years into practice, they still do things based upon the authority of those former mentors.
Perhaps ‘relearning’ medicine is a mischaracterization, it’s really that you have to make it your own, the way a dancer first learns and then possesses choreography. You have to integrate it into the fabric of your being so that you can wield it rather than simply regurgitate it. I guess that’s what third year is for. That’s what the seventy first case of pneumonia is for – for the gelling process to occur. By working through it now and building the foundation just a little bit firmer, maybe my form will actually stick when the molding is removed next year.
Notice of employment
The ‘sorry I haven’t posted in a long time, I promise to be better’ post is such a common one in the blogosphere that there should be a pre-written template or form-post just for the purpose. Simply write in your excuse, and all of the other pleasantries will be taken care of for you. Mine currently is that I’ve been traveling – job interviewing, to be exact. I was looking at hospitalist jobs in the Pacific Northwest and actually found a good one; I’ll be relocating to the greener, rainier Washington this summer. Also, I was rushing to finish a research project on time and trying to meet the deadline for
The Great Sufjan Song Xmas Xchange. Have you ever tried to write a Christmas song? It’s harder than it sounds – Santa, Rudolph, Frosty, and baby Jesus have all been done. I ended up writing some silly thing about imagining that Christmas was in a season other than winter.
Anyway, with employment secured and some of my other projects taken care of, maybe there will be more time for blogging. I hope so. A few thoughts have been bouncing around in my head, and they are dying to get out.
Charades
Think about this one: guy falls down, breaks his ankle, gets taken to the hospital. Wait a minute, falls down and breaks his ankle? How is that humanly possible? Breaks his hip, maybe, or femur, or cracks his skull open, but c’mon, his ankle? Suddenly rounds turns from seven doctors and two medical students slouching against the walls, preoccupied with their own thoughts, to a melee of chaotic activity, as each one simultaneously perks up and starts acting out his or her own rendition of just how the tragedy might have occurred.
Idle call
Rarely but occasionally during our tenure as residents, we have slow call days in which there are no or few admissions, and which can be spent at our own leisure. These usually occur on the weekend, when patients are too preoccupied with their own interests to bother coming to the hospital. Greatly appreciated, they help to make residency bearable: without a lucky break or two somewhere along the way, few residents would likely survive. Often a light call seems to come just when you need it most, when another rough one would surely have done you in.
There's something wonderful about getting paid to sleep, or to read, or to write on your blog. Online shopping at the hospital is scandalously fun. One of the nice things about being stuck there for thirty hours is that, if there is truly nothing going on, you have few distractions. E-mails long delayed get written. Schedules long left unchecked get reviewed and revised. Resumes get updated, bills get paid, books get finished. Being in the hospital is not unlike boarding an airplane and knowing that for the next several hours you will be stuck there, alone with your thoughts, free from outside demands on your time. I tried to keep a journal in college, but the only time I ever wrote in it was when I was flying home for vacation or back to school. Many people only read books when they fly. Surely great medical ideas must have been conceived by physicians whiling away time in the hospital.
The slow call night that lets you sleep is triply rewarded: not only are you able to relax instead of working in the first place, but there will be fewer patients to follow up in the morning, and your post-call day will be spent awake rather than sleeping. It is a gift that carries a generous momentum. A downside does exist, I suppose, in that your idleness can beget laziness. When you do receive that rare page on an otherwise still day, you resent it all the more for disturbing your peace. When busy, you accept such pages matter-of-factly; when resting, you do not want to be called to work. You spend your entire day just hoping and wishing that your pager will remain silent. A call day with just two admissions is doubly as painful as one with four.
Even on the most quiet of calls, though, meals are eaten quickly, and the resting heart rate is rapid. The pager pressing into your hip reminds you of a fact that you would never forget anyway: disaster could strike at any moment. Better, therefore, not to admit that you're having a good call day. Better to deny it. Someone might overhear you and decide you need work. Of that, even on your slowest day, you certainly already have enough.
Hot potato
There’s a certain kind of patient in the ICU who crashes early and hard, who comes in from the medical floor, nursing home, or community clinging to life by the frailest of threads, and who only through aggressive resuscitation is kept alive. These patients are so sick that there is no hope of meaningful recovery. They are doomed from the outset; critical care interventions have been initiated too late to have a chance of reversing the process already set in motion.
