Done Fall Out. In Church.

The Wire on Google Street View

2011-04-25T15:16:00.007-04:00

This weekend I was moonlighting at the VA. The charge nurse was from Philly. He was commenting about how dangerous Philly was and how much safer he felt around here, even in West Oakland and the Tenderloin. I politely informed him that Philly, even the sketchy parts around Temple, had nothing on Baltimore. I explained that Baltimore's contraction (population now around 700,000, population in the 1960s, around 1 million) left hundreds of boarded up rowhomes that have become shooting galleries, squatters dens, and rats nests.
I like to show people that within 1 block of Johns Hopkins Hospital, there are boarded up rowhomes. This is pretty easy to do on Google Street View.

Start on Monument and Broadway. The dome of Johns Hopkins Hospital is visible while looking southeast:

Walk a block north on Broadway to Broadway and Madison. Amdist the northward expansion of the Hopkins medical campus, our first strip of rowhomes has vacants. You'd think for property within one block of a major medical center, they'd be able to find a paying tenant:

Let's see what's going on one more block north, on Broadway and Miller. Looks like the po-pos are out on this fine day:

I wonder what's going on by that tree up there?

Looks like someone is having a bad day:

Ahh, Baltimore. You never fail to impress. I think this series of images was game, set, and match to the charge nurse's argument...

Happy Passover

2010-03-30T00:55:00.001-04:00

YouTube -- the best thing ever invented?

2010-01-24T02:28:00.003-05:00

I can't remember an invention with as near universal appeal as YouTube. Just about everyone can find something to adore about it.

Nobody goes around dissing youtube. None of the hipster-or-homeless crowd that populates vast swaths of this city. None of the right wing circus freak sideshow that's taken over our country again (this week). None of the granola patchouli stink hippies. Nobody.

Everyone loves it. Not One Nation Under God. Not One Nation under YouTube. One World Under YouTube.

I love it especially for music. It seems like every week there is something better. Middle school choirs singing Bjork? Check. Unholy covers? Check. DJs with too much time on their hands? Oh hell yeah. Indie superstars on kids shows? I think we can do that. Doc Watson playing a Chet Atkins tune on a Henderson guitar Check -- maybe my favorite video ever.

Today's time waster, in between writing 20 odd notes for 2 busy inpatient services (14 hr days on weekends aren't that fun, especially if you are doing the 14 hr days on weekdays too) is Boing Boing's feature Adventures in Music. This guestblogger, Stephen Worth, head of the ASIFA Animation Archive, has put up some truly incredible clips of old music on YouTube. I haven't watched all of it yet, but what I have watched is mind blowing. Mind blowing.

His "big finale" today was a big finale indeed. It's 10:51. Watch it all. You'll be a better person for it: Cab Calloway, Bill "Bojangles" Robinson, Lena Horne, and oh-my-word the Nicholas brothers. If you're not interested in being a better person, watch from about 5:30 in. You'll miss most of Bill Robinson and Lena Horne but you'll catch Cab skatting like nobody's business and nobody should miss the Nicholas brothers.

Travel day

2009-12-27T20:08:00.002-05:00

Back to the grindstone tomorrow.

Airport screening was very concerned over my EKG calipers, which prompted a hand search of my bag. I had forgotten them in my work bag in the pen holder. They, apparently, are not a TSA forbidden item to I was allowed to keep them.

Other than that, despite it being the end of the Christmas weekend and in the era of idiot Nigerians burning their balls off with fireworks becoming an international incident requiring direct blame to the administration, I got through airport security in no time and am sitting at the gate. Cheers to Boingo and Google teaming up to give us free wifi for the holidays!

Hopefully the flight will be devoid of M-80s and Roman Candles both.

Co-inky-dink

2009-12-17T00:39:00.002-05:00

They have told me to start posting again. It's been a month and a half. I got out of practice while on my busiest month, consults at the Big Hospital. And then I was an ICU fellow for the first time. That rotation, at the VA, wasn't so bad but it was 1.5 hr commute each way. So it wasn't like I was up to thinking about something witty. Now I'm on an easy-ish rotation with a shorter commute (although today I may have set a record for business -- 7 new consults and 2 outpatients!). So here's to hoping.

We are having a ton of fun here, doing little trips every weekend that I'm off. Point Bonita (windy, beautiful), Point Reyes (windy, beautiful), Mount Diablo (windy, beautiful). I didn't want to rub it in.

Anyway, to ease back into the swing of things, here's a little co-inky-dink for you. I take the shuttle from the General to the 16th Street BART station, at 16th and Mission. And I was listening to All Songs Considered on podcast. As I stepped out of the shuttle, this song came on. Valencia is a block west of Mission.

This version of the song is much worse than the album version, which is almost listenable. This version is not. And Devendra Banhart has never really floated my boat. There's about 5 other freak-folk people I prefer over him (Sufjan Stevens, Animal Collective, Iron & Wine, Panda Bear, Cocorosie just off the top of my head). But here's to him and Bob Boilen for messing with my mind.

And speaking of music videos that mess with my head, here's another one from the same All Songs Considered that is exactly my dream from last week.

San Franciscans, a funny lot

2009-10-15T01:06:00.002-04:00

I do like living here a lot. The main academic hospital in the city doesn't have air conditioning. People wear winter coats in July. And I know it comes as a shock, but people here have foibles.
- One day of rain is the end of the earth. A few hours of legitimately hard rain (2.76 inches of rain in a day, which actually was twice the usual rainfall for October) led to widespread civic dysfunction. It was all anybody could talk about. I'll give them that -- talking about fog vs no fog is the only outlet for the natural human tendency to talk about the weather. I guess cities deal with different things. It would have been the equivalent of 15 inches of rain in Houston, but Houston shuts down with 1/8" of ice or snow. And Baltimore, god love it, gets 10 inches of rain and snow and ice and can also deal with neither.
- Putting a barely noticeable S-curve in a bridge leads to 50% delay in traffic and frequent wrecks which can shut down the city for close to 6 hours.
- People are very, very proud of their commute, their dogs, and their marijuana smoking.
- The most aggressive people on the road are the pedestrians, followed by the bicyclists. A pedestrian will think nothing of standing in front of a MUNI light rail train and yell at the driver.
- Fire engine red hair, chunky glasses, a lip ring, and a low cut t-shirt to show off shoulder and back tattoos is appropriate work attire for health care professionals and exotic dancers alike, where it would be for neither anywhere else in the world.

Ed 0, MUNI turnstile 1

2009-10-13T23:39:00.002-04:00

fail. epic fail.

Study music

2009-10-06T02:26:00.003-04:00

I figured I'd listen to some classical music for a change, as I'm trying to put together a presentation for tomorrow.

Glenn Gould's 1955 recording of Bach's Goldberg Variations came up in my classical playlist. During my breaks, I've watched some of the videos of him as he is a genius and a nut. He had many famous idiosyncrasies -- he would only play sitting on a chair his father made. He sat almost under the keyboard, hunched over in a pose bound to give any piano teacher fits. The piano had to be a certain height off the ground. He liked the room hot during recording. He hummed and swayed along with the music. He made bizarre demands out of fellow performers. There is a famous story about a concerto he played with Bernstein. Bernstein apologized to the audience beforehand because Gould insisted that the first movement be played at half speed.

But his playing was impeccable. Especially when it came to Bach. With some Google-fu, you can find a 47 minute video on Google Videos of him playing the Goldberg Variations, complete with humming, swaying, and ridiculous left hand runs.

Here's something shorter. One of the coolest stories in all of music, if only it were true:

This is the last 2.5 minutes of Contrapunctus XIV, the last fugue from Bach's monumental "Art of Fugue." It was written at the end of his life as his vision was failing. Bach introduces a new theme here -- B flat-A-C-B, or in German musical nomenclature B-A-C-H. That's the four slow notes Gould plays at the beginning of the clip. He then starts to develop a fugue around this theme. A few minutes later, in measure 239, the score abruptly ends. There is a note there from JS Bach's son CPE Bach indicating that at this point, the conductor died.

This story has been widely circulated, including in Hofstadter's book "Gödel, Escher, Bach." Unfortunately, like most things in life, the truth isn't as simple. Bach probably wrote lots of stuff after this, including the ridiculously good Mass in B Minor. It does, however, make an awesome story.

Tsunami watch

2009-09-30T01:38:00.003-04:00

Tsunami Watch!
Tsunami Watch!

In other news, I've become a mass consumer of media. The two hours on the BART have done it to me. Besides slowly chewing through my music library, and adding to it at the limits of my paycheck, I've been reading NEJM religiously, I'm joining ATS tomorrow so I can start to read the Blue Journal, I listen to podcasts of All Songs Considered, This American Life, and Car Talk, and I have burned through Neal Stephenson's Anathem, Cormac McCarthy's The Road (soon to be a Major Motion Picture starring Viggo Mortensen!), and Cory Doctorow's Little Brother in the past 2 weeks. I'm now firmly putting myself into reading that will slow me down. Next up is a book of Chekhov's stories and the only Pynchon I haven't read yet (except the new one) -- Mason & Dixon. Speaking of the new one, Inherent Vice, it's on my Amazon list, along with Infinite Jest which interestingly has a very similar title and supposedly is quite Pynchon-esque. Wonder if ole' Tom named his new book as a tribute to David Foster Wallace.

To recap:
Anathem -- A relatively slim tome by Stephenson (at least it's only one 900+ page volume) about a world in which instead of having religious cloisters, there are "maths" which keep scientific, mathematic, and philosophic knowledge alive through societal upheavals. Quite nice, a great page turner, especially if you turn quickly through the dozens of pages of philosophic discussions over epistemology and the nature of the universe. For those of you who like their books with timelines, glossaries of lingo, appendices with math and orbital mechanics lessons, and so forth. Let's say Dune meets The Name of the Rose. Or Canticle for Leibowitz without so much post-apocalyptic mayhem.

Speaking of post-apocalyptic mayhem, The Road (soon to be a Major Motion Picture starring Viggo Mortensen) puts a mysterious man leading small people across a desolate landscape avoiding evil. To be played by Aragorn himself in a movie, of course. Except this time he's simply "The Man" wandering south across a post-nuclear America with his son. It being a Cormac McCarthy novel, you know things aren't gonna be all peachy. I kept waiting for Javier Bardem to pop out with a cow stunner.

At to make a nice segue, another tale of an America gone wrong is Little Brother by Cory Doctorow. I found out about it because both it and Anathem were nominated for Hugo Awards (Little Brother was nominated for a Nebula as well.) I read it on my iPhone as it is available for free all over the internets (legally). I found it very fitting to read a tale about the next 9/11, where terrorists blow up the Bay Bridge and the BART tunnel while riding through the BART tunnel twice a day. Anyway, as you know it would, Homeland Security goes all apeshit. The story is told by a 17 year old who lives in the Mission as he gets caught up in the inevitable extreme overreaction that would come from another 9/11. A good parable of the pitfalls of security theater and how we will have to actively fight for the right to privacy in the future (as well as giving some good hints as how to go about doing just that). I'm not sure I really dug the 17 year old point of view but hey that's what Doctorow was aiming for.

