Origins.

I am the Barber-Surgeon
Shave and a bloodletting,
Two bits.
Fashion and medicine
The not-so distant cousins
It seems.

Cowboys and Indians

While driving alone through vast Montanan landscapes I decided to stop for coffee in Billings, of all places.  A skeleton of former factory glory, Billings lacked character, lacked charm, lacked any reason to survive.  But they had darn good coffee.  After my cup of joe I stood by my car, stretching.  An indigent Native American in ripped and soiled jeans approached me with fearful and bloodshot eyes. He told me his mother was down the road, dying on the 4^th floor of the hospital.  He wept openly.  I consoled him.  I put my arm around him.  He said he was all she had left.  His brother had died in the rodeo years ago, he said.  I told him to go be with her.  He said he couldn’t bear to see her this way.  I urged him to see her.  He said ok.  We embraced—me, a white medical student from Michigan just passing through, and him, a poor Native American stranger from Billings.  His tears were on my shoulder. Then he asked for money, and I said no. Move along.  

Drunk birds.

Intoxicated patients are a dime a dozen in the ED.  They can be found slumbering on cots in the hallways, running naked through the resuscitation bays wearing a blanket like a cape, or simply shouting at the top of their lungs at all hours of the day. Many are “frequent flyers;” familiar faces that consume nothing but beer, medical resources and free sandwiches.  These individuals are received with palpable disdain in the ED.  Eye-rolling and off-color comments abound with their arrival. The goal is always to “get them out the door” as soon as possible. Emergency Department attitudes towards individuals with alcohol dependence and abuse verge on the unethical.  Alcoholics are not recognized as suffering from mental illness, but rather are more or less derided for their “choices.” Addiction is never addressed in the ED.   Undoubtedly, to do so would be time consuming,  resource heavy, and in many cases futile.  However, by ignoring the true illness we simply set these inebriated birds loose on rough winds. We throw these frequent flyers to the ominous skies, encouraging them to fly another day.

Gerty

There's a 95 year old woman dying in the intensive care unit in a community hospital about 20 miles from here.  Her body is a withered shell, a mere 60-70 lbs of bones and loose, bruised skin. Her mind, however, is vibrant, joyous, and sharp. When I walk in the room each morning and ask "how are you doing?" she invariably responds "I'm feeling better," even as she hacks up increasing amounts of thick phlegm. Equally invariably, she turns to me and squeaks out, "how are you this morning?" She says it with all the sincerity she can muster. She reaches out her feeble, skeleton-like hand while I talk to her about her ailment. Each morning, I take her hand in mine and she clasps her hand tightly, as if clinging to life itself. I lean in close to her--as her 95 year old ears don't hear as well as they used to-- and there we sit, chatting about her sons and her lifelong passion for football. I don't have the heart to tell her that I don't care much for the sport. Her mouth is dry and cracked, so each morning I swab her lips with a moistened sponge on a stick, and my mind drifts to the vinegar held to Jesus' lips in his last moments. After the sponge, I dab her lips gently with a tube of moisturizer, and I think how much more pleasant the cross would have been with some lip balm. Yesterday I was watching her breathe during her sleep, noting how her entire body seemed to gasp for air. She awoke, opened her eyes slightly, and turned in my direction. "Am I going to make it?" she asked. Suddenly my chest was in a vice, and the vice was squeezing me so hard that my eyes welled clear and full. I answered feebly, something about doing our best. Her hand squeezed my own. We smiled at each other, and she went back to sleep.

The Washington Patch

Many thanks to Brother Wrider for the brilliant idea. Allowed me to check out some new single track near my house. Perhaps not the smartest thing to do on a 1 dollar makeshift patch.

The Central Line

A "central line" is a type of intravenous catheter that is inserted into one of the larger veins of the body, typically the superior vena cava, which can be accessed by either the internal jugular vein or, more rarely, the subclavian vein.