When you have one (or more) of these patients, and you are one of four residents rotating and trading call and code responsibilities, the patients represent a constant source of anxiety. If the family is understanding, and the patient is made Do Not Resuscitate for the inevitable cardiac arrest, the situation is defused. If not, passing the patient becomes a frenetic game of hot potato. As laboratory markers and vital signs tell you that the game is nearing an end, each pass of the code pager grows more desperate, as each resident frantically tries to temporize the patient just long enough so that the whistle doesn’t blow on his watch, so that his hands will not be the ones to futilely pump and crack that stiff chest.
Law number three
At first I thought it was one of those guerilla veins that vanishes into thin air as soon as you think that you have him. Alternatively, Dr. Heisenberg, looking down from above, was trying to teach me a lesson about the uncertainties of a vein’s location at any given time. No matter how many times I stuck, I could not find the rascal. I put two fingers over the artery and felt the pulse bounding strongly. A finger-breadth medial, the vein had to be there. Yet it wasn’t. Switching positions, I couldn’t feel the pulse with my left hand. Checking again, yes, it was there with the right. Wait a minute, this was bizarre. Was I losing feeling in my left hand? Could it have been peripheral neuropathy from undiagnosed diabetes? Had I damaged the ulnar nerve putting it to sleep too many times from lying on it in awkward positions? But it was 3 am; strange things happen at that hour. Better to worry about it in the morning. I felt again with my right hand: there was the pulse. Stick and stick. No luck. Actually, wherever I placed my two fingers, there I seemed to find that pulse. Maybe all of the extravasated blood from my poking had made a soup that was diffusing the conduction of the pulse waves. Then I noticed, the pulse on the monitor was faster than the pulse I was feeling. I checked my own pulse. There it was, mocking and traitorous. I had disobeyed the Fat Man’s law. Using my left hand from then on, I found the vein and placed the line.
Blog or blot
Well, the end is in sight -- it's time to begin searching for hospitalist positions for next year. Apparently, it's a doctor's market; the day after I registered an online profile with Locum Tenens, I was bombarded with phone calls from physician recruiters, and a week later I'm still receiving multiple phone calls daily. I'm currently brushing the dust off my resume, preparing it for the market, but I've realized that I have a bit of a dilemma on my hands. Namely, Foggy Bottom Lantern. Should I include it in my resume?
My blog is, after all, one of the most interesting and original things that I do, and outside of work, it is the project into which I invest the most time and energy. A few months ago, perhaps in a moment of daring after a particularly satisfying post, I tagged it on to my resume. Creator and author, I called myself, and listed it under Community and Extracurricular Service, figuring that several of my posts have been informational and possibly of service to the world online community. Now, though, that I'm actually distributing my resume to potential employers, I'm not sure that was such a good idea. At least in the medical community, I'm afraid, blogger is a title more associated with trouble than anything else.
Oddly, when I first started my blog, my hope was that if it became successful, it might be a boon to my program and to my university. That it might become some tidbit of trivia on program tours, that potential residency candidates might hear something like, "Our residents have a variety of interests and hobbies. . . one of them runs the blog Foggy Bottom Lantern, which maybe you've heard of. . ." I wanted to make my program director proud. I saw all of this potential upside and thought that if done carefully, the downside could be reasonably well controlled. Now, though, like everyone else in the medical blogging community, I'm just afraid.
I've kept Foggy Bottom Lantern professional, and I do believe that if a potential employer actually read my blog, his or her impression would be favorable. There's been some talk on the blogosphere of blogs eventually replacing
resumes. Simply listed, though, a blog raises concerns without having any power to overcome them. On a first and blind paper date, that's not what I want to do. Thus, Foggy Bottom Lantern is off of the resume for now. In a more open and sensible future world, perhaps it will reclaim its rightful place.