So after Pynchon what's next? I can't very well follow a Pynchon with a Pynchon (the new one) or even a David Foster Wallace. Any suggestions?

Music for the beatdown

2009-09-12T02:12:00.004-04:00

This week has been a beatdown of an epic proportion.

I worked Saturday and had Sunday and Monday off. And yet Tuesday through Friday was just incredible. Incredible.

Tuesday had the 7 AM bronch so hauled my grudging ass outta bed at oh-dark thirty (actually 4:45) to get the 5:34 train from El Cerrito to Embarcadero. Transfer to the N-line and arrive by 6:30. 12 on service, so the whole day was bronch-round-radiology-bronch-round-repeat then notes. I was done by 8:30 PM and N-line to BART. Between tunnels on the BART, got some frantic pages. After tunnels returned them, and due to some poor communication between teams and attendings, apparently a "routine" Outside Hospital transfer arrived on the CT surgery service without anybody knowing anything. They didn't even give us the courtesy of a big stack of nursing notes. Just the pt (and anybody who's been through Hopkins would know that's pronounced "pit"), reportedly stable and for a simple lung transplant evaluation.

Except she was hypoxic to beat the band and syncoping with florid right heart failure in cardiogenic shock. That's the one-liner that's bound to send a shiver up any medicine doctor's spine. The CT surg fellow was just called in because they were doing a heart and a lung transplant (cases start at 0030!) and only the intern was available to admit the patient. OK, no big deal, transfer to the ICU and let the ICU deal with it.

Oh yeah, the ICUs at the hospital are open. Funny how that kicks you in the goodies. CT Surgery would still have to deal with the patient, they'd just get an extra set of hands to put in lines and do chest compressions if need be. So transfer to the ICU is not an absolution like it is most everywhere else.

The very nice fellow said that they would try to deal. I tried to contact everyone I knew in the hospital (none of whom were there) and my attending and see if there was anything we could do.

There wasn't.

So I changed into scrubs and into the car and back to work by 11:30 PM. And true to form, the pt was sicker than snot and other secretions starting with "s" and proceeded to try her hardest to check out for more celestial climes.

Anyway, I slept in 10ICU bed 16 (it was closed for a water leak) for around 30 minutes between peri-codes and pressor titrations and urine output checks.

Wednesday morning crawled out of the ICU, had the 7 AM bronch and now 14 on service (with the new and the overnight transplant). So it was bronch-round-bronch-round-etc oh yeah and two hours of meeting. Crawled to my car (parked conveniently in the only non-J permit street parking in the Sunset around 9 blocks from the hospital up one of those hills that end up being the scene of slo-mo sequences during movie car chases). Got stuck in traffic for about an hour and managed to make it home by 5:30 where I worked on my notes for 2 hrs before crashing at 7:30.

Thursday had the 7 AM bronch, 4 other bronchs, clinic, oh yeah and 4 new admits. So bronch-round-bronch-round-clinic-round-round-notes until I dunno around 10 PM and then home by 11:30. Must admit some notes didn't get done.

And today yet again with the 7 AM bronch as well as 2 others, 2 hrs of lecture. And all the notes from today as well as the ones that didn't get done yesterday. 17 on service (as one was discharged). Worked on notes until 11 and then sat down to try to blog. So excuse the marginal coherence.

At least I'm learning a ton. And riding the bronchy donkey all day every day.

So here's a new music acquisition that I think of every morning while starting my one and a quarter hour commute. Because the name is so true. In this short life of mine, I've come to realize that you can judge books by their cover and likewise you can judge bands by their names. So you just know that ...And You Will Know Us By The Trail of Dead and Clap Your Hands Say Yeah are going to be awesome. Ladies and gentlemen: We Were Promised Jetpacks. It is so true. We were. Every day, I imagine myself standing in front of the house in an asbestos jumpsuit, pulling down my goggles, lighting the burners, and arcing off into the darkened Western sky on top of 20 feet of white flame only to arrive in the Sunset fifteen minutes later, face windburned but with a permanently tattooed smile.

WWPJ is from the Scottish group of bands on Fat Cat Records that all sound the same (but good! see Frightened Rabbit, The Twilight Sad). Here's "Moving Clocks Run Slow." They have a video for "Quiet Little Voices" but there's no way I'm passing up a reference to special relativity. There's also a killer live acoustic version of this up on the youtubes.

To bed for me. As an aside, as I retire at 12:11 AM, this September 12 2009 Anno Domini, it has started to rain lightly. This is the first rain that I've seen since moving to California.

Music

2009-09-07T00:46:00.002-04:00

While coming home a few days ago, The Unicorns' album "Who Will Cut Our Hair When We're Gone?" came on my iPod. (BTW what a crock that the latest and greatest iPhone can basically wipe your butt for you but can't do Album Shuffle). I started listening to this album in graduate school and I hadn't listened to it for probably 3 years. Just an unbelievably fantastic album in that first wave of terrific Montreal indie music. Cheap keyboards, three quarters of the songs about ghosts, bones, or unicorns.

They share the Belle and Sebastian thing where you find yourself asking "Are these guys serious? Or are they just messing with us?":

Unfortunately, it was that one album and out. Luckily though, most of them got back together, got better keyboards, and made Islands, whose album "Return to the Sea" contains some of the most beautiful pop of the last 5 years:

Enjoy.

Going to the dogs

2009-08-24T00:28:00.002-04:00

Politics.

After seeing her doctor for a chronic cough, a woman had a workup including imaging (an X-ray and a CT). This revealed a concerning 1.5 cm nodule in the right upper lobe of the lung. Unfortunately, this workup was performed as her health insurance ran out, and she had to wait 6 months until she could get enrolled in the California Medicaid program, Medi-cal, and get an appointment with a pulmonologist, get seen, have her old images reviewed, and then get set up for a biopsy.

We, the pulmonologists at the public hospital, diagnosed her with cancer last week. Now we get a PET scan (3 wk turnaround), and then on to oncology or surgery (another 3 wks). But she knew she most probably had cancer 6 months ago.

This is what I deal with every day, and this is one of the good outcomes in our country's health insurance mess. She at least had insurance at one point and was able to get seen by a doctor who was concerned enough to order an X-ray. If she hadn't eked out that appointment on her dwindling insurance, she may have bounced around ERs getting prescriptions for Tessalon, until she had widely metastatic disease. It doesn't even scratch the surface of the absolute disaster our system is.

For wanting to change this, for wanting to make things at least a little better, for wanting to make sure our infant mortality is as good as Cuba's, we get a significant portion of the populace "erupting" at town halls. Our Constitution is under the greatest threat because our President believes that the richest country in the world should at least have a life expectancy as long as Jordan. And now there are people with guns at these events, and being put on national television thereafter. And their representatives just egg them on.

All the while these same folks were silent while the United States adopted an official policy of torture. They were silent when the US government was expanded with the largest non-military discretionary increases, which amounted to little more than corporate welfare for drug companies.

Sure, these nutballs are true believers. But they are true believers of misinformation and lies, planted by assholes on television and radio who will say any damn thing for viewership and market share. They are planted by cynical politicians who know they can get electoral headway as they will never be called on it. They are planted by the same people who have put "recission" and "preexisting condition" in the lingo.

It's enough to make me want to pull my hair out. Worse, it makes me think of what happens when the violent talk actually takes root. Lincoln, Gandhi, MLK, Rabin -- just a few clear-headed thinkers taken out by reactionaries. At this point in time, with the economy still in the shitter, with unsustainable rises in health care, with two wars still going on, I just don't know if we could get through that without this country falling apart. With it over a debate on helping people not go bankrupt when they are diagnosed with cancer, I wonder if we really should...

First post in a month

2009-08-18T02:04:00.003-04:00

Sorry for being away so long, for the four people or so who read this blog.

A lot has happened:
1) I finished at the VA and now am in the beautiful Potrero Hill district at the world famous San Francisco General Hospital. I believe it is world famous for being the most urinated upon building in the Northern Hemisphere. It is the site of a homeless encampment so large that the UN has a permanent platoon of Cambodian soldiers deployed to it.

2) I did a week of sleep medicine. This was an interesting experience. Realty, and by proxy, hospital beds being in dire shortage in the UCSF system, the geniuses in sleep medicine have rented out a wing of a Best Western in Japantown. This hotel, being in Japantown, true to form has giant vending machines in the lobby that dispense Japanized souvenier toys and t-shirts. Regular rooms have giant anime figures painted on the walls. There is a lounge with giant televisions and game systems, and it hosts gaming tournaments.

The sleep medicine folks have geared out 8 rooms with night vision cameras, EEGs, sleep sensors, snore sensors, CPAP machines, intercoms, etc, and have another 2 for control rooms. Every night, the chronically tired and morbidly obese come to Japantown in order to diagnose sleep apnea, narcolepsy, bruxism, restless legs, and so forth. All the while, 14 year old boys point their Wii mats to the same hotel 5 times a day...

3) I took the national internal medicine boards. 240 questions, most of which were three paragraphs and started with "a 54 year old woman" and ended with me trying to remember the correct treatment for cryoglobulinemia. It sucked. It was shorter than I thought it would be. They just had to work harder to cram the annoyingness into a shorter time.

4) Hosted the parents, went to Sausalito, the Muir Woods, Muir Beach and its overlook, Monterey, and of course all over San Francisco and the East Bay.

5) I've eaten like a huge hog. Working in the Mission doesn't help. We've gone to shabu, sushi (and the dude from Mythbusters was at the next table), original Mission burritos, the most unbelievably good tortas, excellent Chinese food 5 blocks from our house, incredible banh mi in San Jose on the way to Monterey (we knew the way...), not to mention countless neighborhood sandwich and coffee places. I need to stop eating. It's wreaking havoc on my gastrointestinal system.

One and a half weeks in

2009-07-12T02:10:00.003-04:00

It's a little weird to identify myself as the pulmonary fellow, after three years of being the medicine resident. It's a little weird to be on strictly first name basis with all the attendings. It's great, though, to be white-coat less (mine is still on order, perhaps a California IOU?) and tie-less. It's about 50/50 here, and I've made a decision to join the tie-less 50%. Which means that the Osler tie will get a much needed rest.

