42

There's often something else in the background. A weird platelet count, a low sodium level, a little anion gap--something that might be easier to ignore than to try to figure out how it fits into the clinical picture. I'm assuming that I'm going to at least notice these annoying details. That is, I'm already assuming that I'm vigilant.

Vigilance makes a doctor good. A good doctor will diagnose the pneumonia and treat it. Curiosity makes a good doctor better. A curious doctor will be driven to figure out why these other lab values are a little off because, it’s true that there could be all sorts of silly explanations for an out-of-range test result, yet the doctor's job is not only to figure out what's not wrong, but also--when the dust settles--what is.

Like any other job, medicine can become routine. The evidence that we have been accumulating on medical and surgical interventions has to some extent standardized our practice. Data have helped to define the 'standards of care' for investigation and management of many diseases. Some of these well-studied diseases for which there is more or less widespread agreement on management include heart attack, heart failure, diabetes, many infections, and certain kinds of trauma, to name a few. The purpose of evidence-based medicine however is not to make the job of the doctor easier nor is it to make sure everyone gets the same treatment just for equality's sake, but rather to apply particular medical decisions that have been shown, hopefully in high-quality experiments, to be effective. The medical community decides that interventions that improve outcomes should become standard because they're better.

The word that doctors use is not 'standard,' though. It's 'guideline.' This is not because doctors think that they're better than everyone else and that rules shouldn't apply to them. Rather it's to make room for judgment because it is impossible to study every intervention in every population of potential patients, and because even effective interventions are rarely effective for every eligible patient. We have therapies that may approach 100% efficacy (eg, penicillin for syphilis), but they are few and even they're not perfect. We think that preventing death in only 1 out of 42 people treated with a beta-blocker for two years after having a heart attack is pretty good. In addition, accepted algorithms for investigating disease will not include every possibility, so the doctor needs to have an index of suspicion for diagnoses that may not be on any algorithm.

So, is this science or art?

Everyone knows that doctors like to say that medicine is as much art as science. My own quibble with this has nothing to do with medicine (nor with art or science for that matter) but rather with the public's perception of these things. The word 'science' evokes--in most people I think--accurate, precise, and reproducible results. But science is nothing more than approximations and arbitrary constants, especially in the practical application of physics, chemistry, and biology. Engineers have to compromise and allow for some inaccuracy and imprecision in their end design ('tolerances') because they have to live in the real world where mathematics has to be a little looser than it is in the classroom.

At its heart, science is built on hypothesis-testing. Who comes up with hypotheses? People. Observant, curious, creative, artistic people. If hypotheses could be generated based on precise formulae then we could just build a science machine and let it figure out the secret to life, the universe, and everything for us. We know how that would turn out.

Science, like art, requires creativity (neither science nor art are sui generis things). I'm not going to pretend that I can define art, but maybe besides creativity it might include some element of perception by an observant person. At its simplest, then, art is a creative person's response to an observation synthesized into some form (canvas, performance, sculpture, music, prose, poetry, speech, hypothesis--whatever). Science is the same thing I think. Isaac Newton observes that an apple falls from a tree. It's fair to say that millions of people have seen this happen before him but he is curious--inspired--enough to design unique and creative experiments to calculate the rate at which it falls. He is finally able to synthesize his data and determine the gravitational constant (which is an estimate). Newton's laws are works of art. Da Vinci's sketches are science.

The doctor is a scientist, but the scientist is an artist and the artist is a curious human. The uncurious doctor is a mediocre one because he is just a human who is happy with what he knows and doesn’t care about what he doesn’t.

Quiet hour

Mr. Peterson has a pulmonary embolism--a clot in one of the blood vessels going from his heart to his lungs that threatens to keep his blood from picking up oxygen. It most likely came from somewhere lower down in his body, sliding up his vena cava and into the right side of his heart. While there isn't much that we can do about it now, we need to prevent the clot from getting bigger and new clots from getting started in the first place--he needs heparin. Because everyone responds a little differently to heparin, we have to make sure that his blood gets tested every few hours (around the clock) and adjust his dose until he is in the therapeutic range.