The ICD gap
We should be proud of ourselves as Americans. This past week, the Journal of the American Medical Association published
two papers showing that white males receive significantly higher numbers of ICD’s (implantable cardioverter-defibrillators) than black males or women. These are little machines that shock your heart if it goes into a deadly rhythm, often restoring a normal rhythm and in the process saving your life. Having one is like having a whole resuscitation team, electric paddles and all, tucked neatly inside your chest. That white men are receiving them disproportionately should bolster our faith that our free market health care system is working: it proves that if you have money, you can buy better healthcare. Granted, patient preferences may explain part of the ICD gap, and bona fide racial and sexual discrimination may also be occurring. When the devices cost $30,000 each, though, and the disease against which they protect (heart failure) affects many pre-Medicare age people, we can rest assured that financial restraints are playing a central role. That’s where we’ve done well; that’s precisely what makes this country so great. Here, the wealthy don’t have to stand in line with everybody else. If they did, you might as well be living in France or Sweden; we might as well just have adapted the socialist model. No, in the U.S., money still makes a difference, and the American Dream is still alive. We didn’t want to share our health care resources with the poor, and the JAMA studies show that under our current system, we don’t.
Medication reconciliation
Aspirin. . . zocor. . . clonidine? I don’t like that drug. It’s dangerous, shoots the blood pressure all over the place. A single missed dose and the BP can bounce up to 200 systolic. Besides, this guy doesn’t look like the kind of patient who is going to take every dose. Maybe I should stop it. Eh, this probably isn’t a good time. It’s not like he prescribed the medication for himself; a doctor wrote it for him because the doctor wanted him on it. Somebody who knows him a lot better than I do decided this is a good drug for him. This drug is hardly good for anybody, though. But why should I override his primary care doctor, who is the one who will be following him after this hospitalization anyway?
Ah, Mr Lamb is back, recently in the hospital. Let’s look at the discharge meds. . . aspirin. . . zocor. . . clonidine? Was thinking about pulling that one. Bad drug. The guy was on it when he first came in, never could figure out why, didn’t want to overhaul his meds on his first visit, though. Maybe I should stop it. But he was just in the hospital and they deliberately left him on it. Maybe they thought he needed it. Maybe they tried to wean him off of it and had trouble. They had him in-house, under observation, that would have been the perfect time. Better leave him on it for now. . .
Bullets from heaven
When it comes to a loved one, death never makes sense, but there are certain ways of dying that just seem to be more difficult to accept than others. Sudden, unexpected deaths, for example, seem to leave deeper, coarser scars than gradual, anticipated deaths. Painful and violent deaths can jar loved ones as if they themselves were stricken. Most frustrating, perhaps, are preventable deaths, which tease us with the possibility that they might never have happened at all. Medical errors are a common reason for such deaths, but at least these are generally good-faith errors; more infuriating are those preventable deaths that result from carelessness, recklessness, or just sheer stupidity. In the movie Babel, when the little boy shoots his father’s new rifle at the travel bus, it is excruciating to watch. We expect to suffer loss from evil, but idiocy makes a surprising and thereby bewildering foe; a terrorist purposefully shooting at the bus would have seemed less senseless and been easier to stomach.
Death by indirect gunfire, thus, may be even more of an outrage to decency than a shooting in cold blood. I for one would rather go by the latter – at least someone will be held to account. We needn’t look far, though, before we see a systemic problem of unchecked indirect gun violence. One can hardly turn on a television of the Middle East without seeing young men firing rifles joyously into the air in celebration of some event or piece of news. I’m sure that for them it’s elating, but there can't be many ways of dying that are more ironic or pointless than being struck down by a stray celebratory bullet. Following the Iraqi soccer team’s victory in the Asian Cup this summer,
four people were killed in such a manner. What an odd but horrible piece of knowledge for Iraqi star player Younis Mahmoud that his championship goal resulted in these deaths. Why does the practice continue, you may ask? Ignorance seems to play a large role; a common misconception appears to be that bullets fired skywards will simply continue outward into space. (
Ordog) This, unfortunately, turns out not to be the case:
The escape velocity of a bullet has been calculated at more than 7 miles per second. Thus a bullet would have to be fired at a muzzle velocity of greater than 36,766 fps to escape the gravitational pull of the earth and end up in space. Obviously conventional small-arms weapons that we see in civilian practice cannot achieve this type of velocity, so the possibility of escape from the earth is nonexistent. Thus all spent bullets will return to earth. (Ordog)
Examining the physics a little bit more closely:
When a bullet is fired vertically into the air at >2500 feet per second (fps), the air resistance slows the bullet down about 60 times as fast as does gravity. When the velocity decreases, air resistance decreases and has less effect. Gravity reduces the upward velocity at the rate of 32 fps until the bullet has stopped its upward flight; then gravity starts it toward earth at 32 fps, and then there is a 32 fps increase for every second that the bullet drops, less the amount that air resistance holds it back. When the bullet reaches the top of its flight, it is still spinning, and if it is stable it falls back base first. Occasionally, it falls back either point first or tumbles, thus either decreasing or increasing its flight time. With a very sharply pointed bullet, the resistance on the bullet is less, and on the square base much greater, so that bullets coming down nose first fall faster than those that fall base first, but even so, a 150-grain, .30-caliber bullet tends to balance its weight against the air resistance at a velocity of about 300 fps. (Ordog)
This, the CDC summarizes, is a force “sufficient. . .to penetrate the human skull and cause serious injury or death.” In Puerto Rico, where celebratory gunfire is quite common, the news media has estimated that on New Year’s Eve, approximately two people die each year and 25 more are injured.
