Until Proven Otherwise

The year in travel

2011-12-31T15:53:00.000-08:00

2011 turned out to be a better year for travel than two residents could have had any right to expect: we managed to travel on four continents this year! We saw in the new year in Mexico. In the spring we traveled in Scandinavia and the Baltics. This summer I was working in Indonesia for a month and Dr. N was able to come for a week of vacation. Finally, last month we were in the DR Congo for a research project (full Picasa album here).

Pretty incredible, actually. Wonder what we'll be able to do when we're finally finished with residency?

Happy new year, everyone.

Is there a doctor on board?

2011-11-21T00:38:00.000-08:00

It finally happened. In 30 years of flying, including many intercontinental flights, I've never been a passenger on a plane where the flight crew asked for medical personnel. But while our plane was delayed on the ground in Brussels, the announcement came over the PA. (This has happened to Dr. N before, but it was the first time since she's been a doctor.) The flight attendants looked a little surprised when the two of us stood up, and we were overkill anyway: two other medical folks were already at the patient's side. Looked like wooziness after low blood sugar, normal vitals, and the patient walked back to her seat. So, no dramatic improvised chest tube at 40,000 feet -- this time....

(Historical note: long-timers at this blog may remember that one of the earliest ben-bob comment threads was on this very topic.)

The fires of creation

2011-11-19T05:41:00.000-08:00

We're in Kigali, Rwanda at the moment, getting ready to start flying back to the US tonight. You may have seen images of Mt Nyamulagira erupting near Goma on Lake Kivu in eastern DR Congo, where we've been working. Although the eruption posed no threat to the city or to the gorillas in the nearby national park, it did inspire us to go see a very rare volcanic phenomenon.

Mt Nyiragongo is the tallest volcano near Goma and dominates the northern skyline. Its crater has the distinction of containing one of the world's very few lava lakes. So, a few days ago we set off with an expedition of 8 other volcano tourists, a guide, three armed park rangers, and a crew of porters, to ascend to the rim of the crater, over 11,000 feet high.

The trail winds through dense jungle, over profusions of jumbled volcanic rock, through areas mostly denuded and still recovering from the eruption nine years ago, and various other ecosystems.

At each stopping point, we were higher and higher: above nearby small volcanic cones, faraway major volcanoes, and finally above the propeller planes coming in to land at Goma's airfield. It was a demanding climb; one of the other hikers developed altitude sickness, and by the last scramble up 45-degree rock fields above the vegetation line, it was all I could do to keep hauling myself up step by step.

But arriving at the summit made it all worth it. Standing on the rim of the caldera, you can look down into a seething lake of magma almost a kilometer across and over 500 meters (1600 feet) below the rim. It's a truly profound experience, seeing the forces that have shaped the surface of the earth since before there was life on this planet.

From our vantage point a couple of kilometers away, the lake generates a sound almost like a heavy surf. The surface of the lake is a pattern of darker, slightly cooler plates that are constantly changing shape and occasionally subsumed into hundred-foot-high lava plumes. Overhead, the glow from the lake turns the column of smoke and steam orange.

We spent the night at the summit in little shelters and awoke to a brilliant sunrise over another nearby volcano. The climb down was also challenging, but it's hard to imagine a more moving sight as the goal of a two-day trek.

Saturday morning

2011-11-12T01:58:00.000-08:00

The first few days of data collection were very productive. I came in to the hospital for Saturday morning rounds, and now am spending a quiet morning here working on analyzing the data.

Update from the Congo

2011-11-11T03:40:00.000-08:00

The trip from Kigali to the border was very smooth, on a well-maintained road with spectacular views (that is, when we weren't in the middle of thick fog). The hillsides are checkerboards of terraces in many shades of green, and laterite-stained waterfalls jump out over rocky cliffs when you least expect it. Just before getting to the border we got a view of a pair of volcanoes (active, naturally) with their tops obscured by clouds.

We had been warned to expect having to cough up some bribes at the border, but the officials just smiled, stamped our passports, and waved us through. Goma itself is a pretty singular place. It's on the north shore of Lake Kivu, one of the Great Lakes of Africa. The city has a beautiful setting, with lush green hills marching up to the shoreline and fishing boats out in the deeper waters.

To the northeast are more active volcanoes, including Mt Nyiragongo (described as one of the most active in the world, and home to one of the world's few lava lakes). Lava from an eruption in 2002 flowed through -- and devastated -- central Goma, and now the city is strewn with piles of volcanic rock and gravel that are being used for (re)building materials. Its neighbor Mt Nyamulagira started erupting again a few days ago (news story here), but fortunately for us the lava is flowing away from Goma. However, the heat from the crater seems to be generating a big thunderhead cloud sitting over the mountain.

We've spent three days at the hospital here now and have already gotten a lot accomplished on our research project. We're staying at a guesthouse right on the shore of the lake, surrounded by riots of flowers and guarded by our faithful new canine friend, Poupé. There was a tropical thunderstorm with lightning over the lake tonight: welcome weather geek entertainment for us thunderstorm-deprived Bay Areans.

I was thinking of taking a shower tonight, but the enormous insect in the shower stall at the moment is obviously the dominant critter in our ecosystem, so maybe I'll just wait until tomorrow morning....

A night in Kigali

2011-11-08T13:18:00.000-08:00

We just got to Rwanda where we're spending the night in a sweet hotel with wireless. Tomorrow we head out overland to cross into DR Congo.

On the flight in watched the sun set over a bend of the Nile in the middle of the deep, deep desert -- very impressive.

Like pulling teeth

2011-10-14T07:57:00.001-07:00

This month I'm on an Oral Surgey elective rotation -- and having a blast. One of my main goals is to get experience extracting teeth. Of course, we deal with a lot of oral and dental trauma in the ER, but when it comes to teeth this usually means temporarily putting them back in after they've been knocked out. In urban ER practice we don't usually take them out, since there will be an oral surgeon or dentist available for referral. But in isolated rural and international settings there are often no dental resources available, so I'm trying to get some experience with the basics of tooth extraction and other dental and oral prcedures that I don't usually get to do in the ER.

On top of getting to perform all sorts of interesting procedures, the oral surgery residents that I'm working with are all-around cool and pleasant folks. I can't even conceive of the training they go through: dental school and medical school plus residency. And they come out of it loving what they do. Kudos to my Oral Maxillofacial colleagues.

Treasure trove

2011-09-14T01:23:00.000-07:00

Just found a cache of hundreds and hundreds of pages of music that I've written over the years: piano pieces, old school assignments, not one but two half-completed operas, other scores I thought were lost years ago -- hell, I found entire orchestral pieces that I'd forgotten I'd ever written!

So now I've got a three-foot-high pile of music in the middle of the floor to go through. Wonder what else I'll find?

Getting closer

2011-09-04T17:57:00.000-07:00

It's hard to believe, but a scant 12 years after starting premed classes in 1999 (!), I'm down to 10 months left to go in medical training. Although there's a lot left to do between now and next July, the end is finally in sight.

All of which means that pretty soon it's going to be time to start looking for a job. Starting from first principles, here's an interesting page from the CDC web site about Access to Trauma Care in the U.S. If you scroll down you'll find a map of the U.S. The purple areas are within one hour of a Level I or II trauma center. The white areas are not. Food for thought....

Alles klar, Herr Kommissar?

2011-07-23T02:57:00.000-07:00

Last month I wrote about the new restrictions on personal expression that have been placed upon residents. There have now been some official clarifications. Ever get home from a difficult day at work and wanted to post on Facebook something like "today was a rough day at work"? Or maybe had an inspirational day and wanted to post on your blog: "today I really feel like I accomplished something?" (And maybe even share what it was that you accomplished?) We are now explicitly, officially prohibited from making any such public comments. The more cynical among us are beginning to suspect that the medical center's concerns have less to do with patient privacy than with potential litigation.

