Remembering the Good in 2016

Well, it's that time of year: time to unload my Rememberlutions Jar. Not only is having a place to store positive memories from the year a good habit to make, but the jar itself is a reminder of the years I spent studying and making friends in Grad Study at the Wesley Foundation in graduate and medical school. In 2015, I stored memories related to the last two years of medical school such as good grades and comments from preceptors, as well as experiences I had at the theater (fun, beautiful) or traveling (memorable, meaningful). 2016 included many more arts & culture moments, as well as big life changes. Here they are, in the order I pulled them out of the jar. Click the links for blog posts or websites.

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The first slip I drew out was the note Dear Husband left me one night when he had gone off to choir practice before I had gotten home from the hospital.

Next was my PACE Palette score card from Pediatric Intern Retreat. Our class had gathered at Cheat Lake, WV, to learn more about ourselves and each other, such as the fact that I am the most analytical, curious person in the class but not as methodical or organized as I like to think I am. Later I posted what DH and I learned about our marriage that weekend.

Ticket to see "Mark Twain Tonight! Starring Hal Holbrook" at the end of April. I had bought us seats to surprise DH, but he spent the night in the hospital getting chemotherapy, so I took a mutual friend. Getting to see Hal Holbrook as Mark Twain is one of the many things cancer stole from him/us in 2016.

Invitation to K.T. and A.S.'s wedding in Knoxville, TN, also in April. My in-laws stayed with DH that weekend so I could get away and enjoy myself. Best of all, I got to stay with friends R. & M.K. on the way down and meet up with J.R. for the shindig.

Ticket to hear U.S. Supreme Court Justice Sonia Sotomayor with J.S. We were lucky enough to score extra press seats way up front. [March]

"My senior resident's delight the day I finished my progress notes before noon." He actually jumped up and hugged me. Unfortunately, the day ended on a sour note, as I got a late admission and ended up staying way after sign out.

"Matching to UPMC in Med Peds." [March]

"DH's 10th doctor-versary and my 2nd. 3/17/16." As luck would have it, we both defended our dissertations on March 17, eight years apart.

Ticket to watch The Grand Budapest Hotel at the Virginia Theater. That was late May, still in chemo season, and a friend came to stay with DH so I could leave the house without worrying about him.

"Snuggling in bed reading together (after laughing uproariously!)" [???]

Ticket to see the San Francisco Giants beat the Pittsburgh Pirates in June.

"O in Medicine and Society." I'm particularly pleased with the presentation I made on "Medicine on T.V."

Ticket to see the Miami Marlins beat the Pittsburgh Pirates in August.

Stickers that read "Delilah" and "Butch Cassidy" from a pre-show ice-breaker at a Wordplay performance at the Bricolage Theater. I found my "Samson," but DH never found his "Sundance Kid."

"The sky from the workroom on 12N. The first time the patient in 1260 smiled her toothless smile at me." She was a cantankerous, manipulative cirrhosis patient, and I had just combed her hair, about which she was very vain.

"Driving to my continuity clinic in Turtle Creek along the river and through the green."

Cover of the program for "Flight: Songs of Migration," a beautiful, moving performance by Amasong, the Lesbian/Feminist Chorus. DH was in the hospital the first time, so I went with A.S. to hear friend R. sing a solo.

"Bath time with DH." While undergoing chemo, he sometimes had a good hour in the evening, when I sat him in the tub (by candlelight when his eyes were sensitive) to bathe him.

Good, old-fashioned
collective action.

Ticket stub from Loving. [December]

Receipt from attending the Winter Flower Show and Light Garden at the Phipps Conservatory, a rare work-night date with DH after starting internship.

"O in Pulmonology."

"Found a woman's wedding ring outside the gym after the snow melted." I believe the staff were able to help me reunite it with her.

"Having D.W. for dinner and playing baseball Scrabble." He and I also took a daytrip to Covington to go antiquing one Saturday.

A sticker name tag from a residency applicant dinner. DH and I are suckers for free food and like the company, too.

Ticket to see Rogue One with my brother-in-law's family over Christmas 2016.

"Paid off the Turquoise Torpedo."

The cap off a bottle of Jones Soda that reads inside: "Your efforts will be well rewarded. Be patient."

"[The Pediatric Clerkship Director/My boss] complimented me on my TA leadership."

"Selling our house! 3/23/16"

"Fixed the toilet." Surely there's a line for that on a C.V.

Ticket to watch the Moscow Festival Ballet perform Don Quixote. That was back in January, and I honestly cannot remember a thing about it. I'd like to think I enjoyed it at the time.

Sweet mini-card from J.R. when she sent my Halloween earrings.