In a war zone like Iraq or Afghanistan, the threat of raining bullets is only one of your concerns when firing weapons into the air. More dangerous is the worry that you might give someone the wrong impression. In 2002, 48 Afghanis were killed and 117 wounded when U.S. airmen mistook their celebratory gunfire at a wedding party for hostile fire. The same sad story has played out in Iraq several times since then. What, also, about that other presence in the sky? You would think that the deeply religious, before firing their weapons skywards, might pause in fear that God would misinterpret their intentions. What if He thought you were actually firing at Him? Would you not expect Him to return fire?
After the 2005 earthquake in Kashmir, a close friend of mine with connections there told me that the faithful reacted in three different ways. One group found its faith to be a source of strength to get through the crisis. Another lost its faith entirely. A third, moved to extreme anger, fought back by shooting weapons into the sky. How people could have that kind of courage, to take on their god face-to-face, is beyond me. As much respect as I have for their bravery, though, I was also just relieved to finally discover a group of people who were firing shells into the air and knowing exactly what they were doing.
Celebratory gunfire obviously needs to end, and the sooner the better. Following the Iraqi soccer victory, I was glad to see mosque leaders strongly condemn it, but unfortunately, their efforts didn’t seem to have much immediate effect. The practice may already have taken too strong of a cultural hold for it to be vanquished overnight. Where young men have guns, they will likely fire them. While that remains the case, perhaps both the Kashmiris and the wild type gunmen would do well to replace their steel bullets with rubber ones; neither deicide nor manslaughter is a crime that weighs lightly on the conscience.
Medical instinct
I’m not normally a superstitious guy. I don’t read horoscopes, I don’t believe in ghosts, and I’m suspicious of all things spiritual. It’s true that I never admit to having a good day when I’m on call, but that’s more because I’m afraid of how my team might react than any potential consequences. (Good days are highly jinxable, or so I’m told.) This past year, though, when a patient informed me on a particular night that he was going to die before morning, I’ll admit that I was unnerved.
This was the kind of guy who was frail enough to go at any time, but there was no real reason that I could see why he should pass on that particular night. His blood pressure was fine, his labs were reasonable, and in eyeballing him, he just didn’t appear toxic. Why he thought he was going to die was a mystery to me, but he had a look in his eye like he knew something. To make the situation worse, he waited until just before I was heading home to let me know.
I’ve had many patients die, but this was the first time a patient had ever told me before it was going to happen. Usually it’s the other way around; I’m the bringer of bad news. Perhaps if he’d have given me a warning shot, as we’re taught to do (“Doc, I’m afraid I’ve got some bad news for you. . . “), I’d have handled it better. But he didn’t, and the news stunned me. The problem was, since I couldn’t identify anything immediately life threatening to him, I didn’t know what to do about it. I ended up signing out for the cross cover to check in on him that night, and went home for a restless night of sleep myself.
The first thing the next morning I went to see my patient, who was doing fine, precisely as I had left him. Silly me. Apparently, my medical instincts had proven more reliable than his spiritual ones. It was a victory for medicine and science, and I was cleared from incompetence. Either that or the Grim Reaper simply hit the wrong room. I can’t claim to know exactly what transpired that night, but at least the next time somebody announces his or her impending doom, my reassurances to the contrary will carry the weight of a little bit more experience.