I am the 'night float' intern; I take care of patients like Mr. Peterson (which is, of course, not his real name) overnight while the three day teams get whatever sleep they can. It's quieter at night, and with only the occasional beeping of infusion pumps, telemetry monitors, and pulse oximeters all just out-of-sync, I'd even say it's soothing. So far I've been too terrified of something going wrong in the hospital to go to sleep, but I've become used to sleeping during the day. Not so for my patients.

I should say that I've never spent a solid amount of time in the hospital at night before this, my first month of internship. As such, I'd never really thought about how care continues through the night. I never considered that, when I ordered a test or a medication to be performed or administered 'q6h'--every six hours--patients would at some point have to be awakened from sleep during at least one of those instances. And, of course, worse for q4h orders, and so on. I just never thought about it.

Now, I am sitting in a call room and waiting for 4 am when I am to draw another tube of blood from Mr. Peterson. Just a few hours earlier overnight, I had woken him for the first tube and the result showed that I needed to increase his heparin infusion rate because his blood was still clotting too quickly, which I did. Now, I need to wake him for more blood and I know that if I don't, and his response to the increased heparin dose was not adequate, the complications could be disastrous. His clot could get bigger, or a new one could materialize and shoot up his veins through his heart and into another pulmonary artery. Pulmonary emboli can be fatal.

Often, with busy day teams trying to get through their mounds of work, little thought goes into how much sleep patients might need. I mentioned this in an off-hand comment to a colleague and he said, "Patients are always in bed and have nothing better to do than sleep!" But what about the quality of that sleep, interrupted as it is without fail for this blood pressure or that blood draw, sometimes barely an hour apart and not usually more than four or five? It's not surprising that patients--even the most positive and pleasant ones--quickly tire of being in the hospital. Insomnia and irritability go hand in hand.

Although many researchers have discussed the importance of sleep, including in critically ill patients, none have actually studied the effect of its deprivation on hospitalized patients and hospitals do a poor job of promoting good sleep hygiene. In the hospital where I work, a large academic medical center, there are signs posted at the nurses' stations telling staff and visitors that between 2 am and 3 am our patients are asleep and would appreciate quiet. Nurses, doctors, and phlebotomists walk into patients' rooms at all hours of the night for any number of reasons--urgernt or not--turn on the light, poke around, and sometimes forget to turn the light off or close the door when we leave. Alarms, chatter, and beeps puntuate the dark hum of the hospital at night, and they would certainly keep me awake. Sleep is clearly not a priority here, nor is it at any hospital where I've trained so far. How could it be? This is not a hotel; these people are sick and we are working tirelessly and at the expense of our own sleep hygiene to get them well again.

But sleep does matter. Several pre-clinical and clinical studies have shown us that deprivation of sleep, and particularly REM sleep (thought to be the most 'restful' phase of sleep, and the most fragile), affects all sorts of brain and body systems from memory and mood to the heart and general health. In one study, rats were shown to be more sensitive to pain the less REM sleep they got. In many other studies, shortened sleep cycles have been associated with obesity and diabetes--in humans. In a very recent Chinese study, also in humans, sleep deprivation increased inflammation and blood clotting--both involved in stroke and heart disease. And pulmonary embolism.

So what is the right thing to do? In Mr. Peterson's case the decision is simple: I'm going to wake him up. His life is on the line. But what about Ms. Simmons in room 436 who's getting routine (that is, not urgent) lab tests at 5 am--the time designated for AM blood draws throughout the hospital--despite having been kept awake until after midnight in our busy ER awaiting admission to the ward? No one really stops to think about how little sleep this poor sick woman has had last night and how important it might be to her recovery here. We have far too much else on our minds.