The VA is very laid back, and not the learning curve of the rotations at the main hospital (I'll start there in September). Which is not a bad thing considering the last bit of my residency, the move-out, the drive, and the move-in. I'm using the BART and MUNI to get to work, which unfortunately takes around 1.5 hrs there and back. Which is excusable now, as I am studying for the boards. But this could be irritating. The VA is the farthest out, though, and the other hospitals should be better.

Immediately, changes become obvious.

The old view from the MICU nurses' station:

The new view from the MICU nurses' station:

The old view from the parking lot:

The new view from the parking lot:

July 1

2009-07-02T02:31:00.004-04:00

Today was July 1, the worst day of the year to be sick. The new interns, residents, and fellows started today. I started at the VA, which apparently has the best view and the worst food in all of the Bay Area.

So far it seems like an easy rotation, though on BART/MUNI it takes me 1.5 hrs to get there. Right now, it's OK as I am studying for my boards and reading while riding, but that may get irritating.

Part of what strikes me about this whole thing is between today and yesterday we had around 9 hours of orientation. Next to none of this had to do with being a pulmonary fellow. Almost all of it had to do with "The ACGME/JCAHO/Regulatory Commission XYZ has required that we tell you about this random fact." Which I have now heard at least 3 or 4 times. It also took me 3 hours in line to get an ID, on a day which every single year they know they will be issuing 200+ IDs. The scary fact is I was lucky to get an ID; there were plenty of people behind me when I got my ID finally at 4:30 PM and they were threatening to close at 5 PM.

Tom Friedman wrote a book about how the world was becoming flat. While he meant this as the development of economic parity between the developing and developed world, I think he missed the boat. What's really going on is, with 9/11 as a catalyst, there is a great leveling of the bureaucratic nightmare between the developed and developing world.

My dear wife, as a semester abroad student in Israel, once attempted to get a deposit back in the days when you needed to put a deposit down on a phone. She showed up with a huge stack of papers and bills in order to do this. My dear uncle explained that the clerk was highly trained by the Israeli bureaucracy to rifle through a stack of paper and quickly identify the one paper which you did not have. True to form, in under a minute, the clerk identified she did not have her first month's bill and to this day we are still waiting for a check from Bezeq.

Such has become the experience in getting licensed in California, in getting a DEA number, in trying to start the process of registering a car, in getting a driver's license, in trying to get deposits back for things like E-Z Pass in Maryland, and so forth. Friends starting in Maryland or *gasp* for the federal government agency of the NIH have had it as bad or worse. Like any good third world nation, though, California's budget crisis has forced most state government to close at random times and on random days with the only apparent rationale being that the days they are closed happen to coincide with the only convenient days for you. I only got my license (today!) after basically cajoling my way through the lackey on the phone in order to talk to the muckety-muck. I applied for it in February, and was lucky. Last I heard they were still processing November applications. I also have a dire lack of protectsia in the new state which doesn't help things out.

Anyway, I expect by 2011 that we will need to be offering bribes in order to get simple tasks done. Mark my words and start hoarding $20 bills.

RIP Ali Akhbar Khan

2009-06-30T01:13:00.002-04:00

Ali Akhbar Khan died last week. One of the luminaries of Hindustani music:

His father, Allaudin Khan, trained him, Ravi Shankar, and Nikhil Banerjee. I had the privilege of seeing him in concert a few times. He started a music college that some of my friends have attended in San Rafael; it has always been in the back of my mind to go out there for some lessons if time permits.

Cape Cod Kwassa Kwassa

2009-06-24T01:38:00.002-04:00

Last year's Vampire Weekend CD was fantastic. One of the standout tracks is "Cape Cod Kwassa Kwassa". Bringing afro-pop back to indie rock:

The chorus starts "It feels so unnatural/Peter Gabriel." So who would you pick to cover the song? With the fantastic Hot Chip, the man himself:

Vampire Weekend, at its heart, only had the afrobeat thing on loan. So when Esau Mwamwaya, a Malawian musician, releases his side project, The Very Best (which features Ezra from Vampire Weekend on the very good "Warm Heart of Africa"), he takes the Kwassa Kwassa right back to Malawi.

Day 4

2009-06-18T21:49:00.010-04:00

Our stuff arrived yesterday, so there was no time to blog. What with 150 odd boxes and bunk beds and cribs to reassemble. Much thanks to granma and my wife who have led the way in blitzkrieg unpacking and organization. We are only about 30% through, I think, but it's been less than 24 hours. And, the main stuff needed for life is all done.

Here's the end of the voyage.

We woke up at around 7:30 AM in Reno. Lisa gave us a call slightly thereafter asking very politely to please please please please please try to move it so she wouldn't have to rent a car in Oakland when she got there. Well, neither of us felt like playing more baccarat, so we hopped in the car and started driving west. 202 miles to our destination.

We quickly were over the last state line:

There was lots of road work on the Donner Pass and the Donner Summit. We kind of got holed up in a bit of traffic, but it was at least nice to be able to enjoy the scenery. Snow on the peaks, giant trees, beautiful mountains and streams. I was a bit peckish, and Paul began to look a bit appetizing.

We breezed west, with a stop for gas in Sacramento. Then Davis, and the western fringes of the Bay Area. All too quickly, we were almost home.

A few turns and we pulled up in front of the new house.

This was the first time for me here. We rummaged through the crammed back of the car to find keys. We walked in at around 11:30 AM and appreciated the fine tartan carpet and the spiral staircase in person.

(the carpet is scheduled to be replaced)

Anyway, we rapidly unloaded the crammed minivan, and then got in the car. We were just pulling up to OAK when Lisa phoned that the plane was on the ground. Paul ran in to help with the bags, and then we were all reunited in sunny (well, overcast and cold) California.

The original plan was to head home but boneheaded me made a wrong turn and we ended up on the Bay Bridge.

So we marked Bay Bridge to Bay Bridge a little sooner than I had hoped (and I didn't really start at the Chesapeake Bay Bridge, because Paul's plane was late). We had lunch at the Embarcadero and then headed home to start laying out our new household.

I'll be posting updates from California in the future. Tune in!

Day 3

2009-06-16T20:44:00.012-04:00

We set out from the oil town Casper, WY onto a Wyoming state road and headed towards the Utah border. We quickly found ourselves in TMOFN again, and there we stayed for many hours.

We passed amazing scenery and slowly the land started to dry out as we went into the high desert. We never really got real honest to god bone dry desert, as I suppose it is spring and everything was really quite green. But you could tell that come 3 months it was going to be hot and dry.

During one of the brief times where we had cell service, I got a call from my mom. She asked what it was like, I said a bit like the Klein Karoo. My father asked if there were bokkies. There were bokkies:

Hundreds miles of awesome scenery and absolute remoteness:

To Utah. Snow on the mountains and some imposing rain, hail, and even sleet greeted us in the mountains above Salt Lake City.

Salt Lake City, with a quick exit to drive by Temple Square. It was desolate on the Sunday mid-day when we came through.

And we continue on west, past the Great Salt Lake and the Bonneville Salt Flats.

We cross into Nevada, and traverse the Great Western Desert.

Crossed the continental divide, and of course obligatory TMOFN.

We kept driving until we got to our endpoint for the night -- Reno. The joke is that Reno is so close to hell you can see Sparks (,NV). Well, it wasn't Vegas. At our hotel-casino, the Eldorado, instead of the usual magician/tiger tamer/Cirque du Soleil, they were playing "Menopause: The Musical." Shit you not. Anyway, we had some fun, ate some dinner, lost some money on roulette, made some on blackjack, and crashed for the night. 200 miles from our Western Terminus, to be handled on Day 4.

Day 2, part 2

2009-06-15T23:02:00.009-04:00

We have arrived in Albany, CA, safe and sound. Children and wife and M-I-L all here and suitably exhausted.

This puts me two days behind on updates. Mostly due to lack of 3G coverage in the AT&T network as well as the obvious fact that casinos don't give you free wifi in their rooms as they don't want you to be in the room.

So, I left off when we branched off of I-90 for the 35 mile Badlands loop in South Dakota. You come out of the Badlands loop at around Exit 110 on I-90; we backtracked to Exit 116 to see a Minuteman III missile in a silo:

"That thing will suck the paint off your house and give your family a permanent orange afro!"

Anyone who's ever been to South Dakota will know about Wall Drug. As I mentioned, South Dakota is filled with national monuments and tourists traps wanting to be national monuments (Sturgis, Crazy Horse, the aforementioned Corn Palace, etc). Perhaps the epitome of the tourist trap for tourist trap's sake is Wall Drug. There are literally thousands of road signs for this store.

It is ostensibly a drug store, but it has expanded to be a veritable shopping mall crammed with all of the tchotchkes and Westernalia that one could ever want. Of course we stopped by, bought a trinket or two, split a burger, and we were on our way.

At Black Hills, we came upon the vast Ellsworth Air Force Base and branched off to the southwest, into some ominous looking clouds. Through some mild thunderstorms. About 30 minutes southwest, we came across the next tourist trap:

It started to rain as we left, so we made a dash to the car and got some nice pictures of Rushmore getting wet.

From Rushmore, we could navigate directly to our destination in California, no more off-course waypoints or big detours or such. The nav pointed us southwest onto a South Dakota state road and soon we were in the middle of nowhere, headed towards Wyoming.

The one thing that had started to become clear is that vast swaths of this great country are The Middle of Frickin' Nowhere (TMOFN). I'd say that it dwarfs more common designations, such as the Eastern Seabord or New England or California. We had tasted bits of the TMOFN in South Dakota, but from South Dakota, through much of Wyoming, Utah, and Nevada, we may have well been in the high steppes of Kazhakastan or Mongolia. Sheep, antelope, cattle, a few fences, and not much else. I'd almost started to expect some Bactrian camels. I know it sounds city-slicker cliche, but it was impressive to watch 3G in Minnesota drop off to EDGE in most of South Dakota, to only occasional GPRS as we went further west. It's amazing to see how dependent we've become on a technology that we didn't use 3 years ago. For most of the time past the Badlands, we were lucky to have any signal on either AT&T or Sprint. If the car had broken down, we would have had to walk our ass -- imagine that!

Anyway, we drove and drove, through impressive thunderstorms including a hailstorm. Shortly after punching through the storm line, we stopped for gas in Lusk, Wyoming, and made it a night in Casper. We could have gone longer but we were unclear about the weather, and we knew that we had another 200 miles on state roads ahead of us.

Day 2 was probably our best day on the trip in terms of stops, scenery, and overall driving enjoyment. The South Dakota and Wyoming TMOFN would certainly be a nice place to return and spend some time. Just don't count on cell data service.

Day 2, part 1

2009-06-14T17:54:00.011-04:00

We just pulled into Reno safe and sound. 922 miles. We're gonna find a cheap prime rib and take some pictures and maybe play some blackjack and crash.

Here's the first part of day 2.