Ticket to Finding Dory, which we saw for my birthday this year. [July]

"Getting DH's scans back--times two!" This must be his negative CT and PET scans in August.

Another interview dinner name tag.

"Today I drove a metal spike into an old lady's spine with a hammer." ~The most audacious thing I did in medical school was perform a (supervised) kyphoplasty during my Pain Medicine rotation.

"Exchanging pickle phones with [the acting intern] to talk about our patients at just the right moment." We were fielding questions on each other's patients.

"Celebrating our Steel Anniversary in the Steel City." [August]

"O in Pain Management (Surgery II)."

Another note left by DH with dinner.

"Took apart and fixed the refrigerator/freezer."

"Walking in Frick Park."

"The trees and bushes heavy with snow as we drove to see Allegiance in the theater." [December]

Ticket to see Sinfonia da Camera perform The Mikado. [March]

Ticket to see "Opening Night," DH's last performance at the Virginia Theater with The Chorale. [New Year's Eve 2015]

Ticket stub from Sherlock, the holiday special that aired in theaters in January 2016.

And finally, tucked under the jar, my program for Back to the Future with Pittsburgh Symphony Orchestra playing the soundtrack. [July]

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Not mentioned: Walking with CureSearch to raise money for pediatric cancer research (top left photo).

The love and support we got through DH's CaringBridge site while he was undergoing cancer treatment.

Oh yeah, and I graduated from medical school in 2016, too, but somehow between the family visiting, house packing, chemo, and celebrating, I forgot to put it on a slip of paper in my Rememberlutions Jar. (Instead, I've got a fancy piece of paper framed and hanging on our living room wall.)

The Wrong Cheesecake

Editor's note: Dear Husband and Frau Doktor Doctor have been reading and watching Sherlock Holmes stories together for the last two years. The opening of this piece is an homage to Sir Arthur Conan Doyle. While FDD may be recording an incident a la Dr. Watson, alas there is no real mystery for DH/Holmes to solve.

If you thought God had a sense

of humor when God created beetles,

wait til you get to the succulent room

of the Phipps Conservatory.

Looking back over my notes, one episode from my intern year strikes me as a singular experience of teamwork tinged with humor and sticky fingers, what I think of as the saga of the wrong cheesecake. It was back in December of '16, when I was assigned to my third straight month of adult in-patient medicine. By then I was used to the rhythm of near-daily discharges and admissions, with a cap time that was the same as sign-out time. (For the uninitiated, that means that the day team had to admit any new patient who arrived on the floor before the hallowed hour of six o'clock in the evening.) Having discharged a patient in the afternoon on the first Friday of that rotation, we waited anxiously for the next one to arrive. Indeed, the senior resident had already received sign-out over the phone on a patient from the Emergency Department, but the minutes after five o'clock ticked by with no page from the floor clerk alerting us of his or her presence. The next intern with an open bed, I in particular was anxious, as I had planned an excursion with Dear Husband for that evening: dinner at the Phipps Botanical Garden and then a perambulation through their winter flower and lights show. Alas, the senior resident discovered from the ED board that the patient was being transported to the floor just in time! So he dashed to the nurses' station and pleaded with the clerk to hold the fateful page until after six, so that the night team would be the ones to admit the patient. She agreed but requested a favor in return--she wanted cheesecake. "Make sure you get her cheesecake!" my resident admonished. I gratefully agreed, signed out my patients to the night team, and went on my date. Inside the conservatory was crowded, and outside the temperature was frigid, but DH and I enjoyed the rare chance to spend two hours together doing something, anything.

The next morning I arose early, showered, and drove to the grocery store to fulfill the bargain with a four-piece sampler of cheesecake. I bought breakfast for the weekend team while I was at it. Once in the teamroom, I made a label for the gift out of red marker and scrap paper, "To the BEST clerk in the hospital." I even cut around the heart to make it extra fancy. I left it at the clerk's computer station. She came and found me during pre-rounds, introduced herself, and thanked me profusely. I considered the whole thing a success...

...until two weeks later, when my senior resident accosted me one afternoon: "You got cheesecake for the wrong clerk!"

"I'm sorry, what?"

It turned out there were two clerks on the floor, and they alternated Friday and Saturday shifts. I had thanked the wrong clerk. Abashed, I asked after the right clerk's schedule and vowed to make amends the coming Saturday. But that week DH and I had a full social calendar, and I had no time in the evening to go out of my way to the store. Friday evening I asked if DH could do our grocery shopping after I had gone to bed, so that I could bring the desired gift with me the next morning. He agreed, and I reminded him several times that I wanted "the one with four kinds of cheesecake," remembering the package in the cooler that had had four pieces of plain cheesecake. 