A "central line" is also a great cause of fear and trepidation for many med students and junior residents. I recently successfully placed my first central line under with ultrasound guidance and close supervision on an intubated patient. Placement of the line requires inserting a 3-4 inch needle into the neck or chest while avoiding any of the following scenarios:

1) Nicking the carotid artery and watching your patient spurt blood from his neck like a cheap zombie apocalypse flick
2) Puncturing the lung (more likely with a subclavian line) and causing a pneumothorax in which the lung collapses as its surrounding negative pressure space fills with air.
3) Stabbing the heart itself with the long guidewire over which the catheter itself is slid; this is a particularly undesirable possibility as large hunks of raw meat typically do not respond well to poking and prodding. Ask any cow.
4) Failing. In this scenario you can't get your needle in the vein and the patient either dies or (and possibly more dreadfully for many individuals) a more senior medical staff has to save your incompetent derriere.
5) Incurring the wrath of a sickly patient who does not take kindly to being treated as a pin cushion; in this scenario the patient may run the risk of breaking the sterile field by squirming, spitting, swinging fists at your petrified face, or possibly snatching the needle from your trembling hand and attempting to place a central line in YOUR neck.

Polo

 New mallet.

 Tapped the end so there's no need for a bolt through the side

 See

 Teip and BBor

 Polo

 The coveted Joust

 Bbor with his new ride

To what end do we save lives?

The end is the same, despite our lofty pontifications and costly interventions. We save lives for the sake of the individual, despite the impact on the herd. We save lives to postpone the tears and nose-blowing of loved ones, despite the knowledge that no tears or hankeys are ever spared. Death is a zero sum game.

We save lives because, for some inexplicable reason, we intrinsically value life- however harsh it may be. We value time. Time on this spinning rock. Yet, ironically, we don't value our own lives enough to quit drinking, quit smoking, quit McDonaldsing, quit winding up in the damned hospital. And we don't value our time on this spinning rock enough to value the spinning rock itself.

Ode to Veterans Affairs

Beards, beards, and beards galore; welcome to the VA. Missing toes, missing eyes, missing the bus to Battle Creek. COPD, PTSD, straight black coffee; welcome to the VA. Diabetes mellitus, old man who yells at us, abscesses full of pus. Delirium tremens, estranged family makes amends, all vets are old friends, come once you'll come again; welcome to the VA. Cirrhosis, thrombosis, please help us. Tote your guns, smoke for fun, terr'rists go'n run, 'Merica's next to none; welcome to the VA. Yessir, Nossir, thankya Ma'amy, firm shake your handy, spank the nurse's fanny, ain't this life grandy, pass me the brandy; welcome to the VA. Fought in war, decub sore, hate Al Gore. Nicest folk you'll ever meet, missing teeth and missing feet, live in trailers live on the street, laughing joking tender sweet- in terms of patients, you just can't beat...the VA.

"Comfort Care": Euphemism of Euphemisms

Mrs. P went comfort care over the weekend. Died a few hours later. She was puffy, swollen, pumped full of a myriad of unforgiving antibiotics and crystalloid solution, a plastic tube jammed down her throat with dried blood at the corners of her mouth. Unconscious, unable to breathe, unplugged, and now unalive.

Her husband, from whom she was separated, was at the bedside soon after she passed- distraught, he prayed with the clergyman assigned to Mrs. P.  He wept openly. A broken marriage and a wife stripped of white cells and stripped of life. Which part was he weeping for?

 He found no comfort in comfort care. I find no comfort in comfort care. Here's hoping Mrs. P had some comfort with comfort care.

may your valves be ever infected.

I met Mr. Archer on the 7th floor around 9 AM on a forgettable day in May. He was basking in the morning sun at the window near the end of the hall, staring out onto Mitchell Field below. He reminded me of my grandfather; an aged farmer with gruff hands and a warm smile like morning coffee. Mr. Archer turned as I approached. He smiled and shook my hand the same as he had done the past three mornings. However, I hadn't come this morning to ask more probing questions about contact with cats and cattle, travel to the Southwest, or to check on his fevers- I came to find out how much he knew.

"It's leukemia," he said, with a twinge of  grief in his eye. Apparently he knew a lot. "They told me last night." He forced a meek don't-you-worry-bout-me smile.  I gently returned the smile through a frown. I had been working Mr. Archer up for possible infectious endocarditis. He had fevers without a clear source and some recent heart surgery, two minor Duke criteria. But he also had a peculiar rash that didn't fit the bill. A skin biopsy of his rash returned the night before- leukemia cutis. Probably from acute myeloid leukemia. Blood cancer.

It was not my place to inform Mr. Archer of his cancer, but I don't deny that I wanted the task. I had liked him instantly. An old-timer with a solid heart, nothing more and nothing less. I had spent time with him. Asked him about his crops and kids. He deserved to hear about his leukemia from someone familiar.

This medical jungle inspires strange desires and peculiar prayers from its inhabitants.  As a prime example, I have never wished so badly that a man had endocarditis.

