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.
Wednesday, July 16, 2008
Monday, May 26, 2008
Favorite words
#3. Diphthong. Diphthong. Diphthong.
A word so ballsy it doesn't even come close to demonstrating its own meaning despite a surplus of idle letters.
I make a point of creating social situations in which 'diphthong' is not only a propos, but rather expected. Yes, I'm very talented.
Come on. You see it and you just want to say it aloud. It makes you want to twist your mouth into trying new maneuvers. Do you pronounce the 'ph' or just the 'p'? Say it both ways. Say it ten different ways. If you're using this word, I'm sure you have the time.
A word so ballsy it doesn't even come close to demonstrating its own meaning despite a surplus of idle letters.
I make a point of creating social situations in which 'diphthong' is not only a propos, but rather expected. Yes, I'm very talented.
Come on. You see it and you just want to say it aloud. It makes you want to twist your mouth into trying new maneuvers. Do you pronounce the 'ph' or just the 'p'? Say it both ways. Say it ten different ways. If you're using this word, I'm sure you have the time.
Thursday, May 15, 2008
L'homme de 70 kg est mort !
I am the exemplar. I am the specimen in your anatomy atlas, the most deeply understood datum in your pathology textbook, the model to whom the parameters of pharmacology apply the most accurately. I am the standard-issue chassis: medically, humanly--decidedly--average. I am the 70-kg male.
Yet an exhausting week weaving up and down midtown Manhattan clearly leaves me thinking that the 70-kg male is dead--at least economically--in the estimation of clothiers and cobblers. Especially this 70-kg male, searching for a simple white shirt with a french cuff that does not make me look like I'm wearing my daddy's nightshirt for walkies. Or for a light jacket, or a pair of trousers, or even a pair of shoes that actually measure what they portend to measure.
As usual, several things are bothering me at the moment and if you know me, then you know that I wouldn't have it any other way.
The fattest common denominator.
It seems that clothing manufacturers and their retail henchmen are complicit in this plot to systematically disrobe those no longer falling within the nation's ballooning average. Put another way, they are seeking to surreptitiously recreate 'average' in their own bloated overgrown image.
This runs deep. Oh I'll feed you, children. Gargle this mindful of truth-flavored listerine:
The people eat. The people get fat. The people try to buy clothes but oh! now they've moved up a couple of sizes and they feel bad, guilt-stricken by their doctors and ridiculed by bufoons in fat suits. Meanwhile, they are herded into Big & Tall and have to start dressing like Cedric the Entertainer. No, you're not going to like the way you look, I guarantee it.
Oh but here's the hat-trick.
The clothing giants, hand-in-dirty-hand with the food conglomerates, agree to slowly increase the real sizes of their clothes while maintaining their labeled sizes. In essence a medium is now the size of what was previously large and a small is now what used to be medium. And the little guy gets shut out. We, the old mediums, are now sifting through piles of small and extra-small and shopping at Petite Sophisticate which is very gay because the stretch-pants-and-skirt look is not unisex.
Système International d'Unités? Bah and harumph.
It doesn't stop there. Not content with the outerwear and the casual vestments of the commonfolk (sized as they are in an appropriately common and course scale: s, m, l, xl, xxl, xxxl, 4xl, 5xl, and two-seat-minimum), the sartorial serpents are infusing their venom into our all-important standard units.
How else could it be that, despite being a very clear 9.5 on the Brannock device (pictured here), I must purchase Johnston and Murphy's in a size 8.5? Or Kenneth Cole's and Aston Grey's in a size 8? So what if I wasn't going to buy them anyway? I should be able to try on a pair of $350 shoes at the store with confidence as I gather the necessary capital over the next few years.
Why is there so much variability in 30x30 trousers? Some fit perfectly, yet many hang from my frame like wet underpants.
Why is it that the neck of this 70-kg male--an exquisitely empiric 14.5 inches--happens to be the smallest size in production anywhere? Still, there is not a 14.5 shirt that will fit me adequately enough to look presentable. When I am told by the helpful salesman at Thomas Pink that I'd be hard pressed to find 'a man's shirt' in my size without having it tailored, and that--if pressed for time--I should shop in the boys' department, I feel so very small. And little boys don't wear shirts with French cuffs, sir. Cufflinks are a choking hazard.
From the ashes, a gaunt phoenix arises!