In Rochester everyone at the hotel, it seemed, was there for medical related reasons. Conversation at check-in and at breakfast rotated around spots on lungs and heart failure. The clerk had just finished discussing CT scans with the dude in front of me.

The Odyssey in the Odyssey would continue west.

Well, we escaped without any questions about the survivability of stage IIB lung cancer. A quick jaunt into downtown to see the object of everyone's pilgrimage:

And then on the road. More farmland through southern Minnesota, including impressive wind farms. Quite a ways to go before our big waypoint, Mount Rushmore.

n
Eventually, we reached South Dakota. We tried to get a picture of the Minnesota sign because we passed into Minnesota sometime late at night the night before.

South Dakota is filled with national monuments, striking scenery, and tourist traps. These often overlap. But there are quite a few notorious tourist traps. We just drove past the first one, the World's Only Corn Palace.

More farmland until we crossed the Missouri River in Mitchell, SD. From there, the landscape began to break into more rolling hills.

From there, we made our detour into the Badlands. We took too many pictures there to post here, so I put them on Facebook over here.

I'll post part 2 in a bit.

Day 1 on the road

2009-06-13T15:28:00.005-04:00

Yesterday, we woke up late in New Stanton, and were out on the road by 10:30 AM. We continued on the Great American Turnpike -- it was all toll-roads from PA to the northern tip of IL. Thank the lawd for the E-Z Pass (though Ohio didn't take it). This kept us out of city traffic for the most part but also kept us on a reasonably boring stretch of roads with the only interruptions being the depressing gas/fast food stops containing Cinnabon and Nathan's Hot Dogs and other barely edible foods. We had planned that day 1 would be the boring day of driving, for fun on days 2 and 3. Day 1 lived up to that expectation.

The Allegheny River crossing outside of Pittsburgh. Or was it the Cuyahoga outside of Cleveland?

Paul was fascinated about the edges of the barns curving down, presumably for the snow.

The Penn turnpike ends and we go to our second state:

The plan was to try to photograph all of these. Indiana, our third state of the day, didn't have one. So we had to settle for something else:

"It's 167 miles to Chicago, we've got a full tank of gas, no cigarettes, it's not dark out, and we're wearing sunglasses. Hit it!"

A little detour. When's the next time I'm, gonna be in South Bend, IN?

You can't hear the Odyssey chanting "Rudy! Rudy! Rudy!"

And on to Illinois.

I-294 took us west of Chicago, but we still managed to see the famous skyline from the car.

From there, north to Wisconsin.

We stopped for dinner, at Glass Nickel Pizza in Madison, WI. This was on the recommendation of my friend Kristi, who is a Badger Faithful. We got back on the road, crossed the Mississippi River sometime around 11 PM and shortly thereafter pulled into Rochester, MN, our goal for the night. 6 states (PA, OH, IN, IL, WI, and MN) in a day, about $50 of toll roads, and a lot of farmland was behind us.

We just arrived in Casper, WY at the end of Day 2. Day 2 was a lot better. We actually saw cool stuff. I'll crop some pictures and select some from the road tomorrow. Tomorrow, the goal is Reno, NV.

Day 0

2009-06-12T10:55:00.011-04:00

Confucius says that a journey of a thousand miles begins with a single step. Well a journey of 2810 miles begins with cramming the car filled with all of the stuff that we didn't send with the movers.

I spent all day packing the last remnants into boxes and then loading the car. I also went into the hospital to turn in my pager (so naked without it!) and say goodbye to everyone. I also took care of a few Baltimore errands. Of course Paul's plane was delayed 80 minutes. So, knowing that it would be a late night, I took a nap instead of driving to the Bay Bridge. It's not that exciting anyway, and I knew it was gonna be a late night.

Instead, a view of the Inner Harbor from Fed Hill will have to do:

And we're on our way.

We decided to try to know back a few hundred miles instead of going back to my empty townhouse. 695W to I-70, and the obligatory sign picture.

Most of the trip last night was through rain and fog in the Allegheny mountains.

Including this cool tunnel.

Eventually, it was 2:45 AM, and it was time to stop in New Stanton, PA. And no, we didn't find New Dunder Mifflin there.

To Rochester, MN tomorrow!

New Stanton, PA, 3 AM

2009-06-12T02:51:00.002-04:00

Made it through rain and fog and late night to New Stanton, PA at 3 AM, as the brother's plane was 80 minutes late.

Will post some pics and some other stuff from the road tomorrow.

Last concert in Baltimore

2009-06-10T01:49:00.003-04:00

So last night we had one of our last resident outings before I leave Baltimore. We went to see a terrific triple billing of Robyn Hitchcock, Andrew Bird, and The Decemberists at Merriweather Post Pavilion. I had high hopes for the arena, mostly because the best reviewed Pitchfork album this year is named after the place.

Sound was OK, arena was OK. Like any number of outdoor venues I've been to. We had seats, which we were thankful for as rain was forecast.

Robyn Hitchcock was OK, not really my thing. Andrew Bird came on, and for the third time that I've seen him, he was utterly brilliant. Just painfully, utterly brilliant. The crowd was just not that into it, which I thought was a bit odd.

Then The Decemberists came out. Now, I think the concept album should have died a deserved death sometime around 1984, when Roger Waters stopped making regular music. The Hazards of Love has some great stuff on it, but there is a lot of repetition and a lot of filler on the album. So maybe, even though I get the whole "concept" nature of it, it would not be the best idea to play it front to back. So that was a bad decision.

But even for the bits that rocked, the crowd was treating this not like a rock show but like friggin' theater. When members of our party got up and danced, we got yelled at to sit down. We were in the seats not on the lawn, so I guess others reasoned that they had paid good money to be able to sit down. But even though it's a concept album, this was not high art. Sorry guys, in the end, it's just rock music. At least give me a head bob. And it's not only the band -- when I saw them in December, the crowd was rocking (but that was at a smaller venue, and they didn't play an entire concept album).

The crowd was a total fun vacuum. Eventually, after getting shushed (yes, shushed at a rock show), we moved to the lawn, where there were at least a few people standing. We sang and head bobbed unmolested for the rest of the show. We watched the "encore" of 5 or 6 old songs and a very odd, but good cover:

At least the lawn got into that. Well, I suppose it speaks to the dangers of a concept album. Let's hope that the Decemberists realize that even when you are playing indie sea shanty music, it's still music that's defined by the phrase "it's got a good beat and you can dance to it."

Cleaning up

2009-06-07T16:28:00.004-04:00

The last few days have been huge. We got moved out, forgetting very little. We finished packing in just enough time. We got the kids and Lisa to Houston, barely

Now it's just me and the detritus here. And 10 bags of trash.

I'm finishing packing odds and ends (so far packed another 2 boxes).

In honor of it, let's do some music. I saw Man Man and Gogol Bordello on Thursday night, much to the consternation of everyone as we were still in the frenzied packing stage.

But it was a good show, even though my inner ear paid a bit of a price. I have had some tinnitus for the past two days. People were moshing and crowd surfing to Gogol Bordello, which says something as their instrumentation is an acoustic guitar, an accordion, a violin, bass, and drums. Even Mr 1979-Punk-Mohawk guy and his 300 lb friend were into it and crowd surfing.

I have had Man Man's "The Man in a Blue Turban with a Face" for a while now, and I enjoyed it but I thought it a bit too Tom Waits-ey, mostly due to the dude's voice. But their show was out of control, and the crowd got very into it.

Here's a taste:

Movin'

2009-06-04T00:34:00.005-04:00

The Big Move is upon us. Today was my official last day of residency (with 3 clinics remaining, but starting tomorrow I am on research time).

Timeline for the next week:

Tomorrow 6/4: Frenzied packing of the last 10% of the house that needs packing that my saintly wife hasn't done yet. Seriously, she's done 90% of the house by herself between working this ridiculous job and taking care of the kids while I selfishly continue my 15 hour days. My jobs -- finish the books, clean the kitchen, pack the liquor, cook some chicken for our friends who just had a baby, finish the coat closet, and pack as many of my clothes as I don't need. TV and stereo system last as the kids may melt into goo without TV tomorrow night. I then sneak out to see Man Man and Gogol Bordello, live and in concert.

Friday 6/5: Moving company should be here bright and early 8 AM. They will pack the rest of the kitchen and the rest of the delicates (pictures, knicknacks including Lladro and other ceramic figurines that I have been desperately trying to break). It is complicated because 9 AM I have a ridiculous clinic starting, and 11 AM my daughter has graduation from preschool. We'll get the suspicious Russian neighbor to look over the movers. One look astray from her and it spells banishment to Kolyma.

Saturday 6/6: My car gets on a truck to go west. Then my wife and children get on an airplane to go southwest. We'll hope that the two don't coincide.

Monday 6/8: My penultimate clinic. An all day affair filled with the finest little old ladies with 15 medical diagnoses that East Baltimore can produce. Afterwards, The Decemberists, live and in concert.

Tuesday 6/9: Senior farewell dinner. Should I try to get tickets for the surprise Beastie Boys show announced today and skip the formal farewell dinner? The Beastie Boys may be worth it. Everywhere I look, I see bridges, I've got matches in my hand, and it's time to burn, baby.

Wednesday 6/10: My ultimate clinic. Another all-day affair that should be sufficiently painful.

Thursday 6/11: Pick up the brother from the airport at 9:45 PM. I will begin photoblogging the trek across the country. We'll probably try to drive down to the Chesapeake Bay Bridge so we can drive from Bay Bridge to Bay Bridge.

Friday 6/12: Can we make Rochester, MN in one day? Tune in and find out!

Cheech

2009-05-30T21:21:00.006-04:00

Two explorers are shipwrecked off of a tropical island. They swim ashore to be greeted by a tribe of natives, who promptly tie them up and bring them to their village. Out of a hut walks a man who is obviously the chief. He walks up to the first explorer.

"Death or cheech?," he asks.

The two explorers look at each other quizically. The first explorer, thinking that anything must be better than death, answers "Cheech, I suppose..."

His boundings are cut and he is dragged into the forest. For the rest of the day and night, the second explorer hears his blood-curdling cries which are eventually silenced.

The next morning, the chief comes to the second explorer. "Death or cheech?," he asks.

The second explorer, not wanting to live through whatever the first went through, answers "Death." The chief replies, "Death it is. But first, some cheech!"

The term "cheech" (having nothing whatsoever to do with anything named "chong") is a term that, if not specific to my institution, certainly originated here and virally spread. Much like the structure of the modern residency program. The origins of the term is a mystery, but the legend attributes it to the above story. Cheech is like The Force: it surrounds us, permeates us, and binds us all together.