I quickly fell asleep, awoke the next morning--and found an entire, sixteen-piece "cheesecake" in the refrigerator. There were indeed four kinds of cheesecake, each represented with four slices. DH had done exactly what I had asked him, had he not? How had I forgotten to specify that I wanted the four-piece "sampler"? There was no way I could give the clerk that much cheesecake. It was too expensive and obviously out of proportion to her gesture of holding the admission page back for us. There was nothing to do but attempt to exchange it for a more modest offering.

Frantically, I threw together a quick breakfast, grabbed some tupperware as a back-up plan, and headed out the back door--right into freezing rain. The walkway behind our townhouse was a lake, just as our neighbors had promised it always was after heavy precipitation. I struggled up the sloping, icy street to my car, tucked the plastic bag with the cheesecake round by the back wheel, and set about breaking through the ice.

Dear Husband had mentioned earlier in the week his plan to keep his ice scraper in the house for just such an occasion, and I cursed my carelessness while using my key as a pick in the seal between the body of the car and the doors. I could not open the driver's door, but I was finally able to wrench the rear door open, crawl in far enough to grab the scraper, turn on the defrosters, and hit the button for the seat warmer. I also put the cheesecake in the back seat to dry off while I turned my attention to the windows and windshields.

When I remembered that the passenger-side windshield wiper had come off, I tugged on the door to retrieve the wiper from the floor for reassembly. It didn't budge. I went round and tried all the doors, but they were not stuck with ice, they were locked. When I had turned the key in the ignition, the car had automatically locked all the doors, with my keys, bookbag, and that damned cheesecake inside. I called DH from my cell phone, mercifully stuffed into my coat pocket. No answer. Twice.

Back down the icy street to the house I went, hopping on our neighbors' porches to avoid the puddle. I banged on the kitchen door--which he opened with some annoyance. I explained about locking my keys in the running car, so he fetched his own. Back up the street through the wintry mix, I left the wiper blade on the floor and drove slowly down the slope to our house, where I jammed on the parking brake, evaded the standing water twice more to return his keys to DH, and finally got in the driver's seat to drive to work. 

There was no question of being able to return the cheesecake now. I would have to make do with Plan B. Once in the workroom, I broke into the cheesecake and managed with insufficient grace to transfer three of the better looking pieces into the tupperware I had brought from home. I wrote another label--this time with the clerk's name on it--and ferried the gift down the hall to the nurses' station, where I presented it in person to the abashed but grateful clerk.

That left me with thirteen pieces of cheesecake, a dessert for which I have no particular fondness but will eat on occasion. I planned to fob some of it off on my teammates, but it was a Saturday, and the medical students were dismissed early. About four o'clock I went searching through my lunchbag for my daily apple, only to discover I had forgotten it in the hustle of the morning.

"I don't have my apple," I announced to my attending, who was working with us that quiet afternoon. "Do you know what this calls for?"

"Ice cream?" she asked.

"Cheesecake!" I replied.

"I like the way you think," she said, as I excused myself to the pantry, where I had stored what was left of the enormous round. 

After some awkward attempts with a napkin, I finally gave up, perched the entire plastic tray in front of my computer, and used a plastic fork to eat a piece of turtle cheesecake. 

"You weren't kidding!" the attending said, when she looked up. I agreed that I was not and offered her a piece, but she declined. The scene was similarly amusing to my co-intern, when he returned after seeing a patient, but he declined as well. 

So I ended up bringing twelve pieces of cheesecake home with me again. My last-minute attempts to invite friends and neighbors over for caroling (and cheesecake) were singularly unsuccessful, so the whole thing will be schlepped again to my in-laws, where I will offer it as Christmas dinner dessert.

What Internship Looks Like XXIV: Hospital Vistas 2

Sometimes internship looks like the stunning vista from a family lounge high up in a hospital tower. This is just the view toward the Allegheny River; there was more window and more landscape to the left. We used this room for end-of-life discussions, and occasionally for a quiet moment in natural light during the long, 12-hour days of our shifts.

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What Internship Looks Like XXIII: Caring For the Patient

"For the secret of the care of the patient is in caring for the patient.”