I know that I am not the smallest man on Fifth Avenue. I know there are people in the Village who share my travails, who've felt the diminution of standing next to the mother of a prepubescent scamp trying not to cringe at the horrible things t-shirts have stamped on them these days. I've seen these men: skinny, lanky men, wispy even. It is as though our money is stained yet we have no voice.
Brothers!
We must speak as one. Join me now to fight the tyrany of these coddlers of the corpulent, these pamperers of the portly, these indulgers of the inhumanly big! They subserviently change their tallies for the tall and the tubby, and yet they spurn the business of the slim and the slight! We say they can't have it both ways! We say we can no longer be the average when it suits science, while being the extra-small when it suits suits. We can no longer abide the slights of this...this obesity-industrial complex! React! Rebel! Revolt!
Or we could just go for coffee. Either way we can meet for sandwiches at Ben's Deli on 38th and 7th but I can't be out too late (my wife, she worries). Or bring a sack lunch why don't you, we might eat outside if it's nice. And a beverage maybe? Whatever.
Yet an exhausting week weaving up and down midtown Manhattan clearly leaves me thinking that the 70-kg male is dead--at least economically--in the estimation of clothiers and cobblers. Especially this 70-kg male, searching for a simple white shirt with a french cuff that does not make me look like I'm wearing my daddy's nightshirt for walkies. Or for a light jacket, or a pair of trousers, or even a pair of shoes that actually measure what they portend to measure.
As usual, several things are bothering me at the moment and if you know me, then you know that I wouldn't have it any other way.
The fattest common denominator.
It seems that clothing manufacturers and their retail henchmen are complicit in this plot to systematically disrobe those no longer falling within the nation's ballooning average. Put another way, they are seeking to surreptitiously recreate 'average' in their own bloated overgrown image.
This runs deep. Oh I'll feed you, children. Gargle this mindful of truth-flavored listerine:
The people eat. The people get fat. The people try to buy clothes but oh! now they've moved up a couple of sizes and they feel bad, guilt-stricken by their doctors and ridiculed by bufoons in fat suits. Meanwhile, they are herded into Big & Tall and have to start dressing like Cedric the Entertainer. No, you're not going to like the way you look, I guarantee it.
Oh but here's the hat-trick.
The clothing giants, hand-in-dirty-hand with the food conglomerates, agree to slowly increase the real sizes of their clothes while maintaining their labeled sizes. In essence a medium is now the size of what was previously large and a small is now what used to be medium. And the little guy gets shut out. We, the old mediums, are now sifting through piles of small and extra-small and shopping at Petite Sophisticate which is very gay because the stretch-pants-and-skirt look is not unisex.
Système International d'Unités? Bah and harumph.
It doesn't stop there. Not content with the outerwear and the casual vestments of the commonfolk (sized as they are in an appropriately common and course scale: s, m, l, xl, xxl, xxxl, 4xl, 5xl, and two-seat-minimum), the sartorial serpents are infusing their venom into our all-important standard units.
How else could it be that, despite being a very clear 9.5 on the Brannock device (pictured here), I must purchase Johnston and Murphy's in a size 8.5? Or Kenneth Cole's and Aston Grey's in a size 8? So what if I wasn't going to buy them anyway? I should be able to try on a pair of $350 shoes at the store with confidence as I gather the necessary capital over the next few years.
Why is there so much variability in 30x30 trousers? Some fit perfectly, yet many hang from my frame like wet underpants.
Why is it that the neck of this 70-kg male--an exquisitely empiric 14.5 inches--happens to be the smallest size in production anywhere? Still, there is not a 14.5 shirt that will fit me adequately enough to look presentable. When I am told by the helpful salesman at Thomas Pink that I'd be hard pressed to find 'a man's shirt' in my size without having it tailored, and that--if pressed for time--I should shop in the boys' department, I feel so very small. And little boys don't wear shirts with French cuffs, sir. Cufflinks are a choking hazard.
From the ashes, a gaunt phoenix arises!
I know that I am not the smallest man on Fifth Avenue. I know there are people in the Village who share my travails, who've felt the diminution of standing next to the mother of a prepubescent scamp trying not to cringe at the horrible things t-shirts have stamped on them these days. I've seen these men: skinny, lanky men, wispy even. It is as though our money is stained yet we have no voice.
Brothers!