Cheech is hard to define except by example. A patient with new arthritis may get the classic rheumatology cheech bomb dropped on them: ANA, anti-DNA, ANCA, Ro/La, Smith/Jo, C3, C4, RNP, RF, CCP, RPR, HIV, HepB/C, cryoglobulins, anti-cardiolipins, Russel's Viper Venom test, etc. A new cardiomyopathy has an echo, SPEP, UPEP, ANA, HIV, HepC, TSH, ceruloplasmin, urine copper, ferritin, iron panel, left cardiac catheterization, perhaps a fat pad biopsy, and maybe a right heart catheterization with endomyocardial biopsy. Don't get me started on a new liver, heart, or lung transplant evaluation. May as well open the computer ordering system, start at the top and work your way down.

A story from my intern year epitomizes cheech. A patient presented with a new finger ulcer. Among the workup suggested was cryfibrinogen and cryoglobulin. The lab cannot draw these samples, as it needs to be kept at body temperature from the patient's room on the fourth floor until it gets to the appropriate laboratory incubator in the basement. Cryoglobulins are a pretty standard lab, and I assumed cryofibrinogen was the same. So post-call Ed ordered the tests, and dutifully took a tourniquet, butterfly, and a red top with the necessary accoutrements to the bedside, drew the blood, put it under my armpit, and walked it to the lab incubator. Ahh, the lab tech says, cryofibrinogens go in a green top. Back to the patient's room, tourniquet, butterfly, green top, and accoutrements, apologize, draw the blood, in the armpit, speak to three or four different lab techs in the basement, and find the appropriate incubator (a different one). The lab tech, however, has another problem. No control specimen in the hospital, so they can't run the test. So post-call Ed puts his coat on the back of the chair, rolls up his sleeve, and has a control cryofibrinogen drawn by the tech, who puts Ed's blood in a tube, into the armpit, and back to the same incubator. The patient was cryofibrinogen negative a week later when the test came back.

The first rule of cheech is that not all work is cheech, but all cheech is work. My god, is it work. It's like extra-virgin work.

The second rule of cheech is that scut is not cheech. Cheech may sometimes by scut, but never the other way around. One could draw a Venn diagram:

The third rule of cheech is that it must be indicated and appropriate. It's not hard to find an indication, but it still chaps my hide when a methylmalonic acid and a serum lead level is sent in the first round of a workup for an anemia in isolation. We can't go hog wild because we want to ensure a future of cheech and Mr Obama happens to be relatively nearby.

The fourth rule of cheech is that the more cheech done early, the quicker to discharge. Disposition is first. Cheech flinging is not only encouraged, but expected out of those overnight on-call interns (and unit residents).

The fifth rule of cheech is that in order to be considered cheech, it needs to be gratuitous. It's sometimes hard to make rule three and rule five jibe, but such is the nature of cheech.

And yes, there is no rule six of cheech.

Now you may ask what relation does cheech have to being a good physician? Hard to say, really. Some cheech bombs are detonated reflexively, like a package of unclear provenance at a federal building. And sometimes, those packages are bottles of fine port from the Portugese consulate. But we spend so much time mastering cheech, it's hard not to think that it is one of the primary things I'll be taking from residency. Cheech forces us to think about disease pathophysiology and about disease mimickers right from the time we put in admission orders (rule four). It's not all cheech for cheech's sake.

Demented music

2009-05-19T21:42:00.003-04:00

I'm done with call! In honor, let's post some music.

I'm always on the lookout for music that is a little, or a lot, insane. Catchy but insane music is among my very favorite genres. Music that could only be conceived by mad genius. Seeds were sewn when blackpetero had me start listening to Frank Zappa sometime around 1990.

In college, the next group to slip right into that spot was Mercury Rev. The song "Something for Joey" is so good, it makes you wonder why every rock song doesn't have trombones, flutes, and noise generators.

Baltimore's own Dan Deacon perhaps exemplifies mad genius for me recently:

BTW, how cool is that Florida NBC morning show to have this dude on? Can you imagine waking up to that? We're talking 16 ska bands! We're talking 19 ska bands! It is one of my biggest failings that despite numerous attempts, I have not seen Dan Deacon before leaving B'more. Perhaps in SF, he does make it out there. I recently got his newest album, Bromst and it is nearly as good as his fabulous last album Spiderman of the Rings. Check out the YouTube for "Crystal Cat."

Tonight, I downloaded the fantastically named Dananananaykroyd. Their song "Black Wax" gives me high hopes. Maybe not as crazy as Mr Deacon, but 1+ more crazy than your average indie band.

Comfortable shoes. And pens.

2009-05-17T14:58:00.004-04:00

I only just barely manage to survive every 30 hr shift. Like a desert nomad or an island castaway, one develops strategies to hang on to life, even if it is just a bare semblance of what your life used to be.

This means routines. How to admit patients. When to sleep, if at all -- do you take your chances before all your patients are tucked in for the night, leaving work for the morning, or do you push it back till 5 AM, when you will most likely be interrupted several times by the lab reporting critical values and the nurses trying to square away everything before shift change at 7? Scrubs when the clock strikes 6PM for the interns. Dinner at the same time every night, if possible (I like to eat late). Sleep vs breakfast vs shower. There's rarely time for all 3, and usually not time for 2.

For me, I have a thing for comfortable shoes. I know exactly which shoes I can make it through call in, and which ones to avoid. I wear Merrells for most calls, because I don't have to lace them if I go to sleep and need to jump out of bed for a code. For the unit, where we have long rounds and we don't walk around the hospital all that much, I wear Naot clogs. Not the most fashion conscious choices, but just a survival strategy.

For me, another big thing is pen selection. We still hand write admission and progress notes, so this is big. Since I am a loser of pens, there's no way that I'm going to use nondisposable pens. Many residents start with the Pilot G2 .07s. I kind of have micrographia so I quickly moved on to the micro point (.05). In my opinion, though, there are a number of problems with this pen. The first, universal to all gel pens, is that they run out quick. They last only a week or two at most. Second, there is a relatively high failure rate for the roller ball -- you'll be using the pen a few days and then it gets either unusuable as it will start to sputter. More importantly, though, is that the G2 is prone to leak. When you are wearing a white coat, leaked black ink in the bottom of the pen pocket is a sign of the G2 user. After my third lab coat done in like this as an intern, I switched to the Uni-ball Signo 207 .05 pens. They do not leak, but there is a relatively high failure rate still of the roller ball. At around $2 a pen, this irks me. Two problems with this pen is that I have yet to find them in bulk at Staples and they cost too much. Like the G2, they are refillable, but I'd rather have a fresh body for the $1 I will save by refills.

Just in time for my Last Call Ever (hopefully), though, I have two new candidates. Today at Target they had the Pilot G2 0.038 Ultra Fine. Enough to make me reconsider the G2. I also picked up the Sharpie Pen fine tip, which I am very excited about.

Wow. Just wow

2009-05-13T22:26:00.002-04:00

I'm now 7 calls into 4 weeks into q3 call. It's a 6 day call cycle, with a 30 hr shift over the first two days, then the third day is a normal 8-6 ish day and then a 30 hr shift and then a day off. It gets brutal after a while.

The MICU at the hospital is small. So small that the other units make fun of it. It's kind of like the movie "Das Boot":

The "MICU resident 7-0" (a call holding on extension -70) comes on the overhead more than you would like. While it means work, it has also has the highest proportion of hit-to-miss ratio in the hospital. As in, calls worth your time because of sick and/or interesting patients versus just other hospital bullshit. In my 2 weeks, I oscillated two people, both of whom are now extubated, one of whom has left the hospital on room air. That guy had acute rejection after a lung transplant. The other was a 3+ sick lady who we diagnosed with Goodpasture's syndrome. She came in on maximal vent settings after walking into a community hospital 3 days prior with a slight cough. Admitted at 8 PM, we oscillated her, had her on maximal life support, pulsed with steroids overnight. By 1 PM the next day, she had a kidney biopsy, she was diagnosed by 5 PM, had plasmapheresis by 6 PM, and cytoxan a day later. She was extubated after 10 days on the ventilator. It was kick-ass.

Now I'm in the CCU. We have absolutely crazy physiology over there and I'm learning lots. But the call schedule is absolutely brutal. That, and it seems like every call I'm totally thrown for a loop. Last night, I watched a very pleasant woman walk in with a blood pressure of 270/170, then drop her blood pressure to 110/70 with almost no intervention (it had been 2 hours since her last dose of BP meds), become obtunded, started pressors, called the Brain Attack Team (kind of the neuro code team), intubated her, sedated her, CT head, MRI brain and neck. I still have no clue what's going on with her but it is sure intriguing for pheochromocytoma or VIPoma. Or maybe just she just vaso-vagal'ed or something.

Though, it is time for it to be done. Call on Friday, then again on Monday, then I'm done with call. After 90+ calls in my intern year, and probably 50 or so in each my junior and senior years, it seems like the day would never come.

Swine flu

2009-04-28T19:22:00.003-04:00

Man, the guys in infection control at the hospital have been running around with their hair on fire. They now have something that looks like it can justify their existence after weekly bioterrorism/pandemic flu pages since 2001.

H1N1 has a reasonably high case fatality rate, and it is killing young people, which regular old flu A does sometimes. But apparently the vaccine is protective, and oseltamivir/rimantidine does pretty well (which can't be said about this season's regular flu A, which was largely resistant to oseltamivir). The killing young people is what everyone worries about, and I think that's driving the hysteria in large part. But mostly, like so many things, I think everyone has been waiting for a pandemic flu for so long, and so many resources have been marshalled in preparation, that people are unloading.

We got at least 20 emails about it today. In the MICU, we will be the ones seeing respiratory failure, so we got 15 or so pages on the code pager about mask fitting, and how acute respiratory failure will be assumed to be H1N1. Everyone (visitors, patients, staff) will be screened for respiratory symptoms at the door of the hospital. It sounds like any respiratory failure will be placed on full droplet precautions, with use of gowns, gloves, and N95 masks (which cost $5 apiece) for any contact. All this is planned without any cases in the area, but up the coast a bit. We shall what spreads down from New Jersey. If it starts heading south, and there is evidence for person-to-person spread, it will be interesting to watch how people start to flip out.

Torture

2009-04-22T20:54:00.003-04:00

So I was sitting in grand rounds last week, it was about conflict resolution, and a near identical talk by a guy who gave a noon seminar last year. Due to the dangers of the iPhone, I was reading some blogs that I frequent, which led me to the Bybee memo. Now I didn't read all 50 pages of it, but some blog posts pointed me to this:

We also understand that a medical expert with SERE experience will be present throughout this phase and that the procedures will be stopped if deemed medically necessary to prevent severe mental or physical harm to Zubaydah.

I thought we had been through this already. Anyhow, just about made me sick to my stomach.