~ Francis W. Peabody to Harvard medical students on October 21, 1925

If the secret is caring for the patient, the practicality is doing little things as a physician to minimize the big and small harms that patients suffer in our hospitals that have little to do with whatever chief complaint brought them to our attention. This was one of my favorite afternoon lessons while on wards, drawn by a physician-administrator who sees the iatrogenic morbidity statistics in our institution. The drawing reminds me of a "wound man," the early modern-era medical illustration technique in military medicine manuals that used one picture of a man with many different wounds to minimize the costs associated with creating and reproducing multiple illustrations. This one depicts delirium and falls that can come from a patient being sick in an unfamiliar environment; we should minimize overnight interruptions and tethers such as pulse oximeters, and make sure patients have their glasses, hearing aids, and dentures. Wearing a nasal cannula for supplemental oxygen can dry out their mucosa and cause nose bleeds. They can develop thrush or Clostridium difficile from antibiotics and mouth ulcers from chemotherapy. Being bedridden makes them susceptible to weakness, myopathy, deep vein thrombosis, and/or pulmonary embolism. The drugs we give them can have side effects like dry eyes/mouth, gastroparesis, and urinary retention. My attending was encouraging us to treat--to care for--the whole patient, not just their chief complaint.

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What Internship Looks Like XXII: Accepting Help

Sometimes internship looks like the lunch your senior resident brings you when you're chained to your computer writing discharge summaries instead of attending noon conference.

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What Internship Looks Like XXI: Teamwork

Shiny silver bow ties for the Platinum team: uncertain medical student, visionary senior resident, confident attending, gregarious intern, thoughtful medical student, side-kick co-intern.

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What Internship Looks Like XX: Bathrooms, Take 2

Remember when I referred to a hospital bathroom with automated hand-washing/drying fixtures as "a germaphobe's worst nightmare"? Well, I found the next level of purgatory: 

You can observe the evolution of sanitary technology in this lady's room at a different hospital. The automatic sinks (with manual soap pumps) are to the right in the first photo (stalls behind). On the wall you see the big black paper-towel dispenser. But that's not very environmentally friendly, so 90 degrees to the left--next to the trash can--is a silver automatic hand dryer. The white leaf in the green cross announces that it is energy efficient. 

However, the door has to be pulled open inwards, or the automatic switch pressed, which would dirty one's hands again. So they mounted a small silver container for paper wipes you can use to touch the door handle (above). So we're back to paper waste again, because if the door could be pushed open outward with one's shoulder or hip, it would impede traffic in the busy hallway on the other side.

Nevertheless, if you look closely in the patterned tile "chair rail" in the second photograph, you can see a tiny black rectangle. That is the touch-free, motion-sensor door opener that allows one to wash and dry hands and escape the restroom with minimal contact with potentially contaminated surfaces. At last, the solution to the germaphobe's persistent question, "Are my hands clean after going to the bathroom?"

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That's So Pittsburgh: the Nationality Rooms at the Cathedral of Learning

Because I had to work Thanksgiving, Dear Husband spent the holiday with my family, and then they all drove up to Pittsburgh so we could spend part of a weekend together. On Sunday afternoon, our friend J.E. had offered to give us a tour of some of the Nationality Rooms at the University of Pittsburgh Cathedral of Learning. We met up in the entranceway to this great building. Reportedly the tenth president of the university had it constructed as a landmark 42-stories tall after he showed up in the city to take the job in 1921 and the cab driver who picked him up at the train station didn't know where the university was. Its Gothic cathedral design makes me want to study with this Gryffindor Common Room sound mixer playing in the background.

The rooms are always decorated for the winter holidays, and there's a big multi-cultural festival the first Saturday of December. J.E. took us to the Czechoslovak room, dedicated in March 1939, which combines elements reminiscent of Charles University in Prague with a Slovak farmhouse and a country church. It very much had an early twentieth-century feel to me. There are portraits of famous Czechoslovak leaders, botanical paintings on the walls and ceiling, and knickknacks.

When we went upstairs to the Austrian room, we were transported to Esterhazy Palace in the eighteenth century. (Click here to read about DH and my visit to the Haydnsaal in the twenty-first century.) In addition to the audible tour that played at the touch of a button, there were Viennese chairs around the long table, a magnificent ceiling painting (above), and--tucked in the corner--a creche. It reminded us of the large antique Krippe we saw when we visited Austria back in 2010.

Finally, here's the whole gang. The parents and grandparents were delighted with the visit, which concluded with stop on one of the highest floors, from which we peered through the windows at the wide vistas of Allegheny County. If you would like to take a tour of either of these rooms--or any of the other 28--just click on the "Nationality Rooms" link above. 

Merry Christmas! Veselé Vánoce! Fröhliche Weihnachten!

Editor's note: If you like to read about architecture and/or history, you might enjoy these other That's So Pittsburgh posts about Motor Square Garden and Homewood Cemetery.