Anyway, it's time to go wake someone up. This time I have the luxury of not agonizing over the decision. It's not always this easy.

Top ten most difficult antibiotics to market

I used to write top ten lists for NYMC's student paper, The Goose (come to our campus, we have the goose droppings to back up that name...do you?). Anyway, I was looking back at some of them and a few made me laugh. Again, being a dork helps.

Top ten most difficult antibiotics to market

10. Ceftriagain
9. Cephalohopeitworx
8. Sulfeggedaboutit
7. Ciprollodice
6. Impotenem
5. Stripteasomysin
4. Anything advertised by John Madden saying “BOOM!”
3. Ouijacillin
2. Aunt Jemima’s Spicycillin
1. Penichillin’ G

Zen diagnosis

So I've been watching episodes of Namaste Yoga on FitTV and trying to play along when my body will allow me to place parts of it where they don't really need to be. It's true, though, that you can only achieve a deep union of spirits when you can surrender your mind and scratch your left ear with your right big toe from behind. It's fun too. Once you loosen up the joints with some strategic dislocations, the ligaments can start to work with you, not against you. That is zen.

As I was reflecting, and because I'm a dork, names of diseases started to force their way into my meditative center to ripple my heart chakra. It was annoying but kind of funny (if you're also a dork). Here's an even nine of them.

• Metaphysical acidosis
• Transcendental thrombocytopenic purposefulness
• Adult Inspirational Distress Syndrome
• Nirvana gonorrhea
• Reflectory anemia
• Spiritual Liberation monocytogenes
• Osteomyelenlightenment
• Haikuphilus influenzen
• Lymphadenopath-to-wisdom

Sorry. That was stupid. Anyway, namaste.

Viva la Revolución Antiséptica!

I've written at length, though never coherently,* about the mockery we make of curbing the spread of nosocomial infections by insisting on wearing ties. Fie upon the tie et cetera.

Anyway, ties are only the beginning of my usually pointless griping. The original idea for my anti-sartorial campaign came in the cliched form of a dream. Actually, it was a nightmare, but it wasn't as scary as it was boring and horribly written and shot. The director was probably asleep during filming. Suffice it to say that the talentless protagonist (through whose eyes this farce was depicted) was being interviewed at a prestigious teaching hospital for a residency position and was not clothed in the complete and traditional interview getup.

Namely, he was missing a tie. But also a jacket, a shirt, and pants. And he was unshaven and crusty-eyed. I mean, he had all of these things with him but he was holding them in his hands as if to say, 'I have no use for these! Ask me your questions, sir, and do not mind the hole in my boxers, for I am confident that you will find me to be nothing less than professional.'

Interpret this however you want, but I take it to mean that something must be done about clothing. Obviously, given the popularity of sculpture, nude photography, and sex and pornography, I am right. Don't argue with me, for I can weave a straightjacket of syllogisms around you faster than you can say 'that doesn't make any sense, you idiot.' And it's true, I am an idiot, I should know.

The point is that in addition to banning the necktie in the hospital we must also ban sleeves, white coats, and pants. Every time a tie, shirtsleeve, or pant leg brushes over some germy metropolis on one person's backside, it takes some of those citizens on a ride to the next person's face and, of course, the physician's lunch and no amount of hand sanitizer or handwashing will address the domino effect of cross-contamination. What we need is leadership on this issue. What we need is a Truman Doctrine--a Marshall Plan if you will--for the containment of microbial evil. While I'm no leader, I will gladly take up my position as behind-the-scenes pragmatist and insidious instigator of antimicrobial attrition and realpolitik. A neurotic germophobic George Kennan if you will (and if you won't).

We must therefore institute funding for an armory consisting of the weapons necessary for this war--for make no mistake, that is what this is comrades and we must not shirk our responsibilities! What this plan amounts to is the distribution of scissors to a contingent of able-fingered guerilla housestaff who will use them to carry out lightning raids, cutting dangling bits of clothing not closely adherent to the bodies of caregivers in the hospital. These soldiers of sanitation will fly by nursing stations snipping off germ-dinghies and bacteria-boats as they swarm, bringing back the sleeveless look from the outskirts of fashion onto the catwalk of the clinically responsible.