Given that grand rounds was a full hour on conflict resolution, I registered a blog and a Facebook group, Doctors Against Torture. Not that I've done anything about it yet, as that hour of grand rounds was about my only non-busy hour this week. And it's not like I'm so prolific with this blog that I need two. But just saying.

Smallpox

2009-04-15T23:15:00.002-04:00

In our senior year, our program director puts together a few after-dinner get togethers with notables from the medical field who happen to live in the area. Lucky for me, this happens at his house, about 2 blocks north of me.

Tonight we had a nice sit down with D. A. Henderson. Interesting guy. He told the whole story tonight of how smallpox was eradicated. Basically, the opportunity to head the WHO smallpox eradication campaign in the 1960s and 1970s was forced into his lap due to a bunch of political machinations. LBJ had a West African smallpox eradication program which he fell into, after working at the CDC's Epidemiology Information Service and rising through its ranks while it was quite small. The Russians wanted the WHO to start a worldwide vaccination program, but weren't willing to back it unless they could pin the blame on America if it failed (as had the previous WHO malarial eradication campaign). So Dr Henderson got basically forced into the position. It sounds like it was a bit of a slog, but in 1980, after a last case in Somalia, smallpox was declared eradicated.

He worked after that on polio, was dean of the JHU School of Public Health, he was high in the ranks in the H.W. Bush administration (besides being a dyed-in-the-wool liberal whose wife headed Planned Parenthood Maryland), and then got sucked back into government after 9/11 to look at bioterrorism.

While it was very fun to speak to him, it was a bit disheartening to hear how many times (as he tells it) he just stumbled, almost by luck, into positions into which he was able to effect massive benefit towards humanity.

Battle stories

2009-04-11T18:59:00.001-04:00

Almost diagnosed someone with this today. Last year, one of my buddies did diagnose someone with that, but I could never hope to be that cool.

Sounds like he had food poisoning.

New music

2009-04-04T00:31:00.002-04:00

I got the Sin Fang Bous disc today, mostly because of good recommendations on emusic. They recommend it as the "Icelandic Sufjan Stevens." That's pretty apt:

Got the new record by The Pains of Being Pure at Heart, which is great as well. Like a Jesus and Mary Chain type sound but with a late oughties pop sensibility. Also got two by Grizzly Bear, and a really nice double disc compilation from the Red Hot series to benefit HIV. It was put together by some of the members of The National (maybe The Very Guy I Sat Next to at Bertha's Wedding). It is called "Dark was the Night" and it has some fantastic music on it, including a great collaboration between David Byrne and The Dirty Projectors, a new track by The Arcade Fire, and a spectacular cover of Vashti Bunyan's "Train Song" by Ben Gibbard and Feist. Not to mention MMJ, Sharon Jones, the aforemention Sufjan Stevens, etc.

April fools

2009-04-01T09:16:00.002-04:00

I don't really enjoy April Fool's Day. Mostly this is because of a pathologic fear of being caught by a joke. I blame it being laughed at in the 4th grade because I thought that the instamatic flu was a real disease (from Shel Silverstein's poem "Sick.") Needless to say, I have diagnosed at least 3 or 4 people with the instamatic flu.

I have, however, grown very fond of the Google April Fool's Day projects. This year's is no exception.

Back to work program, part two

2009-03-27T20:26:00.002-04:00

Yesterday I dragged my jet-lagged ass back to work, after two glorious weeks on the soft underbelly of the planet.

Service isn't too bad right now, only 16 on the board and we actually shrank despite 6 admits overnight, but it still is work. I have 73 more days (10 weeks of work + 3 days of clinic at the end) to knock back, actually now 71 since I have worked 2 days. Not that anybody is counting. In some sense I don't know what I'm looking forward to, because it's just more work after the Big Move. Just different work, in a different place, without fewer shooting galleries and vacants and pit beef sandwiches.

Watchmen

2009-03-10T09:21:00.004-04:00

Me and my superhero-movie watching buddy went last night to see Watchmen. I own the book and enjoyed it, although not in the life-changing way that it has affected others who belong to the Church of High Geekery. Like most fluff that I have processed, I remembered parts of it but forgot most of it, to which my friend (who has a better memory than I for most things including this) filled me in on the way to the theater.

It has been getting pretty mixed reviews. All in all, I found it very watchable -- it held my attention for the two and a half hours without any problems. It was a superhero movie, and was about as true to the story as could be expected (while fixing the original awful ending). There were some very, very noticeable fatal flaws though:

1) The violence in it was not only over-the-top, it was unnecessarily graphic and gory. Slow motion leg breaks, cutting the arms off of people, etc. I'm not normally bothered by cartoony violence (i.e. Kill Bill or a slasher movie), but this was so gratuitous that it made both of us turn our head. And I debride abscesses for a living, and my friend slices up eyeballs (oh oh oh oh - 5 points to name the song).

2) The acting, and especially the sex scene, of the girl was just terrible.

most of all, though

3) The music selection was unbelievably awful. We both commented on this as soon as the final credits began to roll over a My Chemical Romance (ugh!) heavy metal (ugh!) cover of "Desolation Row." Vietnam war footage to "Ride of the Valkyries"? How cliched is that? A funeral for a right-wing nearly fascistic superhero set to "Sounds of Silence"? "99 Luftballoons" just thrown randomly in some scene? A fight scene to "All Along the Watchtower"? A flashback to "The Times They Are A-Changin'"? Cliched at best, totally inappropriate at worst. The low point was the aforementioned terrible sex scene set to the original Leonard Cohen version of "Hallelujah." It was almost laughably bad.

Lighten the mood

2009-03-07T08:06:00.001-05:00

The most ridiculous thing I have seen for a while.

18 large hot dogs!

Yahrzeit

2009-03-07T05:53:00.003-05:00

Priya died one year ago today. She was 29.

In Memory of Priya

Our program is kind of odd that we grow very close with the people in alternating years -- 1st year interns are mostly supervised by 3rd year residents, who are mostly supervised by a chief who was a 3rd year when the 3rd years were interns. There are only a few opportunities to work directly with the 2nd years, who are off at Bayview or elsewhere. Priya was a year ahead of me, so our direct interaction was limited to time we had together in the CCU.

Priya was my CCU resident when I was an intern for just one night of call, and also on my CCU team for another 2 weeks. She was also in my firm, so I knew her pretty well through that. But it was clear from that short time that she was spectacular. When she was a senior resident, she was one of the strongest and the most respected in our programs. Indeed, we learned at her funeral that she was offered one of the 4 chief spots.

It was obviously incredibly painful to have someone so young and promising die. Nothing good can be said of the whole thing. But there were a few points to take away from the whole thing. When Priya got sick, she was choppered in to our hospital from the community hospital to which she had been admitted. She had the heads of many departments at this hospitals pore over her case. Her case was discussed by world experts in neurology, infectious diseases, rheumatology, pathology, and of course internal medicine. Everything that could be done was done. Every stone that could be turned was turned. Not only did she pass, but even after an extensive autopsy, we never arrived at a diagnosis. She will never let us forget that we are always limited in our practice of medicine.

The other thing that can be said is that this program is much more like a big extended family than it is like a regular job. First, obviously, the pain of the loss that we all felt was more akin to a family member than it was for a co-worker. Second, the whole program pulled together, coverage for people who needed to attend the funeral and the other events was arranged without an eyeblink, and support was put into place. I try not to drink the whole "#1 hospital/#1 program" Kool-Aid, but I think it is a huge testament to our program.

Priya will be missed. There will be a dinner for her tonight which I will try to attend despite pulling this 18 hour overnight->day shift.

Wednesday morning, 3:40 AM

2009-03-04T03:40:00.002-05:00

So far, the night has been silent. No admissions for either me or mi compadre, the other resident admitting from 1 AM to 7 AM. That either means that it will stay silent (note how I avoid the "q" word) or that all the admissions will be backlogged right to the time that I start getting groggy at about 5 AM. Since mi compadre has an interview this morning across town, I'm taking all of the late admits. Which of course means that we are talking backlog. I could lay down and sleep now, but my schedule is messed up enough that I'm not at all tired. It's gonna be great when I go to day shift in a few days.

Just catching up on reading, which means instead of this week's NEJM, I just read a fantastic article on a systematic analysis of why Billy Joel is so awful.

I should really go read this week's NEJM...

It's March!

2009-03-01T00:23:00.001-05:00

It's March!

4 months until the Big Move!

Back to work program

2009-02-28T12:25:00.002-05:00

I'm in the self-imposed jet lag that is the day before a night shift after time off. I stayed awake late last night, slept late this morning to the consternation of the household, and I plan to nap this PM. I work from 10 PM to 8 AM for the next 2 nights, then 1 AM to 8 AM for the next two nights. Repeat out for 7 night shifts in a row. Then 4 day shifts and off to South Africa.

The 6 first-year on-call interns admit from 1 PM to 1 AM, then there are three 2nd or 3rd year "float" residents (2 night and 1 day floats -- called NATO and DATO by our program) who cover the admissions from 1 AM to 1 PM. This can be a very, very busy shift and people generally hate it. Where you may take 5 fresh admits in 12 hours as an intern, you may take 5 fresh admits in 6 hours as NATO. One night float gets there early (10 PM) to serve as a modicum of backup for interns who are there alone and may need help with procedures or other stuff. The night floats admit to 7 AM and then signs out their patients to the interns; day float admits from 7 AM to 1 PM.

I'm not looking forward to it. First, there is the issue with switching my schedule around, which I am kind of used to. Second, it absolutely wreaks havoc with me helping out around the house at all. The kids wake up 6-7 AM, and need to get ready for school at 9 AM. They will be leaving the house a few minutes before the earliest possible time I can get home. I'll sleep sometime in mid-day, and I never sleep effectively so I end up sleeping too much during the day. Say 11 AM to 5 to 7 PM. Kids get picked up between 3 and 5 PM so I'm useless for helping with pickup duties as well. Then they are home right as I am getting up, so I'm all groggy and useless with making dinner or cleaning or playing with them.

The third reason it stinks is it is can be extremely busy, with no good time to do good workups, you just hope to admit and to stabilize patients as fast as humanly possible. You then dump them off as fast as possible to the post-post-call interns who hate NATO admissions. It's a great way to ruin your reputation as a thoughtful and complete senior supervisor to these interns. As a senior resident, you carefully supervise and critique their admissions. You review the presentation yourself, spend lots of time carefully examining and questioning the patient yourself, reviewing the literature, and then discussing it carefully with the attending and consultants. It's easy to accept the intern's adoring gazes on you as the Role Model Doctor. That all goes to hell as NATO, when you shovel a hastily thrown together pile of crap right on their head, worse than any admission that they ever would dare to bring to your god-like visage when you were running the team last month...

Medical licensure

2009-02-25T15:39:00.002-05:00

They make it surprisingly difficult to get a license to practice medicine. I wonder why.