What Internship Looks Like XIX: Hospital Vistas 1

One month, the view from my team workroom included both the University of Pittsburgh's Cathedral of Learning (left) and the top of one of the hospital buildings (right). I thought of them as fraternal-twin ziggurats of education and healing. I liked watching the sun rise over them every morning while I worked on my computer. Farther left was the helipad on top of a connected hospital building; we could see the helicopters taking off and landing. They were a reminder that someone was having a much worse day than I was, so I always said a prayer when I heard them (the same one I say for police cars and fire trucks): "God speed, God bless, and good luck."

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Limits in Medicine

Where are the limits in medicine?

Take laboratory tests. First- or second-year medical students are taught "normal values." There are dozens to absorb: how many times "should" someone's heart beat per minute? (60-100 beats per minute for an adult.) What is the definition of a fever? (T greater than 100.4F or 38C.) When is a white blood cell count too low or too high? (Less than 4,400 cells/microliter or more than 11,000 [4.4-11.0 x 10^9/L].) There are very few absolutely good or bad numbers in medicine, as natural human variation ensures that such measurements plot out to a bell curve, with most values falling in the middle and only a few being quite high or quite low. Convention, general consensus, and expert opinion have decreed where the limits of "normal" aka average fall, such that most patients are healthy with those values. As clinical neophytes, junior students are developing a physiological framework by which to determine sick/not sick. Not infrequently a measurement that is juuust outside normal will indicate illness in practice questions or on exams, as a way to judge their knowledge of common test ranges. A result reported in red, or with a telling arrow, alerts them to a critical result.

Third and fourth-year students begin to learn that the cut-offs that were so firm on Step 1 are actually fuzzy. For instance, a WBC count of 15 is abnormal...unless the patient just had surgery. Or, an alanine aminotransferase of 70 IU/L is technically abnormal but in the absence of other signs or symptoms may merely represent a normal variant. Not to mention that different laboratories often have different cut-off points, so a sodium of 134 mMol/L might be normal at one lab but abnormal at another. Senior students have to absorb these medical and technical qualifications in the process of refining their understanding of pathophysiology. The goal is to develop enough clinical acumen to recognize a critical value in the absence of an accompanying H or L ("High" or "Low"), and to appreciate an abnormal but unconcerning result, nagging red font to the contrary.

As an intern, I am getting increasingly comfortable with laboratory values that are consistently out of the normal range. This month I am treating a number of patients with both heart and kidney failure. At baseline, their creatinine ("kidney number") is higher than the upper limit of normal (1.0 mg/dL), sometimes much higher. I know that the treatment for their fluid overload is diuresis with "water pills" or IVs, and that these drugs can elevate their creatinine. The trick is not to freak out when I get the admission labs showing a Cr of 2.5 mg/dL--or when subsequent tests show a "bump" to 2.9mg/dL. Each value needs to be interpreted in the context of the previous one rather than observed in a vacuum. Also, maybe their diuretics need to be scaled back for a day to give their kidneys a rest. Like many things in medicine, there is a delicate balance between effect and side effect, and I am learning to push the limits of my comfort with discomfort.

One of the reasons being the intern on the team is so hard is that there are thousands of such decisions to be made every shift, at the same time that you are continuing to learn and understand which results are actionable and which are not. What test(s) should I order? What am I expecting to find? If I find it, what if anything will I do about it? Does this patient usually have abnormal values? If so, how abnormal is significant for them? A typical morning after sign-out involves at least an hour of "chart review," in which every patient's vital signs and test results are reviewed. That's a minimum of 20 numbers per patient x 5-8 patients = 100-160 decisions by 8am alone. Of course many patients have more or more obscure test results as well.

At some point decision fatigue sets in. The first time I worked more than 80 hours in a row (as scheduled, with a lighter week before and after that), I reached my limit. By the time I signed out the evening of the seventh day, I just could not make any more decisions. My brain was fried. I was done. So of course, while I was waiting my turn to speak with the night intern, a nurse paged me about a patient whose blood pressure had been difficult to control for the last couple of days, since he was put on steroids. She pointed out that the order for his rescue medication only specified that she should give it if his systolic blood pressure (top number) was greater than 160mmHg. However, his most recent reading was something like 155/105. Now, a diastolic blood pressure (bottom number) greater than 100mmHg is also abnormal and arguably actionable. She was right to ask me to change the order. However, I could not motivate myself to care enough to do it. I was moments away from signing over my pager for 24 hours of freedom. I was frustrated that nothing we had tried seemed to have worked. I rationalized that maybe such a high blood pressure wouldn't be so bad, and that it would come down now that the steroids had been stopped. I told her I would sign it out to the night intern--who, in the face of my abdication of responsibility, also chose to do nothing. The patient's blood pressure did eventually come down, but I can still hear the disappointment in the nurse's voice at my inaction, and I count it as a low moment thus far in my term as an intern.