And, by the way, in this public forum I can neither confirm nor deny whether I had a good day at work today.

Life in the tropics

2011-07-03T02:02:00.000-07:00

Leaving Bali

2011-06-30T21:56:00.000-07:00

Enjoying a last peaceful morning here in the open courtyard of the villa, and then soon it's off to the airport. Last night I stood next to a rice paddy and watched the sunset. The big volcano was out, floating on clouds, and I counted over 130 kites as I slowly turned around. I'm really going to miss this place.

Serious about kites

2011-06-26T04:35:00.000-07:00

Several times now here in Bali I've seen kites disappear into low-lying clouds....

Bikinis, fruity drinks, carnage

2011-06-18T04:11:00.000-07:00

I've been seeing some very interesting cases lately, including some great teaching cases for the junior doctors. (Unfortunately, I can't share any of the enlightening, poignant, or instructive details here, for fear of the privacy consequences.)

However, I will share my top five tips for safe travel in a tropical surfing paradise (physician-recommended, mother-approved).

Don't get drunk while on a balcony, roof, or while otherwise not at street level.
Don't try to ride a motorbike in local traffic unless you really, really know what you're doing. (Or while you're drunk.)
Don't try to surf, body surf, or boogie board in circumstances that you're not absolutely sure you can handle. (Or while you're drunk.)
Carry a flashlight if you're going to be walking places without streetlights. (Especially if you're drunk.)
Don't get drunk while on a balcony, roof, or while otherwise not at street level.

As you can imagine, in the past two weeks I have collected multiple clinical cases to illustrate each of these priceless jewels of advice. However, enough people will never follow these tips that an ER doc will always have job security.

Code bluish

2011-06-16T02:05:00.000-07:00

This week I've been teaching an advanced cardiovascular life support course to the junior doctors. (ACLS, in medical certification parlance.) I had just taken them through a role-playing scenario involving a crashing patient, when all of our pagers went off with a code blue (hospital code for a crashing patient). We ran down to the ICU, and I was thinking, wow, best ACLS lesson ever -- well, for the doctors in the course, if not for the patient. But when we got there it turned out that someone had just pressed the button by accident. At least no one could accuse me of arranging a code for educational purposes.

Impressions of Bali

2011-06-14T04:10:00.000-07:00

Bali is very, very serious about kites. There are dozens in the sky in any non-urban place you go. They're big, they fly high, and many of them are quite elaborate. Some even seem to have noisemakers attached. Very cool.

Ah, the weather. Tropical paradise, need I say more? Warm enough for shorts and tee shirt 24/7 but not oppressively hot or humid. (At least not while I've been here.) In fact, at the villa where I'm staying the wall between the living area and the pool (yes, the pool) isn't even a wall -- it's simply open, with bamboo shades that are always raised. This is what it looks like from the balcony:

I know they're an ancient and widely-used symbol, but still, the swastikas can be a bit distracting. Passed a restaurant the other day with a stone carving of a swastika above the door, over which was carved "Welcome." [Sorry, no pictures of swastikas.]

But most importantly, the people are just lovely, genuinely warm and friendly. Among the hospital staff everyone is collaborative, and I've detected very little of the ego and competition that characterizes medicine in the U.S.

Really looking forward to the coming weeks here. And what could go wrong? It's not like there will be a demon sneaking up on me from behind to punish me for my sins or anything.

Limited resources

2011-06-11T19:34:00.000-07:00

Prior to my recent round of music blogging, the last time I had really recorded music was in the late 90s. Now I'm starting to experiment with all the advances in music technology that have taken place since then, and I feel like a technological caveman who's just been thawed out of a block of ice.

Right now I'm sitting in a villa in a Balinese suburb with a laptop, a pair of headphones, and a few pieces of very inexpensive hardware and software, and I'm able to write, record, and share original music. By current standards I'm working with very limited resources, but still, this is pretty neat.

Ya gotta love the 21st century....

Patient privacy and the end of a blogging era

2011-06-10T04:08:00.000-07:00

It's a little hard to believe, but this month marks four years since I started blogging. Despite my occasional digressions (tornado liveblogging, etc.), I've mostly written about the process of training to be a doctor. Along the way I've written plenty about my personal experiences, but I've also tried to convey a sense of some of the larger issues, often by discussing some of the memorable cases and patient interactions I've had over the years.

I believe that writing about these topics is an important part of my being a physician, apart from any clarity or catharsis that it may give me personally. Most of the public's impressions of how medicine works are based on singular, overhyped news stories and misleading fictional portrayals onscreen; almost none of this reflects what it's really like when the majority of us die, lose loved ones, suffer major injuries, or just try to get relief from our ailments. Medicine is a huge, complicated, often impersonal system that interacts with people at their most vulnerable moments. It seems to me that illuminating the process of delivering health care is potentially beneficial for whatever small sliver of the public that occasionally reads this humble blog.

Generally, I've treated the most profound and significant interactions in short essays. I have always tried to do this in the most respectful way: I never reveal details that would identify the patient or situation to an outsider, I never present the situation as comedy (well, unless it's actually funny -- and even then I strive to stay respectful), and my motivation is always to share and illuminate profound experiences of our shared humanity. To the extent I have failed in this, I hope that it is due to my limitations as an author, and not because there's anything wrong with the concept of doing this.

However, a few weeks ago the risk management team from the medical center came to talk to the emergency medicine residents. Their concern is that any discussion of patient care in a non-scholarly context exposes the hospital to legal action (true, unfortunately, in the current “medicolegal” environment). Basically, the message is: don't share your healthcare experiences in a public forum.

Patient privacy is of huge importance; I certainly wouldn't want my private medical details showing up on Facebook. However, I don't think this is what I do. And although I'm certainly not in their company, I don't think that's what Oliver Sacks and Atul Gawande and Abraham Verghese and Lewis Thomas and other medical essayists through the years have done, either. I strive to make every essay that I write about a clinical experience pass this test: if the patient were to read the essay, would they prefer that I had not written it? In every essay I've posted, I believe that the anonymous people whose stories I have shared would feel that I had done them and my readers a service by illuminating the experience. Equally important, I believe that I have followed the first principle of medicine: do no harm.

In any case, the hospital administration has now prohibited us from writing about or discussing anything about patient care or clinical work in any public forum. It's backed by severe sanctions, more than a mere resident physician can really afford to risk.

In the end I plan to practice medicine in the best interests of my patients, and damn the legal consequences. I also believe that my essays matter in some small way to a small number of people, and that they are important. However, after much soul searching, for now I'm going to take down all posts relating to patient care. This is the first time I've ever been censored and what do you know -- I'm backing down. I feel a bit cowardly for caving, since I don't think I've done anything wrong, but I need time to consider the situation.

In the meantime, I'm going to focus more on the music blogging over at Notes from an Open Window. I'll keep writing personal posts here while trying to figure how to adapt to the new situation. And my apologies to the voiceless patients to whom I tried to give a voice.

Ben-Bob in Bali

2011-06-07T19:01:00.000-07:00

Settling in here in Indonesia. Still working on internet access in the villa where I'm staying, so this is a quick post from my office at the hospital. We're already into an intense schedule of teaching and the junior doctors are avid learners, so it's very fulfilling work.

I'm hoping that once I get internet access from home I'll be able to post photos, etc., depending on the speed of the connection. I've been asking about where to go for gamelan music, so keep an eye on the music blog, too.