We must speak as one. Join me now to fight the tyrany of these coddlers of the corpulent, these pamperers of the portly, these indulgers of the inhumanly big! They subserviently change their tallies for the tall and the tubby, and yet they spurn the business of the slim and the slight! We say they can't have it both ways! We say we can no longer be the average when it suits science, while being the extra-small when it suits suits. We can no longer abide the slights of this...this obesity-industrial complex! React! Rebel! Revolt!
Or we could just go for coffee. Either way we can meet for sandwiches at Ben's Deli on 38th and 7th but I can't be out too late (my wife, she worries). Or bring a sack lunch why don't you, we might eat outside if it's nice. And a beverage maybe? Whatever.
Monday, March 24, 2008
The dojo of the master putter of the foot in the mouth
There is an art to making an arse of oneself. I have practiced the ephemeral wushu of the social nitwit, studied the polished crudeness of the transcendent imbecile, and perfected a flawless mimicry of the natural idiot. I constantly challenge myself by dusting the most tranquil social landscapes with my lovingly crafted organic awkwardness. Just a spoonful of sugar may help the medicine go down, but it totally ruins caviar.
I paint my world with an angel's lock brush dipped in smooth golden weirdness.
I make my awkwardness myself in my distillery from the rarest, purest, and sweetest of character flaws. The craft is delicate and arduous, requiring patience and an apetite for one's own foot.
First, I gently warm twenty gallons of misunderstanding in a cherrywood cask. I then crush four pounds of self-esteem and drop that into the cask and stir gently and regularly over a fortnight with a four-hundred year old oak ladle inscribed with the words 'Cave quid dicis, quando, et cui. Quod non cotidie.'
Then, delicately, I add juice of stutter root, a fine distilled licqeur of ignoring better judgement, and granulated introversion.
By this time, the preparation has become thick but clumpy. I scoop out any precipitating self-awareness and inhibition with a gold sieve and feed it to my cat, Minerva.
Then, I bottle the sweet nectar and sprinkle liberally in the center of groups of three to four people seconds before redirecting my foot's Qi through my mouth with the grace and purpose of a master capoeirista. O berimbau na roda de Capoeira!
'What's that you say? Really? You know who else I heard is going? Elizabeth!'
'But I'm Elizabeth.'
'Oh. Then I don't believe we've met. I'm an arse.'
And you may address me as maestro chef sensei Haatem-san.
I paint my world with an angel's lock brush dipped in smooth golden weirdness.
I make my awkwardness myself in my distillery from the rarest, purest, and sweetest of character flaws. The craft is delicate and arduous, requiring patience and an apetite for one's own foot.
First, I gently warm twenty gallons of misunderstanding in a cherrywood cask. I then crush four pounds of self-esteem and drop that into the cask and stir gently and regularly over a fortnight with a four-hundred year old oak ladle inscribed with the words 'Cave quid dicis, quando, et cui. Quod non cotidie.'
Then, delicately, I add juice of stutter root, a fine distilled licqeur of ignoring better judgement, and granulated introversion.
By this time, the preparation has become thick but clumpy. I scoop out any precipitating self-awareness and inhibition with a gold sieve and feed it to my cat, Minerva.
Then, I bottle the sweet nectar and sprinkle liberally in the center of groups of three to four people seconds before redirecting my foot's Qi through my mouth with the grace and purpose of a master capoeirista. O berimbau na roda de Capoeira!
'What's that you say? Really? You know who else I heard is going? Elizabeth!'
'But I'm Elizabeth.'
'Oh. Then I don't believe we've met. I'm an arse.'
And you may address me as maestro chef sensei Haatem-san.
Sunday, March 16, 2008
Friday, March 14, 2008
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
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
Tuesday, March 11, 2008
The journey (don't forget your $400 purse)
I was about to give up on finding my way out of Wolf Blitzer's beard and finally breaking out of the Situation Room when I was captivated by this during a commercial break:
http://www.youtube.com/watch?v=fG79nd8ej94
It was beautiful, and it got better and better, but also worse and worse as I tried to imagine which purveyor of useless crap--which cancerous bastion of consumerism--would take responsibility for this seemingly profound piece. And the answer had me surprised, laughing, and wincing all at the same time. That hurts.
http://www.youtube.com/watch?v=fG79nd8ej94
It was beautiful, and it got better and better, but also worse and worse as I tried to imagine which purveyor of useless crap--which cancerous bastion of consumerism--would take responsibility for this seemingly profound piece. And the answer had me surprised, laughing, and wincing all at the same time. That hurts.
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