These kinds of limits on a new clinician's ability to evaluate and synthesize data are one reason I oppose the proposed relaxation of duty-hour regulations for first-year resident physicians. The Accreditation Council for Graduate Medical Education (ACGME) would like to change the maximum number of hours interns can work in a row from 16 to 28 (24 hours of active duty + 4 hours to sign-out, finish notes, etc.). They argue that the best way to learn about the progression of disease is to observe it in person. Also, that more hand-offs--for instance, between the day team and the night team--means more opportunities for error in communication. They are probably right about the first point, but they are definitely wrong about the second one. Practically speaking, how many 24+-hour shifts can a single intern work in a week? At most 4, assuming s/he is granted 24 hours off in between. Even putting aside the exhaustion factor, there would be fewer handoffs of more information. The historian of medicine in me wishes to remind you that hospitals today take care of more and sicker patients--with more and more complicated test info--than ever before. So prior generations of doctors cannot extrapolate from their training experiences to ours.

It's true that mental and physical stamina differ among trainees, but we all have limits to our ability to transmit and receive information, even when well-rested. When the intern under the proposed rule leaves the hospital, s/he must communicate 24 hours worth of data to the new team--and that, at a time when s/he is likely thinking most of getting home for a shower, some food, and finally sleep. Then, when the intern comes back, s/he will have to absorb a whole day's worth of data rather than only 8-12 hours'. This could leave large gaps in his or her experience of the patient's illness, as the nuances of changes in vital signs or lab values are glossed over in an effort to assimilate what has happened with what should happen next. (It is almost 9 o'clock and time to start morning rounds.) Whether there are more sign-outs with less information or fewer sign-outs with more information, the way to improve patient hand-offs is to improve patient hand-offs.

The last thing I will say on the subject is that the farther into residency I go, and the more discussions we have about better ways to structure the labor of physicians in training, the more I think of the socialist slogan "eight hours labor, eight hours recreation, eight hours rest."* Interns do not need to be restricted to eight-hour shifts, as three hand-offs per day is an invitation for communication errors, but constantly working 12+ hours per day leads inevitably to physical and mental fatigue. It is possible to work both too little and too much to learn, which is purportedly our most important job. Moreover, no resident's job is done when s/he leaves the hospital. We are expected to check in on our clinic patients, to complete administrative paperwork and learning modules, and to study alone and in groups. The margin between (supervised) work and sleep need not be eight hours, but it should be acknowledged as part of both our work day and our personal lives.

Where are the limits in medicine? They lie at either end of the bell curve of "normal" laboratory values. They are at the edge of our ability to synthesize data and recognize patterns in it that could be classified as sick or not sick. And they come at the point of exhaustion and burnout, which is different for every individual but almost certainly lies on this side of the proposed duty-hour modifications. None of these limits should be treated as hard and fast boundaries, and they change over time. An infant's respiratory rate is generally much faster than that of an adult, and a resident in the last year of training is typically more adept at processing patient information than an intern is. Limits in medicine are more often blurry than not, and they are almost always up for discussion. But let us not ignore common sense and sleep physiology in the name of "learning" or "safety," especially when one outcome of the proposed extension of duty hours will be permission to exploit new trainees as cheap labor.



*I was quite sure I had read this lyrical phrase in Karl Marx, perhaps in Das Kapital: "Eight hours for work, eight hours for rest, and eight hours to do with as he pleases." But an internet search for the actual quotation was fruitless, and my copy of DK is in a box in a closet, so I am using Richard Owen's formulation instead.

That's So Pittsburgh: Homewood Cemetery

This week I got Thursday off, and the weather was fine--the kind of day when your cheeks get cold but you don't mind--so Dear Husband and I went for an afternoon walk in Homewood Cemetery. We tramped up the hill and through the fallen leaves, discussing our future surrounded by so many people's pasts.

At the top of the hill stands a veritable city of  mausoleums for Pittsburgh's monied elite. "They all lived next to each other in life," quipped DH, "and they're sleeping next to each other in death, too." Many of the little marble houses for the dead shared similar Greek-inspired architecture, with stained-glass windows in the rear and bronze doors locked and bolted in the front. One still contains the remains of what appears to be an American flag original to World War I, when Capt. Alfred Hicks (1837-1916), veteran of "the War of the Rebellion," gloriously passed away at the age of 79. I wonder what sort of "disability" allowed him to be honorably discharged less than 1 month after enlisting as a private in 1861, but that did not hinder him from becoming a 2nd lieutenant in a different outfit 6 months later. According to the obituary available on archive.org, he was in the Ford Theater the night President Lincoln was assassinated, and later got into the railroad, coal, and steel businesses. "He was one of the most widely known men in the Allegheny Valley."