Taipei airport early morning

2011-06-03T15:51:00.000-07:00

On my way to my next rotation -- Bali! It's kind of an unbelievable stroke of luck, but I'm going to be rotating at a hospital there giving emergency medicine lectures, doing bedside teaching on rounds, consulting on medivac decisions, and on call for consults 24/7.

I'm posting from the Taipei airport, where I'm transiting early in the morning. No place open for post-trans-Pacific flight rehydration but all the duty-free shops are open and there's wireless, so I guess I can't complain.

Anyway, I've never heard a bad word about Bali and I've never been before, so I'm off to see for myself. Hope to have a reliable enough internet connection that I can post about my Indonesian adventures.

Meanwhile, don't forget about the new music blog. I posted a new recording just before I left, and who knows what I'll be posting while I'm in Bali....

Why I love the Mission

2011-05-27T11:25:00.000-07:00

Spent a couple of hours yesterday evening working in a pleasant hipster coffeeshop where I heard Sinatra singing My Way. Then on the way home I stopped off for tacos at one of the best taquerias in the Mission (and, therefore, in the country), where I heard a Mexican band's version of My Way...in Spanish.

Notes from an Open Window

2011-05-10T12:57:00.000-07:00

Music has always been a central part of my life –- at least until I started medical training. For most of my life I couldn't have imagined music not being a part of every day, and for most of my career I couldn't have imagined music not being part of my livelihood. But training to be a doctor has a way of taking over your life and over the past decade the musical part of my life has dwindled to occasional composing, occasional arranging, occasional playing, and finally to nothing at all.

Last year I began feeling the loss more acutely than ever before, and in the past few months I finally started to take some steps to get music back into my life. Oddly enough, though, I found it hard to simply start playing or writing again. After so many years of training so hard and earning my living in the arts, I found it frustrating to approach it as a part-time amateur. I bought my first keyboard instrument in 15 years, but playing it was marred by my excruciating rustiness. Sitting down to attempt pieces I could once play fluently, I could now barely get my fingers to play the first few notes. Of course, every musician experiences being out of practice after being away from the routine, but this was a pretty extreme case.

I tried to persevere, not beating myself up or regretting past choices, and trying to play as best I could for the sheer joy of it. Then last month while on vacation we visited friends who are professional ballet dancers in Sweden. For the better part of a week we went to their performances and rehearsals, hung out in the opera house, attended the symphony, and met their friends, also professional artists, whose life revolves around art and music and planning the next big performance. And I was transported. It took me straight back to the days when I, too, spent all my time in the theater or studio or practice room. The experience inspired me, and I came back home determined to make music once again an integral part of my life.

But then there's this pesky residency: 80-hour weeks, 30-hour shifts, night shifts alternating with day shifts. Forget a regular daily practice schedule; it's pretty difficult to have a regular daily anything. I needed to find a way to somehow keep me in touch with music while I finish this overwhelming, all-encompassing medical experience.

What I came up with was to start a companion to this blog: a music blog. But not a blog about music. I'm going to try to blog using music. Each post will be a piece of music, whether it's an original song or composition, a re-recording of my old music, an original recording of existing music, or something else. As much as possible I want to present my own originals, but I'm constrained by fearsome time restraints and the disastrously atrophied state of my musical skills. Still, even if I can post a few interesting bars from time to time I think it will be rewarding for myself (and perhaps a few dedicated listeners), and I have a hunch that over time the musical choices will start to tell a story.

I'm still going to maintain this blog: medicine remains pretty darn interesting, at least to me. But when you've read enough here at Until Proven Otherwise, plug in your speakers or headphones and check out the latest at Notes from an Open Window. The very first post is up now (a revision and new recording of a piece I wrote 20 years ago), and we'll see where things go from there.

Pictures from the North

2011-05-09T14:16:00.000-07:00

As promised, here are some pictures from our circum-Baltic explorations.

Niels Bohr and me (Copenhagen, Denmark):

Town Square in the long northern twilight (Tallinn, Estonia):

Zeppelin hangers, now housing the central market (Riga, Latvia):

Riding up the hill to the castle (Sigulda, Latvia):

Gothenburg Opera (Gothenburg, Sweden):

Adventures around the Baltic

2011-04-27T02:58:00.000-07:00

We've been on the go for the past week, most recently in Latvia. Just got to Sweden, where I'm trying to catch up with email, etc. Full details soon, including pictures.

(By the way, if you ever get a chance to go to Latvia, go -- it's magical.)

“What about the wife and babies? Leave them.”

2011-04-02T18:07:00.000-07:00

From the NY Times: More Physicians Say No to Endless Workdays.

Harmonic convergence

2011-03-26T18:20:00.000-07:00

Next month comes a true harmonic convergence: Ned-Bob and I have two weeks vacation -- at the same time! The question is, what to do with this rare and valuable commodity? Our original plan was to go to Cairo, but right now probably isn't the best time. (Plus, the friend we were going to visit left during the protests.) Then I had a great idea for a backup plan: go see the Roman ruins in Egypt's quiet neighbor, Libya. Once again, turns out to be probably not the best timing.

So we're going to turn left instead of right over Germany and go to Scandinavia. One of Ned-Bob's best friends is a prima ballerina in Gothenburg, Sweden, so we're going to go hang out at ballet rehearsals there. We're also going to spend some time in Copenhagen (where we've been tasked with leaving a secret note for Ned-Bob's cousin, who's following us there a few weeks after). Sandwiched in between we're hoping to get some quality outdoor time in the Norwegian fjords.

On the other hand, considering my recent track record, Stockholm will probably be in flames by next Tuesday.

On-call liveblogging: An unusual ICU problem

2011-03-01T22:26:00.000-08:00

I'm on call in the intensive care unit tonight. Several of the rooms in the unit are temporarily closed for maintenance reasons, so I've got some time to sit down. In fact, I thought I'd get ahead of the sleep curve by heading over to the call room to lie down for a nap. (After all, who knows what's waiting out there later in the night?) But I have a problem I've never had on call before: I can't sleep. It's hard to even imagine it. Being on call every fourth night there's never a time when I don't feel like sleeping, but here I am, sharing my insomnia with everyone in a blog post.

Synchronicity

2011-02-21T11:01:00.000-08:00

This month I've been working upstairs in the ICU. I was on call Saturday and Sunday and at the end of the shift was signing out to the oncoming on-call resident after 30 blurry, sleep-deprived hours of adjusting ventilator settings and fine-tuning medications. When I was done my colleague said "see you Tuesday." Waitaminit, Tuesday, you say? Not Monday? There are no holiday or weekend schedules in the Emergency Room, but it turns out that today is President's Day (who knew?), and if you're not on call in the ICU you don't have to come in. Amazing! Especially since I'm in the middle of a run of 17 days on duty with no days off -- what a gift!

Then, on my way out, a couple of nurses grabbed me and insisted that I look out the window. Incredibly, it had snowed overnight and there was a dusting of white on the hills above the Marin headlands. A day off, and snow in the Bay Area: two once-in-a-residency events, and at the same time!

I celebrated by going home to sleep.

Multiple choice

2011-02-01T04:53:00.000-08:00

While doing some practice questions for the Emergency Medicine Board Certification exams, the answer to question 366 happened to catch my eye: “C, remove the amputated part from the cooler, wrap it in saline-wrapped gauze, then refrigerate it in a plastic bag.”

I'm in a strange line of work....

Responsibility

2011-01-31T04:09:00.000-08:00

The job's been going great lately; I look forward to my shifts these days, I've been doing a lot of teaching, and in general am enjoying medicine more than at any time since I started on this path. (12 years ago now!)