The cost of learning
They say you haven’t put in enough central subclavian lines until you’ve given someone a pneumothorax (an air leak into the chest). That’s when you find out how deep is too deep to plunge your needle. Likewise, you haven’t performed enough lumbar punctures until you’ve given someone a headache, intubations until you’ve chipped someone’s teeth, paracenteses (abdominal needle taps) until you’ve left someone with an ascites leak, or hysterectomies until you’ve punctured someone’s bladder. You haven’t learned how to administer fluids until you’ve put someone into pulmonary edema, or how to diurese someone until you’ve shut down his kidneys. The point being this: to become a competent doctor, you must hurt people along the way. Just as the evolution of a species occurs through the death of its less fit members, the evolution of a physician from inexperienced intern to practiced attending requires spilt blood. Residency, of course, is the prime time for this bloodletting, and the old piece of inside medical advice holds as true as ever: if you value your health, don’t get sick in July.
It’s a little bit depressing to start residency and think that before you finish, there will be scores of victims left in your wake, people who will entrust their care to you and for that trust have to pay a price. Sometimes the price will be small, such as a missed meal after a procedure when a late-tray was never ordered, and sometimes it will be significant, such as when inappropriate antibiotics were ordered for an infection. Rather than sulk, though, I think as residents we have to be vigilant and fight against the threat that our inexperience poses to our patients. In some areas, we are already probably less likely to make mistakes than our seniors; our awareness of our considerable limitations makes us more likely to pay extra attention to detail and to check our facts. The truly dangerous practitioner, it is often said, isn’t the one who knows that he doesn’t know something, but the one who thinks he knows something that he doesn’t. Residents, especially interns, are less susceptible to this particular pitfall, and so one of the best ways to avoid mistakes in residency is also one of the most natural: to ask for help when it is needed. It’s a terrible thing to harm a patient because you are too proud to seek help.
A second way of avoiding mistakes is by learning from those of others. That means being open and honest about mistakes and willing to share them to help others learn. If residency programs collected and distributed a monthly list of mistakes made by their residents, it could be an amazing teaching tool. Personally knowing the people involved would make the lessons all the more memorable.
My purpose here isn’t to methodically go through the ways of reducing medical errors, but simply to point out that, for residents who care, the mistakes of residency and their impact can be greatly lessened. Also, before I start scaring patients away from teaching hospitals, let me point out that there are many reasons why it’s good to have students, interns, residents, and fellows participating in your care. For one thing, our mere presence keeps the attendings on their toes; teaching concepts requires a higher clarity of thought than simply acting upon them. We like to ask questions, and having an additional bright, eager young mind going through the details of your medical case can’t be a bad thing. Less bound by time constraints, we will listen to your full story, and the substantial knowledge that we do possess, while hopelessly incomplete, at least is current. Some procedures we even perform better than attendings, because we do them more often. Truly, to request that no residents or students be involved in your care is to miss an opportunity for excellent care.
Like everyone else, I’ve had my fair share of blunders during residency. I’ve dropped people’s blood pressures, dried out their kidneys, and stuck them with needles to the point of absurdity. There were days when calling me a walking disaster would have been entirely appropriate. I’ve also saved lives, though, and for most of my patients, I know that their care was better because I was involved. Maybe I’m giving myself too much credit, but I think my patients would also attest that despite its fearful reputation, the cost of learning turns out to be surprisingly manageable.
Out of the fog
Like any activity that requires effort in its maintenance, with blogging it's just really easy to fall into a period of inactivity and neglect. What starts as a day off quickly turns into several, and then several more, until that nagging feeling that you are overdue to write something finally just fades into the background. That's when things get dangerous and blogs go for months without posts. Thanks to Grace, we have a label for the blogger who behaves in this way:
neglectablogaroon. It's a funny name for a curious problem. After all, as amateur bloggers we supposedly create our blogs voluntarily because we enjoy writing, not because we're looking for more responsibility and stress in our lives. Yet, the blog takes on a life of its own, and when we don't write we feel guilty, like bad parents or binging bulemics (Grace is wrong about no remorse). To be completely honest, I'm surprised that I was able to keep my blog going for as long as I did without any major interruptions; the last time I started a new workout routine, by comparison, I lasted only one session.
These relapses serve a purpose, though. They help to purge us of our primal needs (passing out on the couch, in this case) and of our excuses that we've been working really hard. (Rationalizing that you need a break is more difficult when you haven't lifted a finger in weeks.) They allow for rest, for rejuvenation, and for the marination of thoughts and ideas so that when they eventually come out, the flavors are more zesty and vibrant. They let the hunger return, the ambition grow. With just a little perseverance, the energy used to return from relapse can build into a raging force.