In my residency program, I am protected by an institutional license to practice medicine. When I move to California, I think I can still use the institutional license but they encourage you to get your own. This also allows you to moonlight.

Last week, I started looking into the process. It became immediately apparent that This Was No Joke. "Allow up to 6 months to get a license." California gives a 10 year window for first applying for a license from the date of your first USMLE (licensing) exam. Mine was....August 1999. Extra documentation and possibly an extra exam may be required if it is longer.

Well, I guess I better get started.

Web application then fill-in PDF application took a few hours to do.
$1330 paid online. You know that is going towards the salaries of the best bureaucracy money can buy, finely trained in the art of rifling through a stack of documents and finding incorrectly filled out spaces and missing forms. Then, printing, collation, pasting (not taping) a photograph (not scanned or otherwise modified and Polaroids not acceptable), then notarization of said forms. Web form and $50 for USMLE transcripts. Forms submitted to the medical school for official diploma and transcript. Forms submitted to the hospital for certification of training, along with hospital seal and notarization. Forms submitted to fellowship to attest to enrollment in training program. Cover letters for all of the above. And everything got mailed off at the beginning of the week.

One last thing to take care of. California requires background checks from the FBI and the state. So I contacted the webmaster to send me fingerprint forms, which I got three days ago. Two days ago, I romped around Baltimore to figure out who could roll some prints. Eventually, I found out that not 3 miles from my house there exists a specific Baltimore City office to do just that.

Unsurprisingly, there are a lot of people in Baltimore who require background checks and fingerprinting. The first time I went to the office, there was a line of an interesting pie-slice of humanity out of the door of the office. That line was just a line to the clerk. After waiting in that line, one had to wait to get fingerprinted. I'd estimate about 100 people waiting, so seeing I had to get the kids in an hour, I left. I went back this morning. I got there nice and early to beat the crowds, only had to wait 1.5 hours (I was 9th in line), paid my $20, and got my fingerprints rolled. Mailed them off this afternoon.

It is a good thing because pretty much starting Saturday, I have solid work until June save the 2 weeks of vacation for the Big Trip. Let's see what parts have to be repeated after the world-class bureaucracy gets their mitts on my application.

The Great GRO Game

2009-02-22T16:03:00.007-05:00

The Big Move is turning out to have many analogies to The Global War on Terror. Both are frightening, present seemingly insurmountable challenges, and are without a clear exit strategy or end-game, i.e. there's no way to get from here to there without unacceptable amounts of blood and treasure, but now we are locked into it.

If our house is like the worldwide multifactorial complex societal ills that lead to terrorism, our basement is like Afghanistan. It is cold, largely inaccessible, and filled up entirely with obstacles to our success. That is, it is a huge mess. There are three storage closets not only filled up completely with stuff, but the big storage closet is not even accessible due to all the stuff piled up in front of it. Much of it is in boxes not unpacked from our move from Houston 3 years ago. It is where empires (of cleanliness) go to die.

We have a lot of stuff. I don't know how we acquired so much stuff; of course much of it is the kids, but I think the consumerism boom of the 1990s and 2000s happened to occur at a time when we had a lot of space. Now we have no money or space, and both are gonna get less as we go out West. This necessitates the Get Rid Of, by garbage truck, craigslist, and eBay.

I filled two black garbage bags of stuff to Get Rid Of today, and packed a large box. I then looked around and realized that I've maybe now dealt with about 1% of the stuff down there, not to mentioned in the house in general.

It's gonna be a bloody spring.

Life insurance

2009-02-22T11:09:00.003-05:00

Because I have 3 children (that I know about) and some time off, I figured there was no time like the present to take care of grown-up stuff that I've been avoiding to this time. So I called our car/rental insurance dude and asked him about life insurance.

After usual formalities, he had only one question for me -- "Do you have an exercise program?" Nothing about smoking, or family history, or smoke detectors in the house, or seat belts while driving, or my hobby of fighting bulls with chainsaws glued to their horns.

Of course with my (normally) 60-80 hr a week job, 3 kids, and aforementioned toreador duties, I don't have an exercise program. I barely have a seeing-the-kids program many months. I walk the stairs at work (I work on the 4th floor and we often have patients on the 8th), I am on my feet most of the day, and of course I try to at least roll around with the kids a little.

The question struck me as a little weird. Not because I completely doubt exercise -- it has proven benefit in preventing prediabetes turning into diabetes, also bunches of stuff on it improving COPD, heart disease, obesity, osteoporosis, yada yada yada. But it got me thinking about the science of exercise in someone like me -- mid 30s, no comorbidities, not overweight, last I checked not hyperlipidemic or hypertensive.

It proves there is not much out there. I spent a few hours flipping through the PubMed results for different searches in which I was specifically looking for outcomes. As you can imagine, most searches bring back several thousand articles, so I narrowed in to review articles. This absence of evidence is unsurprising, as a study to look for adverse outcomes on healthy adults would have to be enormous in order to show any sort of effect (because events are rare). As always, absence of evidence is not evidence of absence. The interesting thing, though, was a number of papers (for example here that I found that support really moderate physical activity (30 minutes of walking a day and it doesn't matter if it's at work, plus a bit of resistance training) in healthy people. More activity, in some studies, is associated with negative outcomes.

This makes physiologic sense. Among the only things that have prolonged lifespan in animal models are reduced caloric intake. The metabolic process itself generates bad things, like the over-hyped "free radicals", which contribute to disease and aging. It doesn't make sense to overeat and then to try to burn it off in the gym because you are just causing metabolism to go into overdrive.

In short, I think I'll have to incorporate some resistive exercise and increase my walking, probably to stave off hypertension, hyperlipidemia, and frailty. Also to keep myself from becoming overweight, which is expected as metabolism normally slows down with age. But it's far from clear that a regular exercise program beyond the very mild recommendations does anything to promote health or survival in a healthy age group, and I don't see why it's the first question from a life insurer.

2009-02-19T23:39:00.003-05:00

New Music! New Music! New Music!

Got Andrew Bird's "Noble Beast." I don't like it quite as much as "Armchair Apocrypha" yet, but "Oh No" is a terrific song. This YouTube demonstrates what a weird musical genius he is (and how cool the Line6 delay looper pedal is in the right hands, I bought one after seeing him the first time and I'm not even in the same galaxy...)

But how can it get any better than this?

Speaking of cool festival performances, here's Shearwater doing Rooks at SXSW. Cool, cause they're an Austin band (even cooler, the lead dude was/is an ornithology grad student at UT).

Anyway. Also got the new Beirut today. Very excited about it, but I haven't listened to it yet.

Deodorant and call

2009-02-17T23:35:00.006-05:00

I had another all-day clinic today. Same old, same old. Systolics above 200, fingersticks in the 400s. Blah, blah, blah. I am a terrific clinic doctor...

I ran out of deodorant two days ago. I have a backup stick, which I never use, except in situations like this. This is because it was part of my "call kit", which I bought in the Monument Street Pharmacy on my third call as an intern because I realized I had left my overnight bag at home. It consisted of a stick of antiperspirant (not my regular flavor), a very cheap toothbrush, tooth floss, and a small travel-sized tube of toothpaste that was quickly used up and replaced by the Crest out of the patient supply cabinets on the wards. The Monument Street Pharmacy was never known for its amazing floor stock.

The neuroscientists teach that the reason that smell is so closely linked to memory is because the olfactory bulb projects to the piriform cortex which is on the inferior surface of the brain, in the median temporal lobes and by all the mysterious knobby bits, one of which is the hippocampus. The hippocampus (or seahorse) is a bit of gray matter that is key in formation of short term memory. Damage both hippocampi and you end up like HM (who just died) or Mr Short Term Memory or Leonard Shelby.

I suspect this is all bullshit, just like most overly simplistic mechanistic explanations of how the brain works. Needless to say, this antiperspirant brings back the post-call in a bad way.

I'd wake up around 9 AM on a call day. Into work at noon; lunch seminar if my patient load wasn't out of control. At 1 PM, the hits would start and just keep comin' just like Casey Kasem would like it, as the on-call intern is open for business for new patients from the Emergency Department. "Chart biopsy", run down to the ED, make sure the patient was as advertised, start the history and physical, and admit the patient.

As the afternoon moved to night, your fellow interns sign out their patients to you. Before you know it, you have 20 odd cross cover patients. Now your pager is going off with small fires ("Mr H hasn't got a diet order") to big fires ("Mr H isn't waking up") not only on your patients, but on the 20 odd cross cover patients that you only know in passing. And, by three months into it, it's just you. No other doctors around except your fellow first-year 'terns (unless you call in the cavalry).

By late night, hopefully you have had time to eat, change into scrubs, and maybe take a dump. Better hope for 2 of the 3. You've done the ED shuffle 4 or 5 times, maybe taken a downgrade from the intensive care unit or a day float patient. Now you try to think clearly as you formulate the all-important Plan. Go back to those 4-7 H&Ps in the corner, and actually try to 1) stamp out disease and 2) logically express those thoughts on paper in a coherent way after 14 hours on duty while 3) putting our fires and 4) recognizing that you are nearly halfway through your shift.

If you are lucky, maybe you can nap for 15 minutes or an hour if things are the unspoken Q word (it's 5 letters and rhymes with "riot"). Maybe if you are a sick freak, you can take a shower before rounds in the morning. Hopefully, you can break out the travel sized Crest and the strange antiperspirant. Change back into a shirt and tie for rounds. Most often, you'll be greasy, tired and bleary, and stinky-covered-over-with-strange-antiperspirant. Honestly, though, the teeth brushing makes all the difference. The only way I can describe intern year to a lay person is imagine working a full day, then flying to Tokyo on a turbulent flight surrounded by screaming babies, then working a full day. Do this every third or fourth night. Lather, rinse, and repeat for 10 and a half months in a year.

By morning, though, another little miracle part of the brain kicks in: the pineal gland, where Descartes thought the soul resided and by some thought to be the residual third eye. It tells your brain that since the sun is up, it's time to wake up and go on about your business. And that cocktail of melatonin, endorphins, caffeine, adrenergics, and stupidity gets you through until your shift is up at 6 PM. Or rather, usually till around 4 PM when you are working on your signout list to get ready to hand over care to the next intern.

Needless to say, 90-odd post-call days with this antiperspirant is just a wee stimulus for bad memories. It's going in the trash right after a trip to Rite Aid tomorrow.

Packing

2009-02-16T22:43:00.003-05:00

This weekend we started packing for The Big Move. I packed away all of my CDs. I filled 2.5 boxes with them; a total of around 800 I suppose. I do this with the full realization that once they are in a box, they are probably not going to come out for the next two decades, given that most of them have been ripped.