And yet, here it is, 4:00 in the morning, and I'm sitting up thinking. During my shift yesterday there was a situation that could easily have led to one of my patients dying. Quickly. It was a systems issue and nobody blames me for a failure of knowledge or skill. But it was still my responsibility. Even though there wasn't a bad outcome for the patient -- this time -- it's a reminder of how high the stakes can be in this business.

Feliz año 2011!

2010-12-31T16:29:00.000-08:00

By an enormous stroke of luck, Wife-Bob and I both got a few days off at the same time! So we slipped out of town for a few days to Puerto Vallarta. It's a rough life; my forearm is sore from all the tennis, and I've got a sunburn on my leg. I'm sure everyone dealing with winter weather north of the Rio Grande will sympathize....

Boxing Day in the ER

2010-12-26T22:45:00.000-08:00

Thank you for all of the comments and kind words on yesterday's post. It came straight from the heart, trying to make sense of things. Wife-Bob came home after I was finished writing it to find me dead asleep on the floor next to my laptop....

As regular readers know, I try to convey a sense of what the emergency department and medicine in general are like for folks who don't spend much time in the hospital. (The best description I've ever heard of my job is that working in the ER is as close as you can come to living in a Vonnegut novel.)

When I write about patients on the blog I always struggle with how much to reveal. Patient confidentiality is an inviolable part of the relationship with the doctor, but I firmly believe that sharing the extremes of the human experience is how we all get stronger and wiser. I'd like to think that I honor my patients' experiences (or memories) by sharing the essential, universal parts of them, as long as there are no individually identifiable details. I wrestle with finding the line in every one of these mini-essays.

Christmas Eve in the ER

2010-12-25T10:18:00.000-08:00

It's 10:00 am on the 25th and I just got home from a long and bloody Christmas Eve in the emergency department. The wife's still finishing a 30-hour shift in the hospital, so here I am sitting alone at home, exhausted, but not quite ready to sleep.

Last night was as busy and challenging as any other night in the ER. There were victims of heart attacks, assaults, and motor vehicle crashes. There were the suicidal, psychotic, and just kind of lost. I worked to control a spurting arterial head bleed while the patient cried about losing his girlfriend. I took care of a man who was riding his bicycle without a helmet and came in with his scalp half torn off, slumping down to reveal a broad tract of his skull.

I find myself thinking about why I wanted to get into emergency medicine in the first place. Partly it was a sense of adventure and of pushing myself to the utter limits of capability. A large part of it was a desire to take part in the extremes of the human experience. And I liked the fact that the emergency medicine, more than most other branches of medicine, is directly connected to the world outside the hospital.

Early in the morning the paramedics brought in a forty-something woman in cardiac arrest. I ran her resuscitation. We gave her all the medicines that might get her heartbeat back. We defibrillated her, and I struggled to place a breathing tube. But it was hopeless, and despite everything we know about physiology and pharmacology and the art of healing, there was nothing more we could do.

Stopping a resuscitation is termed “calling the code” and is fraught with a mixture of emotions. It's hardest when the person is young, when you know the family is waiting just outside (or, sometimes, in the room with you). I asked if anyone in the room had any other ideas for resuscitation: no answer. I asked if anyone in the room had any objections to calling the code: again, no reply. And then I announced the time of death.

I stripped off my blood- and vomit-stained gown and gloves, steeling myself for the talk with the family, checking my scrubs to make sure they were clean. One of the paramedics who had brought the patient in stepped up and complimented me on how well the code had been run. There's very little positive emotion to take away when a resuscitation fails, and I'll admit, his comment meant a lot to me. But now it was time to talk to the family. I was well aware that we were several hours into Christmas day, and that now and forever this family's grief would be tied to this day.

It turned out that her adult sons were, in their grief, verging on hysteria and violence. (This is not unusual; sometimes family members will become so violent on hearing the news of a death that they must be restrained by police officers to prevent injury to staff or others.) There were several of us present, and I briefly explained what had happened and that their mother had died. As I finished talking, one of the sons was literally crushed to his knees with emotion and began wailing. Another brother grabbed him, and without another word pulled him out the door, disappearing into the night.

When a patient dies in the ER we place them in a private patient room with as much dignity and repose as possible, and then allow family members time alone with their lost loved one. Several hours later I was collecting equipment for a procedure and happened to walk past the room where my patient was lying on a gurney. There was nobody there, and the lights were off, but somebody had turned on the overhead operating room-style light and trained it on the head of the bed. A small shaft of bright light cut through the darkness and glowed over her head. It was a moment of utter peace, of a strange chapel-like beauty. It was an image that will stay with me for a long time.

Eventually we reached the last hour of the shift. My fellow resident on duty and I congratulated each other on making it through another long night; too soon, as it turned out. Twenty-five minutes before the day team was to come on, we started to get patients from an MCI, a mass casualty incident -- a four-car crash, in this case. I ended the morning taking care of one of the passengers, a young woman. Just before I left she started being rude to her nurse about not fulfilling her requests quickly enough. When the social worker who had provided invaluable help with the family of the woman who died asked for her last name, she snapped “You couldn't pronounce it anyway.” My colleague asked her to spell it, and she spat out an unintelligible burst of letters. I was well past the end of my shift and trying to get out and go home, but still felt as protective of the staff as I did of my patients. I walked over and politely (I hope) but firmly explained that these people were trying to help her and deserved her respect. And then she slowly spelled her last name.

When I left the hospital I walked home in the gray Christmas morning light through the Mission District, past middle-aged men drinking malt liquor in doorways, past homeless people asking passing hipsters for change, past Spanish-speaking street evangelists in suits. In some ways it was a typical shift, but there was something about last night that was a little different; hopeful, somehow. Anyway, I'm too exhausted and sleep-deprived to draw any lessons now. Time to get some sleep and recuperate for tomorrow's shift.

Merry Christmas, everyone.

Oil rigs, prisons, and schools

2010-12-20T17:49:00.000-08:00

Watching a DVD the other night I happened to read the fine print of the "WARNING" -- "The definition of home use excludes the use of this disc at locations such as clubs, coaches, hospitals, hotels, oil rigs, prisons, and schools."

I can understand the importance of not losing revenue to a bunch of felons and elementary school students, but who knew that wildcatters were such intellectual property pirates?

Asmara memories

2010-11-15T01:37:00.000-08:00

Saw this on the Beeb: Asmara's last Jew recalls 'good old days'. I used to walk past this synagogue; wanted to go in but it was always closed.

Let us beat pagers into plowshares

2010-11-14T12:43:00.000-08:00

After three weeks of carrying my pager 24/7 on backup call, in just 12 more hours I take it off and start two weeks of vacation! Man, that thing just gets heavier and heavier the longer you wear it.

Movember

2010-11-13T18:43:00.000-08:00

Yes, this month is Movember, and the male residents in my program are sporting 'staches to support prostate cancer research. Check out my Mo Space page, and please consider making a donation. You know you want to look....

Prove it

2010-11-10T08:38:00.000-08:00

The other day, while going through some papers left over from my last year of medical school, I found a single handwritten page of notes from a talk I was asked to give offering advice to the first year students. My big rhetorical flourish was a riff on the old cliche that so many people going into medicine have "something to prove." My point was that it's okay to have something to prove, as long as 1) you know what it is, and 2) you prove it.

I wonder if I proved anything?

Ugh

2010-11-08T10:25:00.000-08:00

A whole month gone by without a post. Sigh. Let's see if I can turn this around....

Explosion in San Bruno

2010-09-09T21:52:00.000-07:00

Just woke up to head in for my overnight shift and this is the lead story on the NY Times website: Calif. Homes Ablaze After Massive Explosion. Local news is saying five people have already been sent to our hospital in critical condition.