Malaria Man

ID consults this month. The other day my fellow threw me a new patient- "middle aged HIV+ guy in the Obs unit with 5 days of fever and malaise: go check it out." Needless to say the differential diagnosis for this guy could stretch from here to the Indian subcontinent. I scouted out his records, checking his last CD4 counts and viral loads. Lingering in a healthy range and undetectable, respectively. I reviewed his admit and ED notes- some nausea (an equally nonspecific symptom), fever of 104, maybe a day of upset stomach. Nothing to grasp onto too tightly.

Then the story got strange. This guy was an academic, and as such he had traveled in recent years to Thailand, Myanmar (or Burma depending on your political persuasion) and remote regions of the aforementioned Indian subcontinent. He was a bit of an eccentric guy (I already told you he's an academic, right?) and had apparently eaten some pickled chinese mustard root and pork pot stickers earlier in the weak. What in the name of Buddha is pickled chinese mustard root, you ask? I have no idea, and apparently neither do the medical databases I searched in my over the top efforts to piece this dude together.

Then I stumbled on it: eosinophilia. The guy had two CBCs showing eosinophils in the 26-28% range, grossly elevated (should be around 3-5% or so).  Eosinophilia occurs in a few different scenarios, specifically:
1. Helminth infections (worms for the lay folk out there- we're talking blood flukes, hookworms, roundworms, etc.)
2. Fungal infections (your basic aspergillosis, coccidiomycosis, histoplasmosis, etc.- these can get real nasty, especially in an immunocompromised HIV+ guy).
3. Allergic reactions- (nuff said).
4. Eosinophilia syndromes (these are some oddball conglomerations of symptoms that constitute things like the infamous Churgg-Strauss syndrome)

The fact that his eosinophils were so elevated gave me something to work with- it allowed me to narrow my differential and cater my interview to specific risk factors and exposures (like caves and bat guano for histoplasmosis, for example).  But wait! What's that there? Another CBC? A CBC WITHOUT eosinophilia (2%)? Why are there two auto differentials showing elevations and one manual diff showing normal levels????

I phoned up the hematology lab, inquiring about the discrepancy. No explanation. The slides had been reviewed and the counts confirmed, but it made no sense. The nice lab tech on the phone offered to review the slides personally. Perfect. I marched off to the obs unit to interview the guy.

Halfway through the interview I get a call from the lab.
Lab: Is there anyway this guy could have malaria?
Me: Uhhhhh......yeah, actually, there is.
Lab: Good, because he has malaria.

Plasmodium vivax had been lying dormant in his liver for at least 9 months. He had no idea. The lab had missed it completely on three different CBCs that they allegedly reviewed. Had I not called about the eosinophilia discrepancy he would have likely remained undiagnosed for a long long time. As it is, he'll take some chloroquine for 3 days and primaquine for 2 weeks. That's it.

Malaria. Best day of med school yet.

Detroit Delight Ride

O'leary, Mack, and I leisurely cruised Detroit one fine day. Here's a glimpse.

O'leary in the lead. 

Atwater Brewery for an IPA.

O'leary and Mack with a storm a brewin'

Waterfront ride.

Gynecology Oncology: A Venting

I've had my fill of these smelly-vagina, blood-spatter-on-my-scrubs, 4:45-AM-wake-up-to-three-alarms, stand-in-one-spot-for-five-hours-without-a-piss, yessir-nosir-thankyousir-mayikissyourbuttsir, stickin-my-fingers-in-deep-dark-dank-unmentionable-places-to-say-i-felt-ovaries-i-didn't-feel kind of days.

Conversation w/ Psychosis

Student doctor Grizzle: sir, how are you feeling this morning?
80 year old Veteran: we're both deadheads right?
Dr. Grizzle: you mean like the band, the Grateful Dead?
Veteran: the Grateful Dead goes to my church.
Dr. Grizzle: what?
Veteran: we're going to give them the church because we have less than 35 members
Grizzle: what kind of church is it?
Vet: Presbyterian
Grizzle: so you're giving your church to the Grateful Dead?

Vet: Yes

Grizz: Who's in the Grateful Dead anyway?
Old Vet: There are about 120 children. They killed a lot of people in San Francisco.

Grizz: I see.....