People (internets), I'm back. I'm sorry I left you hanging for the last couple of months, but stay with me and you will see action over the coming days and weeks.
Watermelon man
Have you ever, on a hot summer day, gorged yourself on watermelon, letting the sticky, sugary juice dribble down your chin as you chomp down upon mouthful after mouthful of sweet, succulent fruit? Last summer, in a bid to overcome the powerful mid-July heat, I devoured an entire half-watermelon in one sitting. It felt similar to how pregnancy must feel, my belly reaching absurd levels of distension that I wouldn’t previously have thought possible. If I hadn’t been overcome by such a strong desire to lie down and take a nap, in fact, I would have sought out the nearest sumo ring to find out whether my new body habitus was associated with any talent. As it was, though, I had a hard enough time just stumbling over to my bed. My hope was that after a few hours of sleep some of the fluid would redistribute out of my belly to somewhere with more room, and that I would be feeling quite a bit better. Redistribute it did. Every thirty minutes the threat of bladder rupture had me up to the bathroom, urgently opening up my spigot to let the water run out. The ultimate diuretic, it turned out, was not lasix or a thiazide, but a red and green melon named after its affect on urine. (Interns take note, if a patient’s urine output hangs frighteningly low, a little bit of the red stuff aptly slipped onto the right dinner tray may turn the I’s and O’s in your favor.)
Imagine, though, if I had not been a healthy young male, but an end-stage renal disease patient on dialysis who didn’t, who couldn’t urinate. All of the water that my kidneys so happily had drained off would now have had no place to go. It would have overflowed – into my belly, my lungs, my legs, anywhere that the path of least resistance might have taken it. A watermelon man, that’s what I would have been. Or is that what a dialysis patient always is? With no drain, water never stops to accumulate in the body; its level steadily rises. Present not just in the fluids we drink but also in the food that we eat, water is unavoidable. A man will drown who doesn’t get to dialysis on time.
Strange that a watermelon, of all things, could be a deadly food. Stranger yet to think that the miserable way I felt after ingesting half a watermelon is the same way that a dialysis patient must feel all the time, every two days before the water again is mercifully removed.
Medicine upside down
Sometimes in medicine, the hierarchy breaks down. Our etiquette, which rivals the military’s in its degree of structural rigidity, fails to inform our behavior in particular situations. It happened to me the other night in fact: I had a physician as a patient. That may sound trivial, but here’s how I ended up introducing myself to him: “Hi Dr. Lambert, I’m Wyatt, and I’ll be the medical resident handling your admission this evening.” Of course, he loved it, instinctively raising his chin and straightening out his posture in the gurney. By my addressing him as doctor and myself by first name, I had just indicated that I was planning on giving him the full respect that I would afford one of my own attendings. Not only would he receive the utmost politeness and consideration, but his opinion would be given a very heavy weight. From my few words of greeting, he knew that the full VIP treatment was his.
Myself, I felt more ambivalent about the tone I had set for our interactions. By addressing him as a superior, I had just conceded my power as the doctor over to him. This would be one warped doctor-patient relationship: he would be calling the shots and I would simply be carrying them out. In fact, in all actuality he would be his own doctor. The implications of this were still unclear to me, but I figured that basically I would run all of my orders by him while avoiding any uncomfortable questions or elements of the examination that I might otherwise have performed.
Directing your own medical care may sound nice, but I can testify that in reality, it’s not. For one, it’s impossible to see yourself objectively. To verify this, simply take a stroll around the hospital ward counting the number of bare buttocks that you see. Those nice hospital gowns that cover everything up so neatly in the front, it so happens, leave gaping holes in the back if even a single renegade string goes untied. Moreover, doctors are notorious hypochondriacs. When you know the constellation of symptoms for hundreds of rare diseases and see people sick with them on a daily basis, you forget that rare diseases are actually rare. If left to yourself, you’d likely cause your own drawn out death from bleeding due to excessive lab testing. Alaskans, already familiar with the concept of death by mosquito bite, know what I'm talking about.
Fortunately, this doctor was much cooler than expected, and he pretty much let me run the show. Having an attending physician asking and caring about my opinion felt really great and restored the standing that I had abdicated earlier. It turned out that he actually wanted to have a doctor, rather than be one, so we both ended up satisfied. In fact, the experience was so positive that next time not only will I keep the same introduction, I won’t even skip out on the rectal exam.