We must then fortify our offensive with daring propaganda. This is no time for bashfulness comrades, for the revolution cannot wait. Our message must be clear and strong:

The noose of the enemy chokes you! Off with your tie!

Cut off support to the enemy of the people! Cut off your sleeves!

Pants are the haven of the antisocialite germ! Remove them from our midst!

May the sounds of steel kisses and flying fabric resonate in the halls of healing! Viva la Revolución Antiséptica!

* On a parenthetical lever, I don't want to give you the wrong impression. This post will certainly not be coherent either. Homie don't 'play that' and he's n't about t' start today. D' n't question m' use of the apostrophe. It's ours to dispense with as we each please. I don't come to your house and tell you not to end sentences with a preposition.

Locomotivation

A train leaving New York Penn Station at 8:50 am and traveling north at 120 miles per hour, stopping in Poughkeepsie, Albany, and St. Lambert will arrive in Montreal 18.5 hours later because:

• The train is operated by Amtrak and will leave 4 hours late 'for your safety'.
• The train schedule was assembled by 2 liars and 1 asshole all of whom work for Amtrak.
• While the train is capable of traveling at 120 miles per hour--in theory--no Amtrak engineer in their right mind would ever attempt this to avoid speed-related damage to the space-time continuum of upstate New York. This is all based upon research conducted by Amtrak in 1998 when a test animal was strapped to the chassis of an unmanned locomotive traveling at speeds in excess of 40 mph. The train vanished (but was then found later that afternoon at the bottom of a gorge in Ithaca). Amtrak responsibly believes that it is safer to travel at the more reasonable speed of between 0 and 35 mph with frequent lengthy stops for no reason at all.
• Canadian customs officials speak very slowly and use 35% more words than the average speaker of English. And we all know what that word is, eh?
• The train did not qualify for the carpool tracks.

I have been studying for the second in a series of three standardized exams for medical licensure. It is not going well. Over the past three weeks, I have attended two weddings; helped Nurin study; helped Nurin move to Detroit; got my car fixed; hit my car and got it fixed again; watched all the episodes of Aqua Teen Hunger Force and Robot Chicken I could find on YouTube; finished the entire game of System Shock for the fifth time; played hours of Worms; Lemmings, and Prince of Persia; and spent a total of 49.5 hours in transit.

I think my problem is largely one of motivation, but I don't know how to prove it. I think I should watch more TV just to be sure.

Sometimes a phallus is just a phallus

Psychiatry is a field that makes sense in the sense that if you have any sense (in the sense that you are sensible) you will find it difficult to make any sense of it. My feeling is that there is a nearly invisible boundary between effectively mapping out the currents deep in the id and prancing about at the shallow end of the ego, unless you can't swim.

Where do you look for meaning in relationships with people? Can a label that one uses to define a relationship be simply a preemptive defense of that relationship? I mean, saying 'we're married' is clear and in any case more an apology to one's tamed and beaten demons than anything else. But what about relationships that can be approached in an accusatory way? So-called platonic relationships, for example. If you have to specifically preface a friendship with 'platonic,' then is it really platonic? Psychoanalysts make phallic balloon animals out of unsuspecting platonists. True, sometimes an apple is just an apple, but that's so uninteresting. (Even a granny smith is mildly tantalizing at best, compared to a shiny green boob with a stem that grows on trees and tastes so sourly delicious.)

Enough psychobabble. I like the stuff and appreciate it, but I'm not creative enough to whip up a la carte syllogisms around a patient and still be composed enough to fill out the invoice with a straight face. Another feature of the inpatient psychiatric experience that has struck me is the staggering degree of impairment with which some psychotic patients have to live. I don't know what I would do without reality. Well, reality is reality, and what we experience is what we experience, and it is nothing if it does not depend on the sartrean cogito's automatic comprehension of existence--the human-reality at once creating and created by the juxtaposition of l'etre and le neant.