Many, however, have not -- I went through and ripped most of my classical CDs this weekend finally. But in identifying ones I have not processed, I am faced with a momentous decision: will I want to listen to this CD any time in the next 2 decades?

Hard drive space is cheap; it is more a question of having to look at these in my iTunes library. I have managed to acquire a CD of digeridoo music, 3 (count em) CDs of classical guitar, 6 CDs of bits of classical music from a music history class I took in college, and many, many, questionable rock albums (Ocean Colour Scene or Kula Shaker anyone?). I've gone ahead and ripped most of them, with only the truly unlistenable (Tibetian Buddhism chanting, the aforementioned digeridoo, some god-awful stuff that I detest now) left out.

I betcha I'm gonna want to listen to "The Riverboat Song" tomorrow.

Random medical fact

2009-02-15T22:19:00.002-05:00

Pseudohypoglycemia can be caused by severe Raynaud's phenomenon, for instance in scleroderma.

Computer day

2009-02-15T17:37:00.003-05:00

My calendar needs are kind of messed up. I love Google Calendar, but I have years of calendars in Apple iCal (and iCal in OS X Tiger can read-only read gcals). I got an iPhone (mostly) for this simple reason, because my old Samsung couldn't quite understand iCal or for that matter gcal. Since I am poor and haven't upgraded to Leopard, iCal doesn't speak to gcal. The new iCal, of course, can speak both ways to gcal. So I use a unix hack, gcaldaemon, which apparently has stopped working. So I reinstalled it today. Rather than spend $116 to get Leopard.

In the process of getting this working (it is still kind of splotchy after most of the day of reminding myself how to use vi and editing conf files), I noted that now gcal can synchronize directly to the iPhone (beta feature!). The problem again is that gcaldaemon is kind of splotchy. So the third leg isn't working. But I figure since gcal and the iPhone are the future, I'd rather base the triangle on those two legs rather than iCal and the iPhone, as I am away from my Apple and therefore I should let iCal be the passive leg.

I did this all without managing to delete all of my calendar information, which is what usually happens. Luckily, the Big One was at a playdate and the Medium one was out shopping with mom. So just me and the baby and she can't/doesn't complain as much when I am using the computer.

Lazy Saturday

2009-02-14T15:52:00.002-05:00

It's nice to actually live like a human on these weekends that I now have off. We ordered a pizza, I played Wii with the kids, cooked the NY Times chocolate souffle. Now it is nap time for the Boy One. After, it will either be my wife's nap time or my wife's shop time.

I'm very proud of my family in that we did absolutely nothing for Valentine's Day.

Here's a little Bruce for you:

Research

2009-02-12T21:15:00.003-05:00

Today was the first day of my 2 week research rotation. Last year, I had a full 3 months of research, enough for me to do a project and get enough data to present a poster at ATS in Toronto. This year, I'm on a CCU rotation at q3 call during ATS so I'm less motivated. That, and I have 3 separate 2 week blocks of research which makes meaningful research a bit more trouble than it's worth.

So my research project, which will be completed (I swear!) by the end of my two weeks will be entitled "A prospective randomized trial of watching TV from my love seat versus my couch." I'm devoting nearly 100% of my time, apart from two all-day clinics, to data collection.

This and the two weeks of vacation in which we will be on The Big Trip to the Motherland, are my only dead time between now and my last day of work, which is looking to be June 10th. Between now and then, 13 or so clinics, 8 night shifts, and about 9 calls. And probably 3 jeopardy shifts so potentially 3 more calls.

Time off at this point is refreshing and of course well appreciated by me and my family. But the ember of the type A personality in me wants to put my head down and just get done with those last 12 weeks of work now, instead of knocking back 2 weeks of down time now, 2 weeks of night float, 2 weeks of vacation, and then 10 straight weeks of hard rotations. This is added to by the fact that I only have 1 hour of TV on the DVR up on which to catch. Hah, prepositions you won't get me today!

I'm ba-ack

2009-02-10T23:43:00.003-05:00

It's been over a year, but since my wife can write a blog I figured I restart mine. A good place to document the upcoming Big Vacation to the Motherland and then of course The Big Move in June.

Hard day today. Hopped on the bronchy donkey at 7:30 AM (courtesy of the pulmonary consult team, letting a lowly resident do the BAL) and then off to all day clinic where 12 of 13 showed up. Only took me till 7 PM to get through all of them.

We have around one clinic day a week, where we see patients that we follow through our 3 years of residency. Actually how it works is that intern year you get a hodge-podge of new clinic patients and overflows from your "clinic pair" who is a 3rd year resident. Then July 1 of your second year comes around and suddenly you have this whole continuity clinic of patients who have been seen by the same progression of doctors since the mid 1980s, of which you are the latest in a line.

Well, it has taken me over a year and a half but I know this collection of 80 or so unfortunate souls pretty well. I know which ones need extra coaching, which ones need a shoulder to cry on, which ones are on the button, and which ones are dumber than a bag of hammers. I don't get intimidated by 15 bullet point Problem Lists that include things like "amiodarone induced pulmonary fibrosis" and "multisystem sarcoidosis" and "Wolff-Parkinson White" and "gastric cancer status post Bilroth II." I imagine that it is almost like a real doctor's practice except that a real doctor may actually have ambulatory skillz, something which I decidedly lack. Don't let my patients know, as the last 4 or 5 residents who ran the clinic were God-like and inspired adulation from my collection of fawning old ladies who make up the core of my practice. I guess I'm breaking the streak, but I'm really trying to eke out the last momentum of that adulation and hope it lasts me until The Big Move in June.

What's starting to get me is that they know what is coming. They are starting to get a bit of the abandoned puppy dog look in their eyes. They know the goodbye form letter is coming. Oh to be sure, I've connected with a good number of them and I'll miss them too. It is just our clinic is so under-emphasized in our program that it seems that the only way to keep things from careening out of control is moxie and gumption as opposed to competence. I lack all three, as it happens.

What also gets me is that I have to get things a little tidied up so I can successfully hand off these slow-motion train wrecks to two soon-to-be-overwhelmed junior residents (my clinic is now so large that it will be split in two). I know quite well how to do that in the hospital. But besides from making sure everyone has had a colo and a tetanus shot, I have little idea how to do it in the clinic. I'm hoping that these soon-to-be-juniors have a bit more moxie and gumption than I ever had.

Every time a code bell rings, an angel gets its wings

2007-12-27T23:05:00.001-05:00

I finished another short run through the MICU. It's what I want to do. For me it is the most bang-for-the-buck, in terms of learning and thinking, in terms of intervention, in terms of patient/nurse/doctor interaction. When you are working a 30 hour shift, and you know that your active patients aren't going to let you sleep much if at all, might as well be busy instead of sitting around repleting potassium. That said, it inevitably comes with soul-crushing disasters: sad stories, sadder families, a feeling of utter powerlessness in the face of overwhelming disease.

It is one thing being busy overnight. It is another being busy and dealing with a flaming trainwreck of a code and then having to wake up a husband and tell them that their wife died. But it comes with the job. I guess some people have to suction septic tanks. We get that.

We get good at having a firm grasp on patients and their diseases. The MICU is the place where that grip is constantly challenged. It's a bad feeling to not be able to get your hands around a new admit. It's far worse to have someone slip out. And I'm on a bad run of that.

The second one

2007-12-09T22:24:00.000-05:00

Top 14 albums of the year:

1) Radiohead -- In Rainbows
2) Andrew Bird -- Armchair Apocrypha
3) Wilco -- Sky Blue Sky
4) Arcade Fire -- Neon Bible
5) Budos Band -- Budos Band II
6) Okkervil River -- The Stage Names
7) Dan Deacon -- Spiderman of the Rings (Baltimore's Own!!)
8) Modest Mouse -- We Were Dead Before the Ship Even Sank
9) Caribou -- Andorra
10) Beirut -- The Flying Cup Club
11) Bjork -- Volta
12) Blonde Redhead -- 23
13) The National -- Boxer
14) The White Stripes -- Icky Thump

Also strong efforts from My Teenage Stride, Spoon (whom I don't ordinarily like despite going to school in Austin), Ted Leo, Sigur Ros (despite it mostly being live), Dr. Dog, Deerhoof, The Shins, etc...

I have to say Radiohead gets top spot in my book for the sheer revolutionary-ness of the whole thing. Name your price, eschew label, etc. But Andrew Bird is my big new discovery this year; the album is a pearl and destined to go into my "comfort album" list. Some people have comfort food -- sweet cornbread, fried chicken, turkey and dressing, etc. I have comfort albums that get me through the night or the post-call day: Curtis Mayfield "Superfly", Arcade Fire "Funeral", Pavement "Crooked Rain Crooked Rain", Badly Drawn Boy "Hour of the Bewilderbeest" and a few others. "Armchair Apocrypha" is securely on the list.

And I bought the Iron and Wine 2 days ago so I can't rank it yet.

Recruiting dinner tonight. Drank heavily and ate like a glutton. Life is good for now. It will be miserable soon again.

The first one.

2007-12-07T23:59:00.000-05:00

Rather than wasting time on bad TV or trying to find redeeming value in Second Life and rather than being productive like reading or studying for the Step or even signing up for the Step or cleaning the house or even practicing piano, I've decided to start a blog. Mostly because it seems like one of those things you should do to consider yourself internet-savvy. I have no delusions that people will actually read the thing. Nor do I have any delusions that this will be a grand project that I will continue once I get bored with it. Or once work gets busy. Or once the new baby gets here.

I'm a second year medicine resident. I'm in the process of applying for Pulmonary and Critical Care fellowship programs. I'm on my first 2 week vacation of the year, though I had a month for research in August. I spent the first week visiting parents and in-laws. I'm pacing myself during the second week so that I won't be so bored that I'm knocking over liquor stores by the end of it. Mostly, though, I sleep. A lot. Unapologetically.

I've had 2.5 months of q3, 1 month of q4, and 1 month of running a team without call since July 1. So it's been busy. Not as busy as intern year, where I was q4 or q3 for 10.5 months out of 12. There is still a kind of sucking dread associated with July 1, 2006 to June 30, 2007, a Lovecraftian Thing Which Cannot Be Named. It is like there is a giant pair of parentheses bracketing off that year. I suppose it did make me Strong, however, and I'm grateful that those parentheses seem not to be extending around the whole 3 year residency shebang. Although you never know -- it could all be a giant math equation and those parentheses could really be inside a set of square brackets inside a set of curly brackets...

So I'm going to tuck in now. Back to the new Pynchon, made accessible by the wiki. In fact, it is a great utilization of the wiki concept. No more sitting with Gravity's Rainbow on the lap with the Weisenburger reader's guide next to me. Now I get to sit with Against the Day on the lap and the wiki on the laptop open next to me. Ahhh, the march of progress.