A day in the life

My day:
Bike ride to work. Coffee.

substance abuse, borderline/paranoid personality disorder, generalized anxiety disorder, paranoid delusions with agitation sexual disinhibition and progressive psychosis with auditory and visual hallucinations. Quote of the day? "Kroger wants me dead."

Bike ride home. Glass of wine. Bedtime

Polo practice

Polo Practice. 5 stories up. 2 pbr. 1 bike 1 ball 1 mallet.

Rigor Mortis

This post is actually from a couple years ago when I was head over heels for anatomy and jogging, two equally horrifying pastimes.

There's nothing that can inspire you to run like a room full of dead bodies. I spent four hours today with my hands immersed in bowel and bile-- probing pancreas, massaging mesocolon, and oggling omentum. After standing in one spot over a semi-rotting body for so long, one feels the urge to move-- not only to flee the scene of decomposition, but also to exercise the right to exercise; a right that my donor no longer possesses. In a way, my run today was an homage to my benevolent instructor (the donor), who inspired me to "shake it while i got it."

However, for those of you who have not had the pleasure of jamming your appendages into the deepest darkest recesses of the human body...(I just realized that that introductory phrase could be misinterpreted as a euphemism for coitus. I am not referring to coitus, grow up)...for those of you who can not fathom the mystery of mesentery, you must understand that dead people, regardless of the preservation process, stink. The stench varies from body to body, and my donor emits (thankfully) a relatively tolerable odor. Relatively is the keyword. The scent is indescribable, but imagine an elderly recluse-- you know that musty "old person" smell?-- now leave that recluse unbathed for a solid ten years, add some feta cheese and fetid bacteria-infested sewer water, and you may begin to understand the complexity of this odor. Now, you must also understand that the smell of cadaver is remarkably clingy. It grabs your clothes, your hair, your skin, and sometimes it seems like it doesn't leave unless you scrub til you bleed.

That being said, I decided not to shower between my dissection and heading to the gym. Hence, I stanked. I stanked bad. I also have not washed my running clothes this week (and I have already put in a solid fifteen miles). So as I hopped on the treadmill next to a cute Middle-Eastern girl I became self-conscious of my stank. Would she notice the smell of death oozing out my pores with every stride? Would she mistake this nasty DBO (dead body odor) for regular BO? Luckily, I didn't care what this girl thought. As I reveled in my sweat, stank, and apathy for the girl next to me, my eye caught glimpse of a cute girl a few treadmills down. I had seen her the night before at the gym. She runs like a gazelle, and (though I've yet to be close enough) I presume she smells like cinnamon and sunshine. So the question soon begged itself: how far did my stench of death reach? What was my range? Would the gazelle be forced to suffer the DBO instead of my usual enticing musk? Would my passion for human anatomy and my overzealous approach to the peritoneum undermine my passion for beautiful women and my underzealous approach to flirtation?? My question was soon answered as the gazelle leapt from her treadmill and fled to an elliptical a few rows down. She had smelled me.

But who needs her? I have my education.

Photo trial

Sister Grace bites it in the bushes.

Just wanted to try posting a picture.

The Battle of How to Die Right

Mr. T is a far cry from B.A. Baracus of the A Team. He is a frail, cachectic Asian man with a bowel obstruction. He sinks into his bed to the point that he disappears. You would think he is dead until he eerily turns his face towards you and speaks in mostly inaudible croaks and groans. He has an NGT (nasogastric tube) pumping out the contents of his gut- bilious fluid that, for some reason, never fails to remind me of the "ooze" from Teenage Mutant Ninja Turtles.

In simple terms, Mr. T is about to burst. He already had one small bowel obstruction last month that required surgical resection of a portion of his 80-something year old gut. He's spent weeks trying to recover, but his tenuous convalescence was complicated by necrotizing pneumonia, abscesses, and underlying depression. And now he's obstructed again. About to take another spin on the merry-go-round. If he doesn't get surgery soon he will burst, perforating his small intestine and spilling bile, bacteria, and shit throughout his peritoneal cavity. Infection would set in quickly, and he would die a rapid but excruciating death.

Mr. T has chosen this. He is declining surgery, opting instead to embrace death, however unpalatable the process. His family wants him to stick around awhile, and thus the Battle of How to Die Right begins.

I was working with the psychiatry resident on call when were consulted on Mr. T-- a capacity eval. The gist of the question was whether or not Mr. T had enough neurons in his noggin to make the decision for himself. Is he of sound enough mind to decline the operation? We set ourselves to the task. We battered the old shell of a man with a barrage of questions and tasks, including gems like identifying a picture of a rhinoceros (the poor guy thought it was a hippo, he must be deranged! No points awarded, by the way).