Dying and not dying in the SICU

2010-08-17T22:08:00.000-07:00

Working in the emergency department tends to give a person a thick skin when it comes to strangers' tragedies: catastrophic trauma, devastating strokes, massive heart attacks are all to be expected on any given shift. It's not that it doesn't affect you, but you have to learn how to keep going, to delay processing, because no matter how bad the situation is for the patient and the family there's always a waiting room out there full of people who still need to be seen.

However, this month I've been rotating in the SICU -- the Surgical Intensive Care Unit -- and it's been a very different experience. I really like the people I'm working with, and I've been learning a lot. But at the same time it's been a somewhat depressing experience. So many of the cases are almost unbearably tragic: the eight-year-old shot in the back and now paraplegic; the middle-aged man locked in after a stroke; the young man who shot himself through the head in front of his girlfriend and infant child and now lies in bed with his brain swelling through flaps removed from both sides of his skull; the young man whose spinal cord was severed by a bullet and is now quadriplegic, the man from Guatemala brain-dead after a stroke and sustained on a ventilator but, due to miscommunication with his distant mother, whose organs could not be donated and whose body could not be repatriated to his family.

Almost every day I spend my walk home trying to re-engage with daily life, where people walk around in the sun and almost nobody is at risk of suddenly collapsing in a coma. Often I buy myself ice cream.

Of course, I've already dealt with a fair amount of suffering and death along the way. In fact one of the most beautiful moments of my intern year revolved around a death. My patient was an elderly woman who was gravely ill. It was time to make a decision about whether to escalate medical interventions or transition her to comfort care; that is, focus on controlling pain and providing a peaceful environment. She had two adult daughters who were very involved and they asked that those of us on her medical team meet with the family to decide what to do. I still remember that meeting vividly. It was late, about 1:30 in the morning, and when I got to the family room it was overflowing with maybe 40 family members spanning four generations, from elderly to newborn. I remember sitting on a chair on a wood-paneled floor under low lights, in the middle of the room, surrounded on three sides as this family listened to my description of the medical facts, asked me questions, discussed the options, and with love and dignity decided to let the matriarch of their clan go to a comfort care suite where she died, surrounded by family, two days later.

But there's something about the surgical cases -- perhaps the suddenness of onset that characterizes them -- that seems to make them particularly demanding emotionally.

A couple of days ago I was taking care of a very ill elderly woman whose outlook was looking less and less promising by the day. Her devoted adult only son was spending hours sitting at her bedside, trying to come to terms with the fact that his mother, a vibrant active 85-year-old only weeks before, was now sedated, intubated on a ventilator, and acquiring new lines and tubes for antibiotics, pressors, and all the other interventions of modern medicine. As he told me himself, he was shocked and overwhelmed. We talked for a while, and I told him a bit about how I had recently lost my father. I wanted to do something to normalize the reactions he was experiencing, and I hope I helped ease things a bit for him. I think maybe it helped ease things a bit for me, too.

Years ago I was talking with a wise friend of mine about how curious the process of learning about sex is. It's a part of life that is central to adult life, to society, to biology, and yet we go for years early in our lives being only dimly aware of it, and spend more years trying to understand it. I remember jokingly wondering whether there was anything else out there waiting, another huge part of life that was largely unknown to us as young adults and would not be revealed until later. She answered, “of course there is: dying.”

I spend a lot of time thinking about my locked-in patient. He is utterly paralyzed, except for being able to blink and move his eyes up and down. He was estranged from his family for 20 years, but eight months ago had gotten in contact with one of his adult children. He has made it clear that he wants to live, that he wants everything done. Every morning, when I go to check on him, I make a point of standing in his field of vision. I address him by name, re-introduce myself, ask him if he remembers me. He indicates that he does with our convention for “yes,” by looking up. I touch him, squeeze his hand, ask if he can feel me squeeze his hand. One morning last week I noticed that he had had an enormous spike in his blood pressure overnight. The Neurology team said that was when they told him -- told him that he had almost no hope of recovery, that his interaction with the world would be forever limited to a few eye movements, that his only hope of survival was ventilators and feeding tubes and teams of skilled health care providers to keep his body from breaking down.

As a doctor, what is success and what is failure? We'll never “cure” him, but if he wants to survive in this state we can sustain him for a while. Every day we're privileged to be able to bring to bear therapies and interventions that would have been magical dreams come true to most healers throughout human history, but in this setting I'm not always sure whether we're doing good by deploying them. All I can do is to keep adjusting the ventilator settings, squeezing hands, talking to families, enjoying the ice cream on the walk home.

Penny for your thoughts

2010-07-25T20:59:00.000-07:00

The other day I noticed a shiny new coin in my change with a striking design. At first I didn't recognize it as a U.S. coin, but when I turned it over I found the familiar Lincoln portrait of the penny. But the reverse is now my favorite bit of U.S. currency redesign. Check it out:

It's dynamic, yet dignified; a combination of early 19th-century elements with the quasi-modern look of Captain America's shield! It's enough to make me want to keep the penny, after all.

A dangerous place

2010-07-21T20:54:00.000-07:00

When I show up for a shift in the emergency room I scan the board, looking for how many patients are in rooms, how many are in the waiting room, and what injuries and illnesses they're billed as having. My last two night shifts in a row, unfortunately, there were familiar names on the patient list: before each shift one of our own residents was registered as a patient following an injury or exposure during the previous shift.

We sometimes get complacent about it, but it was a reminder that the emergency room can be a dangerous place -- physically, emotionally, and mentally.

Via maritima

2010-07-17T10:47:00.000-07:00

There's a store around the corner from our new place that rents containers for shipping. Not that I have anything to ship to foreign ports at the moment, but it's comforting to know it's there.

Edge of the clouds

2010-07-05T16:32:00.000-07:00

Between night shifts at the moment, which can be pretty disorienting in lots of ways. I went for a coffee earlier and couldn't quite tell if the sun was out or not. Turned out that the fog cap that generally sits over the western part of the city during the summer was extending to just about a block from here, making the sun fade in and out. Cool, although a bit much for my sleep-deprived brain to process.

Family business, part 2

2010-07-05T03:23:00.000-07:00

Tonight was our first shift working together! It was fun, and a reassuring glimpse of our hoped-for future, working together in the field.

Family business

2010-06-23T22:33:00.000-07:00

Today is Ned-Bob's first shift as an emergency medicine intern! I've been working upstairs in the Peds ICU, so I stopped by the ER and found her initials on the board while she was off seeing patients....

Back in the Mission

2010-06-04T01:29:00.000-07:00

Ah, the Mission. Murals everywhere, best burritos in the city, and the corner shop -- "Chinese Food and Donuts" -- with the sign in the window that says Abierto.

Would you go back to work?

2010-05-28T14:27:00.000-07:00

Recently I had a patient who was a podiatry student. She'd been in an accident but fortunately a thorough workup showed that she had escaped without any injuries. As she was about to leave she asked for a work excuse. I told her that I'd be happy to write her a note saying that she'd been seen in the emergency department, but I couldn't say that she was impaired -- after all, I'd worked her up and found nothing wrong, and if I had found anything wrong she wouldn't be leaving the ED, she'd be staying for treatment.

Then she said to me, "but I have to go back and take care of patients. You wouldn't go back to work if you were in my situation, would you?" Generally I avoid discussing my personal health experience with patients, but if they ask directly I try to answer honestly. So I said that yes, I wouldn't have a choice, I'd have go back to work and take care of patients. She didn't really believe me and pressed the question. Especially since she was a healthcare student herself, I wanted to level with her. So I told her about how I had just broken my foot two weeks ago. Not only did I not get any time off work, I worked back-to-back 12 hour shifts, hobbling around in an ortho shoe.