Saturday Night Syndrome
One of my least favorite things about residency is the one-day weekends. If it wasn’t bad enough already, the one day off is marred by the certainty of work the next day. Most people are familiar with this feeling on Sunday evenings – knowing that a long and hard work week is about to begin and being unable to fully enjoy the evening because of it. To have Sunday Night Syndrome on a Saturday, though, is particularly painful. Everyone else is out living up the prime night of the week, staying out after hours with the comfortable knowledge of a late sleep-in and casual brunch coming the following day. You on the other hand are at home, stressed out about the next day and going to bed depressingly early. It’s hard to get used to.
The holiday season, they say, is the most active for suicide because seeing others happy and together intensifies loneliness. I know, I am supposed to be grateful to belong to this profession and to have an opportunity to serve. It’s just that sometimes that gift of service feels like a double-edged sword when it demands that you serve even when you’re not yet rested and ready.
Question and answer
Attending: How does heparin work?
It prevents clot formation by enhancing the action of anti-thrombin III. . . wait, heparin’s not a thrombolytic, it’s not supposed to break up clot, it just prevents more clot from forming. . . anti-thrombin III breaks up clot that’s already there so that can’t be right. . . wait, where the hell does anti-thrombin III actually act? . . it must inhibit thrombin. . . maybe it doesn’t break up clot after ---
Someone else: It activates anti-thrombin III.
Damn.
Attending: Right. And how does plavix work?
It inhibits platelet aggregation. . . but how? . . . can’t be a IIb-IIIa inhibitor because integrillin and reopro are the IIb-IIIa inhibitors. . . but IIb-IIIa is the way that platelets crosslink so it must act somewhere on those receptors. . . hmm, could it act on fibrin or fibrinogen?. . . that doesn’t sound ---
Someone else: It impedes platelet aggregation.
Arggh.
Attending: Very good.
Petits morceaux de France
I spent this last week in France, dividing time between Paris and Monaco, which explains why I haven't posted anything on my blog in awhile, and which led to these morsels of thought.
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The yogurt in France is so creamy and delicious that it's no wonder they feel the need to ease their guilt by studding it with cholesterol medication. I'm just wondering what happens to a foolish American tourist who downs four cartons of the stuff all at once.
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It's a good thing they don't have Coca-Cola Light in this country. I’m having a hard enough time controlling my Diet Coke addiction as it is without them throwing that dangerously tasty brew into the mix.
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Beautiful old buildings that give Paris its characteristic charm and evoke the early 20th century: great for city ambience, scary as hospitals.
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Getting rid of all public toilets in fact does not eliminate the human need to urinate.
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I don’t understand the foie gras controversy. You could force-feed me baguettes all day long without a whimper of complaint.
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The contrast between French waiters, whose tips are for the most part already included in the bill and who often seem annoyed to serve, and American waiters, who work for tips and really try to satisfy their customers, really speaks to the power of positive incentive. It makes me think that more positive encouragement and feedback in the over-critical world of medicine could go a long ways.
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Smoke-free DC was a great idea. Air never felt so breathable.
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Please tell me that fruit tarts count as one of my recommended daily servings of fruit.
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It's possible to forget an awful lot of medicine in one week.
An American duality
Let’s say you want to invent a killing machine. You have anything and everything at your disposal: toxins, germs, drugs, explosives, radiation, lasers, sharps, gears, and gadgets. If brought forth and marketed in the U.S., you can expect your invention to be highly scrutinized, its use heavily controlled and limited to a military or police setting. Unless, of course, it involves firing a projectile through a cylinder (one projectile per pull of the finger), in which case instead it will receive near immunity from regulation and instant approval for distribution to American homes.
Now let’s say you want to invent a new medicine, one that will cure a human disease. On average, you can expect laboratory and animal studies to take 3.5 years, your phase 1 clinical trial to establish basic safety one year, your phase 2 clinical trial to establish dosing and efficacy 2 years, your phase 3 clinical trial for further assessment of safety and efficacy 3 years, and your FDA review another 2.5 years. You will be lucky if your medicine can be sold on the market in less than 12 years.
It's the difference, I suppose, between protecting life and destroying it.