After much contemplation and verbal hand-waving, we determined that Mr. T lacked capacity. We stripped his autonomy to give up on this world. So sorry Mr. T, but we simply can't let you die the way you want. We ain't in the business of lettin' folks die round these parts. Reflects poorly on our stats. Nobody dies on our watch, y'hear?

I believe it was the right decision to not let Mr. T make his own decision in the state of mind he was in. Nevertheless, why should he get surgery? What is the sense in prolonging this man's life? Is it to comfort ourselves so we can say, "we did everything we could."

He is old, decrepit, depressed, and disabled. Is it just of us to fix his bowels without fixing his brain? Is it inherently cruel to save a man from an imminent death only to destine him to a slower demise by depression? The Battle of How to Die Right rages on....

Dot's Death

Dot was my first patient who died. Emphysema had carved out her lungs like a pumpkin, and she had bacteria coursing through her vessels like rats in a sewer. She had infective endocarditis. Enterobacter had coated her heart valves, now gnawing at the adjacent myocardium.

An hour after I prerounded on her, she dropped her sats to the 70s on 100% nonrebreather. “Shit,” I thought, “she’s a CO2 retainer.” She needed oxygen, but the more oxygen she got, the more her respiratory drive would drop. Her eyes were vacant as I shook her and called her name. She was obtunded. Her face took on a shade of purple, like a terrified grape. They intubated her at the bedside. I escorted her sister to the unit, spewing calming words of reassurance like an idiot. I smiled knowingly, though I knew next to nothing.

I had lectures that afternoon, and it was a Friday. I suppose I was tired. I suppose I wanted to go have a beer and sit on my porch. I suppose I thought Dot would be right as rain after a stretch in the ICU. I went home instead of checking on her. I was sipping a PBR by 5:15.

She died around 5:30.

the tale of frank and doug

Frank liked cycling. Doug liked cocaine. Frank got a tumor. Doug infarcted his cord. Frank had left-sided neglect. Doug neglected hygiene. Frank pondered cycling. Doug pondered suicide. An unlikely pair, Frank and Doug. Best of friends. Hospital rooms forge strange bonds.

poverty on the church steps

(wrote this last fall)

There is a beautiful church down the road from my house. Replete with a majestic bell tower, magnificent stain glass windows, tall wooden doors, and intricate stonework. It stands out like a flower among the weeds of cramped old homes housing dirty college students like cockroaches in a tin can. As I rode by the beautiful structure this afternoon I spotted a homeless man resting on the steps of the church, his back propped against a stone wall to shield him from a harsh October wind. His belongings were strewn about him—his long burly beard his only real comfort as the days turned cold. I pitied him as I rode.

Across the road from the church I spotted a minivan. A middle-aged woman had her window rolled down with her arm outstretched, iphone in hand. Was she taking a picture of the poor homeless man? Was she that heartless? Was she some kind of soccer mom monster who relished documenting the misery of others? I glanced back at the homeless man, but his wind-shielding stone wall concealed him from view. She couldn’t even see him, I thought. She had simply stopped to take a picture of the pretty building… from inside her minivan… with an iphone. She couldn’t see the poverty behind the wall of the church steps. I pitied her as I rode.

Sunday Best vs. Winter Worst

My fancy clothes require adequate protection from the elements. I work in a hospital, sporting shiny shoes and dapper ties on a near-daily basis. Scrubs are my only occasional respite from the world of cuffs and collars. My Sunday best, however, is no match for winter's worst. As such, I layer up each morning for the commute. I am meticulous- zipping on my waterproof pants, tucking my crisp white cuffs into my mud-stained gloves, and donning a thin but warm hat that fits snugly under my helmet.

As I churn my way out the driveway on my jimmy-rigged single-speed into the slush filled streets, I feel the cold water flick onto my legs, my back, my face. My argyle socks and leather shoes are not spared the onslaught of winter's piss and spit, but the rest of me arrives warm and dry at the Emergency Room. I strip out of my "wet" suit, and emerge like Superman switching back to Clark Kent after soaring through the skies. I am indistinguishable from every other employee of this hospital who drove to work in their heated cars with windshield wipers and cupholders. We all arived safely, ready to tend to the needs of whatever patients may walk through the door, but I had more fun getting here.