She paused, then said, "Sounds like you need a podiatrist." True! Then she turned to her father and said, "Podiatry is a lot nicer than Medicine." I wrote her a note for the rest of the day off.

My foot's feeling much better, by the way, although it doesn't look like I'm going to get time off work to go to my scheduled Orthopedic appointment.

Moving day

2010-05-25T16:27:00.000-07:00

We moved into a delightful new apartment in the Mission yesterday. And despite the broken foot and the back strain and the muscle ache, I was able to function at work today.

Winning the Game

2010-05-24T00:46:00.000-07:00

One in a great while, we manage to clear the board in the Emergency Department -- that is, discharge every single patient. This is known as winning the game. There are people who have worked in EDs for years and have never been there for the occasion.

Last night we won the game. Totally surreal. We celebrated by turning down the lights and having a party: funk playing over the PA system, the bar code lasers on glucometers for strobe lights, an oxygen tank with a nebulizer for a fog machine, and a Wood's lamp for a black light. It was amazing. Of course, we needed to document the occasion:

Then, about half an hour before the morning shift came on, we were back down to one patient in the department -- mine. "No pressure," said the attending. I ran back to the room, dressed the patient's wound, and we cleared the department again; we were able to sign out an empty board to the oncoming team. Of course, we had to get proof again:

I've never been in the ED for one of these, and I doubt I'll ever see it again twice in one shift. But I'll savor the memories forever....

On-call liveblogging: What's Grandma been up to?

2010-04-08T01:04:00.000-07:00

In the hall behind the Emergency Department just passed a pleasant-looking 70s-ish lady wearing a sundress.

Being escorted out of the hospital.

By a police officer.

In handcuffs.

Wash me

2010-04-03T22:36:00.000-07:00

Saw this written in the dust on the back of a delivery van:

["I wish my girl was this dirty."]

Ohrwurm

2010-03-30T13:42:00.000-07:00

Had a patient this morning who kept answering his cell phone while I was trying to unwrap his splint and examine his broken limb. His ringtone was the theme from Sanford and Son. Guess what'll be going through my head all night?

Quote of the night

2010-03-28T21:37:00.000-07:00

On Orthopedics call the other night, went to see a seven-year-old girl with a busted arm. She was crying when I walked into the room, and as I knelt down next to her she turned to me with tears and sniffles and said, "I need to pee. I'm not kidding!"

Remembering Dad

2010-03-06T20:49:00.000-08:00

My father died last week. To the very end he faced his situation with grace, dignity, and humor. I miss him terribly.

His obituary is here. Mom is very strong and is doing well. Thank you to all who have been so generous with condolences, cards, flowers, food, wishes, and support.

On-call liveblogging: Graffito

2009-12-26T01:19:00.000-08:00

In one of the surgical call rooms, on one of the bunk beds, someone has written on the slats under the upper bunk so that the person lying in the lower bunk sees just above their head: "You need to preround."

This may not mean much to someone who's never been on call, but trust me -- it's funny. Sort of.

Merry Christmas Eve!

2009-12-24T08:25:00.001-08:00

Hmm, that last post was a little unsavory for the holidays....

Overheard

2009-12-24T08:24:00.000-08:00

Housekeeping, entering a bathroom this morning while I was checking labs nearby: "What's that in the toilet?!?" I did not go over to offer my clinical evaluation.

Yuletide prediction

2009-12-23T19:45:00.000-08:00

First trauma call last night was pretty mellow. However, tonight one of my fellow EMers and I were watching the escalating levels of drunkeness in the street and realizing that we're probably in for some interesting cases in the next few days.

Holiday cheer

2009-12-09T21:38:00.000-08:00

Just got the schedule for my upcoming trauma surgery rotation; turns out I'll be on call both Christmas and New Year's. At least it simplifies the holiday schedule.

Flags

2009-11-10T15:30:00.000-08:00

Hometown main street.

You're welcome

2009-11-09T19:26:00.000-08:00

Weekend overnights at the county hospital ER can be a parade of drunken brutality -- accidents, assaults, all-around bad judgment and poor life choices. These are the patients whose stories so often begin "I was just minding my own business...." They're generally soused to the gills. We spend hours stabilizing their fractures, scanning their head bleeds, sewing up their lacerations, and in return we get cussed out, vomited upon, spat at, and even assaulted. All part of the job, although sometimes it gets a little stale.

And then, usually once a night, there will be the patient who has equally bad injuries but who was, in fact, just caught in the crossfire -- a sober citizen who was assaulted out of the blue, or who had the unfortunate but non-alcohol-related auto accident. These are the patients who, as we're sending them home with a cast or admitting them to the Orthopedics service at 4:00 in the morning, will say "thank you." And that usually makes all the rest of it worth it.

Golden spire

2009-11-04T11:31:00.000-08:00

The human condition

2009-11-03T00:44:00.000-08:00

Halloween aftermath

2009-11-02T00:21:00.000-08:00

When you're in San Francisco for Halloween it can be hard to know who's in costume and who's just in their regular clothes. And the leftovers on the train today were fascinating: bits of fluff and sparkle and hairpieces littering the platforms; a dazed and very authentic looking US soldier; the guy who got on the train carrying his enormous curly wig and sporting a big, fresh black eye (the real thing). As late as this evening (the day after) there were still plenty of people out in full costume and makeup.

Photos from Ghana

2009-10-27T17:36:00.000-07:00

Spent quite a bit of time on the beach.

The lovely coast.

Our accommodations near Busua.

Helping out with a procedure in the Mampong District Hospital.

Suspicious finding on an X-ray.

Helping out with training.

This boy had been hit by a car and needed a leg splint.

Working with the plaster of Paris.

Another satisfied customer!

The countryside near Mampong.

The balcony of the Doctors Transit Bungalow.

Sunset from the balcony.

Evening in Accra

2009-10-24T14:29:00.000-07:00

All alone in Accra tonight, having left the gang behind in Mampong. The highlight of the flight from from the north was seeing Lake Bosumtwi -- a water-filled meteorite impact crater -- from the air.

Made it to the happening Osu district without much hassle and took myself out for what turned out to be kind of a nostalgic dinner. Needing to spend the last of my cedis before I fly out, I picked an expensive Chinese restaurant that came recommended where I had a delicious fish dish (the fish all along the coast in Ghana has been first-rate). Dining alone, I found myself reading over the meal in a Chinese restaurant full of Africans; weirdly reminiscent of many of my meals during my time in East Africa. And the waiter even brought a candle to the table for reading light!

Afterwards wandered around for a while, taking in the frenetic sights and sounds (and music) of Saturday night in a big West African city. But an early morning to catch my flight looms over me, so it'll be back to the hotel soon.

The Doctors Transit Bungalow

2009-10-24T02:22:00.000-07:00

The electricity bill on the dining room table reveals that the physicians' residence officially goes by the delightful name of the Doctors Transit Bungalow. I'm spending one last morning on the second-floor balcony here, which has become one of my favorite spots anywhere. Following a downpour earlier this morning, there's mist lying low over the green hills, with solitary trees sticking up above the canopy and bright flowers everywhere. And, as always, there's a rich variety of birdsong on the breeze.

Yesterday morning I took a long walk out into the countryside (where I noted the formidable local insects -- do not mess with the ants and bees here...) and then back through the adjacent village. In the afternoon we made an expedition to the clinic in the nearby town of Kofiase. This is one of the feeder clinics for the district hospital here in Mampong. Although resources may seem limited at the hospital, the clinic in Kofiase really has to make do with the bare minimum: no doctors, half-stocked shelves in the dispensary, no running water. The delivery room in the maternity ward left us all a little thoughtful: a bit of a grim prospect to be there as either a patient or a provider.