Saying that kind of crap without smoking a cigarette just looks and sounds stupid and I have the most delicate pink little lungs. Whether or not experience and reality are the same shouldn't make any difference to us, social interactions notwithstanding. If this is a blue ball, but I see a pair of orange galloshes, it's still my experience and its accuracy is irrelevant even though I am laughed at by my peers for stumbling around in the rain trying to balance myself on a blue ball like a clowning sad kierkegaardian lunatic full of anguish and pneumonia. So I suppose reality is not as important to me as I thought. Who's to say that I experience reality anyway except me? You can say I'm crazy but then I can say I know you are but what am I times infinity times infinity plus one squared to the power of you're stupid! In fact, I renounce reality. A bas la realite!

Alright enough of that nonsense.

Paranoia, on the other hand, is truly debilitating. Voices, hallucinations, the government melting your ice cream on purpose via satellite. So maybe reality is a good thing after all. But if my brain were forced to choose between a reality that really bites on the one hand and a Statler and Waldorf commentary trained with deadly aim on my inadequacies on the other, maybe I'd take the two grumpy old beans rather than the haldol. Of course, if I'm up in the balcony with them and they're telling me to jump off in that endearingly funny gruff heckling tone of theirs, I hope I'd reconsider or call for Dr. Bunsen's help. Yes I know he's a PhD, but who else am I going to call, the green frog? That's crazy.

Speaking of haldol, my tic has been out of control over the past few days and my neck, shoulder, and wrist are quite sore. Antipsychotics are good for mental psychosis as well as somatic psychosis but oh so bad for your liver.

Paradoxically, however, this is a sentence for which the word 'paradoxically' was completely unnecessary. But what discussion of psychiatry--no matter how half-baked--is complete without 'paradoxically'? In my next post, my judgement may improve but I will always lack insight.

Domo arigato Mr. Moschino

I've got a secret I've been hiding under my coat. I starve my brain for blood every morning using a 100% silk Versace noose that is home to a delicate menagerie of biological opportunistic bastards (of the highest caliber) that I've collected during my travels through other people's nasty bits. My dilemma is this: how do I look presentable, and yet demand more of this season's catalog by not killing people who touch me?

I have considered the collarless shirt. Elegant, simple, no WMDs, and quite frankly, sexy. And I'm nothing if I'm not a sexy son of a blastula. But my neck is half a meter long and a size 14 1/2, so the collarless shirt makes me look like a closed tufted umbrella with an Adam's apple. Still sexy, but come on, add 1 crucifix and stir and I'm Father Late-for-Baptism. (Yes, of course the shirt will be black. That's how I roll.)

The bowtie. A timeless accoutrement that is as infused with suave lightness as it is heavy with brainiosity. Each bowtie comes with a spray bottle of 10 extra IQ points applied straight up the nose where you can smell the ideas.

No, the bowtie is not really timeless, rather wherever it goes it drapes everything within 2 meters of its frilly ends with a thin dusty coat of 1925 and a nice lacquer of pre-depression art-deco Gatsbitude (you're not going to get this stuff anywhere else, I speak a quaint dialect of northern arse, 3, 2, 1, never mind).

The bowtie offers the dull shirt an opportunity to charleston its way into the limelight. That might make the shirt yellow and accentuate my sweat stains (which are almost as sexy as my remarkably toneless ass) but every day wearing a bowtie is a day of greatness and respect.

Certainly the bowtie is more difficult to weaponize.

There is a simpler option. If Yossarian can get a medal pinned to his naked chest in wartime, I could certainly get used to the feel of stethoscope rubber around my bare neck and pens tegadermed to my chest hair.

You know what else is timeless? Styx.