The life-sized statue by George A. Lawson at top right is entitled "Motherless" (1897); DH and I surmised that it memorialized the departed wife of Mr. James Ross Mellon (1846-1934) and mother of his child, but a quick Google search revealed that the sculpture was originally in his garden, but none of his heirs wanted it.

Who builds themselves a pyramid-shaped tomb in western PA, 20 years before they die?

Come on, you know this guy was an asshole in real life, too.

(The answer is William Harry Brown [1856-1921], who made his money shipping coal on the rivers.)

In the Jewish section of the cemetery, the newer grave markers are often quite fancy, featuring engravings of the deceased and tokens of their hobbies. Above, you can see that Erwin is waiting to be reunited with his soulmate. Among the stones left for him is a golf ball, so you know he was a Mensch on the course. Below left is the most creative memorial we found on our walk, for a woman who died this spring. Her loved ones have left potted plants, seashells...and mini Diet Coke cans with straws.

Finally, we had to laugh when, on our way home, we passed the tombstone of one "Addison Murray Imbrie, Atty. at Law," who is still advertising for himself from beyond the grave. On the other side of his marker is a condensation of Mark Twain's sentimental poem "Warm Summer Sun":

Warm summer sun,

    Shine kindly here,

Warm southern wind,

    Blow softly here.

Green sod above,

    Lie light, lie light.

Good night, dear heart,

    Good night, good night.

Adapted from Robert Richardson's poem “Annette.”

Editor's Note: If you enjoyed this installment of the That's So Pittsburgh series, you might also like our visit to Beulah Cemetery, or to these Churches.

What Internship Looks Like XVIII: Humoralism in Modern Medicine

This graph of descriptive terms in heart failure blew my little history-of-medicine mind in its melding of ancient humoral and modern pharmaceutical medicine.

On the Y axis are body temperatures from "cool" and poorly perfused to "warm" and well perfused. Clinicians check this in their patients by touching their hands and feet to feel the temperature, and maybe pressing down on a nail bed to push out the blood, and then counting how many seconds it takes for the blood to come back after letting go (we call this "capillary refill time," and a good number is less than 3 seconds). If a person's heart is pumping well, then their extremities will have good blood flow and be pink, warm, and with a quick capillary refill. If a person's heart is pumping poorly, then their extremities will be pale, cool, and have a prolonged cap refill, as the body clamps down on peripheral blood vessels to keep most of the blood in the core to nourish the major organs.

On the X axis are relative body-water volumes from "wet" to "dry." A patient is "wet" if their blood is being pumped so poorly that it starts to seep out of the blood vessels into the surrounding tissues: this causes peripheral edema in dependent areas like feet, legs, and buttocks; "crackles" in the lungs; and even bowel-wall edema, leading to poor appetite and slow gastrointestinal transit time. Sometimes these patients have gotten off their usual diuretic, or they have had a "dietary indiscretion" (like Bugle chips, or holiday dinners) such that they have too much salt and/or water on board. A patient who is "dry," by contrast does not have these findings on history or exam.

The symbols inside the graph tell the practitioner what to do: a patient who is "warm and dry" (X marks the spot) is in "compensated" heart failure; their body is balancing poor cardiac output with the needs of peripheral tissues. A patient who is "warm and wet"--well perfused but volume overloaded--should be treated with a diuretic like Lasix (furosemide) to help their kidneys pee out the extra fluid. A patient who is "cool and dry" needs an inotrope to help their heart pump better. But the patient who is "cool and wet" is in trouble indeed, for they have entered a spiral of fluid retention in which the body perceives itself as intravascularly depleted (more water in the tissues than in the blood vessels) and kicks off a cascade of hormones to retain more fluid in the kidneys, which then leaks out into the tissues, and so on in a vicious cycle. These patients are in end-stage heart failure and need a lot of support on the way to heart transplant, or else palliative care and hospice.

I was tickled when my senior resident drew this graph on the board, because of course I recognized the opposing dyads of warm-cool, wet-dry from ancient Western humoral medicine. Each patient could be described as more or less of each one, although women and younger people were typically assumed to be "wet" (menses, etc.), while men and older people were thought to be "dry" (hence wrinkles). Women were also "cool" compared to men's "hot" tempers and virility. The four humors then named the various combinations: hot and wet was "sanguine" (predominantly blood), hot and dry was "choleric" (yellow bile), cool and dry was "phlegmatic," and cool and wet was "melancholic" (black bile). The result of an imbalance in these internal fluids was disease, and the treatment was its opposite. Was the patient too wet (fluid overloaded)? Dry them out (e.g. bleed them). Were they too cool (lethargic)? Warm them up (e.g. with wine).