Last night we headed out to one of the two restaurants in Mampong, the Farmer's Cave. Far out of town on rutted roads, it's the Ghanaian equivalent of a midwestern supper club. We stuffed ourselves on jollof rice, goat meat, chicken, and yams while watching distant lightning on the horizon.

Sadly, I need to leave Mampong this morning. I'm off to Kumasi, capital of the Ashanti district, where I'll catch a flight to Accra; then tomorrow I leave for home. However, I've already been talking with the program coordinator here about the possibility of coming back for a rotation when I'm further along in my residency and get some elective time. Until then, I'll content myself with fond memories of the balcony of the Doctors Transit Bungalow.

Training day

2009-10-23T01:41:00.000-07:00

Yesterday I helped out with the Basic Life Support training here at the hospital. It went well and turned out to be a lot of fun. The program had brought a set of adult and peds training mannikins and there was a good crowd in attendance. Everyone was very involved. When we were teaching the Heimlich maneuver, the enthusiastic nurse I was working with practically left bruises on me. Very curious to see whether the next patient to arrest in Casualty will get CPR.

Ghana

2009-10-21T09:38:00.000-07:00

Writing this sitting on the balcony of the doctor's house on the grounds of the Mampong District Hospital. We just had a refreshing mid-afternoon rain, and now I'm looking out across the dripping trees and listening to all sorts of birdcalls.

Last week was spent at a series of lovely beach resorts along the coast. Beautiful beaches, almost no one around, and surprisingly fantastic food. And nothing beats falling asleep to the sound of surf.

Heading north to the hospital involved a fairly typical 12-hour trek involving multiple taxis, long-distance buses, roads in various states of repair, and that workhorse of intercity travel around the world, the mini-bus (called a "tro-tro" here). Had an interesting changeover in Kumasi, Ghana's second city, where we waited after dark in a what was basically a smoky, excavated pit for a tro-tro that turned out not to be coming. But the daylight segments on the roads were very scenic -- lush greenery and all sorts of interesting roadside activity.

Mampong is a town of about 20,000 with a district hospital. I've been hanging out in Casualty (basically the emergency room) and following along on rounds. Have already seen some interesting cases, including a relatively rare tropical worm infection.

Today was market day. On the way back to the hospital we passed what was obviously a recent and serious two-car collision and hustled back to Casualty, figuring that the victims had probably been taken there and to see if we could help. As we pulled up we saw two men wheeling a person-sized metal cart from the mortuary to the hospital, and inside we found one of the patients dead in the room used for resuscitations. Another patient from the accident was also being treated and was fine, and a third person had already been seen and released. We tried to figure out what had happened to the dead man, but realized that it would have been unlikely that we could have done anything for him, given the limited resources available.

Tomorrow is a big training day and I've offered to help out; we'll see if my vacation-dulled mind can recall any emergency medicine.

Back to Africa

2009-10-11T17:43:00.000-07:00

12 years ago I started out for an adventure in Africa. That trip changed my life and set me on the path I've been following ever since. In just a few hours I leave for Africa again....

Smoke and a roar

2009-10-08T21:43:00.000-07:00

I've been sleeping during the day, working night shifts, and this afternoon I was awakened by loud jet airplane noises. It took me a moment to realize that it's Fleet Week, and the Blue Angels were practicing. We live pretty far up the hill where the hospital sits, so those F-18s were flying just a few hundred feet above our apartment, rattling it pretty good. Ordinarily I'm into loud fast things, but I realized with a sinking feeling that they're going to be flying every afternoon -- on the days I need to be sleeping! Basically, I'm gonna have jet flighters waking me up at my equivalent of 3 am for the next several days. "Smoke and a roar," according to the Chronicle. Even more sleep deprivation than usual, according to me.

Back on the road

2009-10-08T11:29:00.000-07:00

Off to Ghana next week to visit Dr. N, and since I'm now on nights I was actually able to stop by a travel store during business hours for some odds and ends. It was a bit of an upscale place. The woman working there asked where I was going, and when I told her she looked up and said "that's great! Mostly people say Florida. I didn't think people did adventure travel anymore." I think it made her morning -- and I hope she gets a vacation and a chance to travel soon herself.

Neurological exam

2009-10-07T13:36:00.000-07:00

We see large numbers of intoxicated people in the emergency room who come in after unknown events. The problem is, most of them are just drunk or high, but some of them have had injuries including head trauma. So we need to watch them and see if they sober up or if they have other problems that we need to take care of.

The other night a young lady came in, apparently drunk, and spent a few hours face-down on a gurney. As she started to clear and move around, it was time for a repeat neurological exam. I looked down the hall, and saw that she had put on her 4-inch stilettos and was starting to walk around. I figured that anyone who can walk around in those shoes must be neurologically intact, and started printing out her discharge papers.

Unstormy weather

2009-10-06T11:33:00.000-07:00

Today I was going back through some older posts, looking for something that might be expanded into a larger piece. (Any suggestions?) I'd forgotten that I used to have a category called Weather Geek. Gotta say that moving from the extremes of Iowa weather to the Bay Area's temperate climes has kind of eliminated that category for me. Time was when I would blog about tornadoes (even live-blogged a couple), ice storms, heat waves, blizzards. I think the most I've managed from the Bay Area was a short post about rain. Not even a torrential, car-floating downpour; just noting that it was raining, as opposed to not.

Washing up

2009-10-02T21:33:00.000-07:00

This recent exchange with a houseguest is what passes for normal in our little apartment full of residents:

Houseguest [noticing something in a plastic basin]: "What's that?"
Me: "It's a bloody shoe that I'm soaking in hydrogen peroxide."
HG: "Is it your blood?"
Me: "Is it better if it is, or better if it isn't?"

Entertainment news

2009-09-27T11:37:00.000-07:00

A while back NBC shot a pilot in San Francisco for a new medical thriller called Trauma. Many of the folks who work in the hospital here, including some of my co-residents, were extras. We didn't know if anybody made it into the final cut, but the intent young physician on the right in this promo pic is one of ours!

Rapid cycler

2009-09-27T11:20:00.000-07:00

Working the night shift can be difficult, but it's even harder to cycle between days and nights. In the past 10 days I've worked swing, day, night, day, night, with no more than two of the same in a row. I've got today off, then I'm back to days tomorrow. Truly disorienting.

Harmonic convergence

2009-09-24T00:12:00.000-07:00

This evening all three of us residents who live in the apartment were briefly home and awake at the same time. I think that's the first time it's happened in about a month.

Pet peeve

2009-09-23T00:27:00.001-07:00

Waking up at 4 am to catch the bus to work and realizing that I don't have any clean scrubs....

Invisible Immigrants

2009-08-30T21:42:00.000-07:00

Hmm, seem to be reading the Times a lot lately. Was struck by this article, by its poignant subject, its proximity to where I'm living, and the fact that these issues are ones that we deal with daily in the emergency department.

Remembering the floods

2009-08-28T02:34:00.000-07:00

I was touched to see this article in the Times. Our little crew moved away from Eastern Iowa just as the floods hit, and it was a very emotional experience.

District 9

2009-08-21T01:30:00.000-07:00

I've been cycling between day and night shifts, which leaves some odd chunks of time off in the middle of the day. So a few days ago, unable to decide whether I should be sleeping in the middle of the afternoon, I went to see District 9. Then on my very next shift, a young man came in having his first psychotic episode. The subject of his psychosis? Among other things, he believed that he was trapped in -- District 9! By the end of my shift, I was beginning to suspect that I was, too.

