Tsunami watch

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

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

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

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

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

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

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.