The problem's plain to see/
Too much technology/
Machines to save our lives/
Machines dehumanize.

This of course makes so much more sense if you take out all these words and add different words that are more relevant. Actually I just like this song because I'm old skool and I kick it like hitops in 1983.

And I found a Moschino bowtie that matches my chest hair. Domo arigato, Mr. Moschino.

The happy place

The morgue under our hospital looks just like a morgue.

The long hallway smells of wet dog like it's supposed to. A quorum of aproned antisocial types with knives stand around like chefs. Jars and plastic buckets full of pieces of humans neatly line the walls like barrels in a candy store. In the corner, a table with a camera rig and lights is set up for photographing specimens against an ugly blue background like on a porno set. Dull metal autopsy tables with cutting boards straight out of Martha Stewart's kitchen take up most of the space, separated by stretches of nasty green tile like in grandma's bathroom. A light box for radiology films hangs on one wall with an old stereo from 1986 on top of it (dual tape deck, one with auto-reverse, the other not so lucky) with an actual tape inside, also like in grandma's bathroom. And in the corner, also like in grandma's bathroom, a toilet.

I know, for that is what I also thought. But nay. It was a toilet.

This was not your grandma's toilet. I walked over to it for a closer look and no, it wasn't a sink or a basin, it was just a toilet. But something didn't look right. I looked at it for a while and went down the list of essential criteria for toiletness. There was a toilet plunger. There was a toilet flush lever thing. The piping looked appropriate to me. At its heart was a bowl with toilet water. The rim was there, though I wouldn't want to touch it. In the bottom of the bowl was the sine qua non of toiletude: the drain of oblivion.

Still, something was off. So I imagined myself going through the motions of using this toilet to discover what was missing and promptly ended the imagination when I got totally wet and cold and grossed out. This toilet was way too big for humans.

My colleague was standing next to me and noticed that I was staring at the toilet busy with my calculations. She leaned over and whispered, 'This looks like a good place to shoot Saw 4.' That's grim.

On the other hand, the morgue is actually the least grim place in the hospital since nobody actually dies here. In the tape deck: 'Bhangra mix 94.' Who cares what the toilet is for? Party in the basement, yar.

The pouch of Reda

A word about the title of this blog. This is the story of Reda's pouch. It is an anatomical pouch that I claimed one day while dissecting a cadaver. It is not a pleasant pouch, but it carried a generic and quite replaceable nomenclature and I could not resist but to strip it of its genericity and apply my own eponym to infuse it with life and especially vanity.

Specifically, Reda's pouch (also known as the pouch of Reda) is the compartment created by the interface between the uterus and the urinary bladder. An unfortunate location, but I was disappointed to find that the narrow communication between the third and fourth ventricles (that I had coveted so much since my youth) had already been snatched up and out of my reach forever by that half-wit Sylvius a few hundred years ago. Clearly, I far surpass this moldy ignoramus in medical knowledge at this point yet he still gets to keep his stupid aqueduct. His name contaminates several miscellaneous desirable sites in the human body (all highly lucrative real estate and some so elegant and ethereal that his audacity--and begrudgingly, deftness--in even trying to get his name to stick shocks me to no end). A fissure. My fissure.

Standing over me sprinkling salt on my wounds was Magendie, who filched my foramen while Treitz and Oddi ganged up on me and wrenched the duodenum from my fists and spat on my ligament and sphincter with their gross acidy eighteenth century spit to claim them for themselves.

No. I am left with a pouch that can be found in less than half of the population, and even so, is absolutely useless. It is there by accident, an anatomical default, the unavoidable and purposeless outcome of space and tissue. A dank, reeking swamp, a sewer for the female inards, a tripe basket!

That is what I, bloodied and defeated, was able to wrestle away from those entitled buffoons. And even so my claim is still disputed. The best I can get is 'the vesicouterine pouch' and then in pen and in my own handwriting: 'of Reda.'