Bitten

2009-08-16T17:46:00.000-07:00

Yesterday we had a great teaching conference: how to protect yourself when attacked by the out-of-control/psychotic patient. For example, what is the correct reaction when a patient bites you and won't let go? Or when you are grabbed by the hair? (My answer to that one: "I'd just walk away.") There's a reason many ED docs don't wear their stethoscopes hanging around their necks....

Transitions

2009-08-04T13:00:00.000-07:00

Very interesting article in the Times today: Doctors in Cuba Start Over in the U.S.

One thing that struck me was the way certain aspects of American medical training are addressed in this article. By coincidence, earlier today I was talking with another resident about how almost every article we see in the general press about medical training tends to use the same formulas and cliches.

"...most hospitals seek young doctors who can work long hours for little pay. A 40-year-old doctor is often deemed too old to be accepted in a residency program." Oddly refreshing -- and, in some ways, more accurate -- to see the issues examined from a different angle.

Contempt for the newbies

2009-08-02T21:59:00.000-07:00

Reading this article, I was reminded of an impression that I've been developing as I spend year after year in medical training. Health care places enormous value on an individual's cumulative experience, and appropriately so. However, I often see that value expressed as disdain, even outright contempt, for inexperienced individuals -- i.e., people who are simply in an earlier stage of their training. I can't even count the number of times I've seen a student, intern, or junior member of a team publicly excoriated, not for incompetence, not for doing anything wrong, but simply for their lack of experience.

Case in point: a while back I was a few days into a new rotation, trying to operate in a system I'd never worked in before. I was trying to get a patient's visit wrapped up expeditiously, and made a mistake filling out a new lab form. A senior nurse walked up to me in the hall with the form, and in front of waiting patients flicked my nametag and half-shouted "you don't know anything!" in my face.

Now, I don't think that this person was actually questioning my clinical judgement or my ability to make reasonable choices about appropriate lab tests. We're all trying to do our best for our patients. And frankly, health care is very, very hard, and we all feel insecure about our own abilities from time to time (daily, even). But I'm frequently shocked by how often this comes out as what seems like little more than hazing of the junior personnel, simply because they're junior. I guess this is much on my mind these days because with every year's turnover I become more responsible for teaching -- and modeling behavior for -- junior members of the team.

Of course, I've been lucky -- the worse things that have happened to me during my training so far have been trivial compared to things that are routinely inflicted on trainees other places. But still, I'd like to think that there's value in consciously striving not to perpetuate these behaviors.

Spider bite

2009-07-30T22:48:00.001-07:00

It's quite common for people to come to the Emergency Department reporting a spider bite, but most of the time it turns out that they weren't actually bitten by one of our eight-legged friends. (This phenomenon is very interesting to me, and I have a theory about it that I should share in a future post.)

However, tonight our team in the ED had a rare moment of being able to sit down together for a few minutes, and as the newly-minted big bad R2 it was my duty to use the time well to do some teaching for the intern and medical student. So we talked about black widows and brown recluses and the diagnosis and treatment of actual spider bites. And the weird part wasn't the medical information (although some of it is kind of weird), but that I was sitting there, knowing a little bit about the subject and able to share it. Maybe these long hours in the hospital are driving something through my thick, sleep-deprived skull after all.

$64 word

2009-07-26T17:51:00.000-07:00

My iPhone spell checker knows "opisthotonos." I'm impressed.

Getting out early

2009-07-25T21:12:00.000-07:00

Today I had a 12-hour shift that ended after... 12 hours! To a resident, this feels like getting the day off.

Phrase of the workday

2009-07-24T00:24:00.000-07:00

"Aerosolized vomitus."

That is all.

Diapers

2009-07-21T23:34:00.000-07:00

I'm on Pediatrics this month, seeing a full range of kids from the very sick to the not really sick at all. Lots of diapers, and I've managed not to get peed on. Yet.

Fly fishing

2009-07-20T19:47:00.000-07:00

The other day I bought some new underwear. It looked like my current favorite model in the packaging, and I was glad to be extending my laundry cycle. (Unlike a 90s-style politician, I will not be revealing what type of undies I wear -- although rest assured that they are both sporty and sexy).

Imagine my surprise, then, when I got home and discovered that they have no flies! I checked the packaging, and not a word about this design update anywhere. What the hell? Is this the new thing? Have I drifted so hopelessly behind the tide of fashion during medical training that I don't even understand underwear anymore? I don't want to get too hung up on this, but when you work a resident's hours convenience is very important.

Mass casualty incident

2009-07-19T21:24:00.000-07:00

Long time, no post. A week of vacation followed my last post, and now I've started R2 year -- the second year of residency.

I worked an overnight shift last night on the Pediatrics team. When I arrived in the Emergency Department things were pretty chaotic; there had been what we call a mass casualty incident: two light rail trains had collided. As you can imagine the department was pretty backed up, but fortunately no one who presented to our hospital was too badly hurt. One of the trains involved was headed to a Chinese-American neighborhood, so when I got there the halls were full of elderly Chinese people in cervical collars.

Vigil

2009-06-22T21:02:00.000-07:00

Last night went to a candlelight vigil for Iran with N and her mother. It was a very dignified affair at San Francisco City Hall; visually striking, since most people wore mourning black with green accessories. One guy tried shouting political slogans, but was shushed (literally) by the crowd. Lots of poems and songs, a speech by city supervisor Ross Mirkarimi, and I learned the tune of the unofficial Iranian anthem, although the Farsi is still a bit beyond me.

Milestone

2009-06-22T11:36:00.000-07:00

Having finished the last shift of my intern year, I am now officially no longer an intern. Whew. That year was getting a little long.

Now comes life as an R2 -- a second-year resident. This year I'll be spending much more time in the Emergency Department, and if all goes well I will either pass pass the next step of the medical boards and get a medical license, or join the swelling ranks of California's unemployed.

Post-delivery comment

2009-06-22T11:31:00.000-07:00

Sometimes birth can be a bit less than tidy. The other day I was doing a routine post-delivery repair when the new dad wandered down to the end of the bed and saw the aftermath. "Honey," he said, "you look like a Quentin Tarantino movie."

Happy Birthday to Sis-Bob!

2009-06-19T02:06:00.001-07:00

Just noticed that it's past midnight -- sending out big birthday wishes to Sis-Bob....

On-call Liveblogging: Labor & Delivery

2009-06-19T01:59:00.000-07:00

Have a rare opportunity here in the middle of the night on L&D to revive my old habit of on-call liveblogging. Many babies delivered in the past weeks, including one the other day to a mom who declined anesthesia and labored to the end full of grace and with a smile on her face; very inspiring.

The new OB interns started yesterday. In fact, one of them moved in with the J-Bomb and myself. Seeing as how we now have a Peds, Emergency, and OB resident living together we should be able to handle any precipitous delivery that comes along in our apartment.

Whirlwind

2009-05-30T08:50:00.000-07:00

The last few weeks have been a whirlwind, but -- unusually for this year -- in a fun way. EM conference in New Orleans, wrapped up a delightful rotation at the VA Hospital (I love working with the vets), then a much-anticipated week off, most of which I spent in Puerto Vallarta with N and her family. Currently whiling away the weekend in Palo Alto at a wedding, then I start my OB rotation on Monday; time to deliver some babies!

I can hardly believe that I'm only a month away from being finished with intern year; R2 year (i.e., second year of residency) starts on July 1. It's reported to be more difficult in some ways than the year I just finished, but at least it will be mostly spent in the emergency department, where I want to be.