Modern physicians do a little of this--in the nineteenth century mainstream practitioners were called "allopaths," meaning they treated disease with drugs that opposed the symptoms, in contrast to "homeopaths," who treat(ed) disease with drugs that reproduce(d) the symptoms. We speed up a slow heart with inotropes or a pacemaker, and we open constricted blood vessels with vasodilators (nitrates for angina). But we also replace hormones that the body no longer produces (as in hypothyroidism or type 1 diabetes), we kill invading microorganisms (as in pneumonia or cellulitis), and we reduce inflammation (with steroid creams, pills, and inhalers). So twenty-first-century clinicians are no longer only or primarily allopaths but could be called "omnnipaths" (all-treaters), or at least "heteropaths" (many-treaters). We see this diversity of approaches in the heart-failure graph, counteracting fluid overload with a drug that dries out the patient, poor cardiac contractility with a drug that improves contraction, and heart failure with surgical options such as LVAD or transplant. However, patients in compensated heart failure get good, old-fashioned life-style advice: stay on your maintenance medications, watch your diet, exercise, and sleep. Even Hippocrates could agree: all things in moderation.

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A Meditation on a Familiar Theme, or “What’s in a Name?”

When I was a first-year medical student, our anatomy course lasted a full year. We were divided into teams of about 8 to a body, taking turns dissecting one section each semester. I got the upper extremity and lower extremities of our lady and distinctly remember having the lab to myself in October 2008, listening to the presidential debates on the radio while scooping fat out of the back of her knee. At the end of the year, the class gathered with our instructors to honor the dead. One of my mentors gave a succinct sketch of the history of body donation. I delivered the following piece, composed in protest against the professors who pooh-poohed the tradition of naming cadavers, and as a gentle admonishment of the tradition's well-meaning hubris.

I do not own the rights to this poem, or to the body that was donated to my medical education.

~ * ~ * ~ * ~

A Meditation on a Familiar Theme, or “What’s in a Name?”

A Reading for the Cadaver Memorial Service on May 12, 2009

 

“Map of the Interior, a Mostly Found Poem”

by Leslie Adrienne Miller,

as published in The Resurrection Trade

Vesalius has failed to give his name

to any anatomical part.  In this

he differs from intrepid others

who found it de rigueur to map

with pen and paper after they’d applied

the knife.  Hence we have the airway

of Eustachius, the tube of Fallopius,

the duct of Botallus, the circle

of Willis, the lobeof Spigelius,

the fissue of Sylvius, the glands

of Bartholin, the island of Reil,

the ganglion of Gasser, the  cartilage

of Arantius, the sinus of Valsalva,

the tubercle of Lower, the valves

of Morgagni, the torcular of Herophilus[,]

the veins of Galen, and the alleged

spot of Grafenberg.

To name is to claim ownership or mastery. Adam named the animals in the Garden of Eden as a sign of humankind’s dominion over the created world. When these men in Miller’s poem bestowed their names or their colleagues’ on glands and fascia, they staked their claims to mastery of the recesses of the human body.

We called our donor Gertrude.

But to rename does a certain violence to what is being erased or covered over. Europeans often renamed places and people in Africa, Asia, and in the New World (new only to the colonizers, of course). In the last century, Communists renamed St. Petersburg “Leningrad” and Saigon is now “Ho Chi Minh City.”

Sometimes we joked about “Good Old Gerty” and her anatomical variations.

Developing a relationship with my nicknamed cadaver was an important part of my anatomy lab experience. I would greet her when I got into lab, and I talked to her about the joys and frustrations of dissecting. I tried to remember these were not “my” muscles and nerves and blood vessels, but hers.  So although I want to acknowledge the violence we did to substitute our idea of our donor for her lived identity, I also want to give us credit for good intentions. “This will be your first patient,” we were told. If you did not rename your cadaver, hopefully this was the last patient you did not refer to by name, instead of by disease or number. I’d like to think that Gertrude would understand.

Happy Halloween 2016

Previous FrDrDr Halloween posts have included a spooky Lego mansion and a vampire wombat. This year's post is more of a photo essay. If you'd like to read something substantial, I highly recommend the humor piece "It's Decorative Gourd Season."

Dear Husband and I started celebrating with a pumpkin-carving party at a fellow pediatric intern's house. It was a mild night, so they dragged the big-screen television up from the basement so we could watch THE Ohio State Buckeyes beat the Wisconsin Badgers while eating pumpkin kettlecorn and drinking pumpkin beer or pumpkin mimosas or spiced/spiked hot apple cider. The host and hostess provided several books of designs and those little tool kits. Designs included a bat, a cat face, a silly face whose errant pupil was "fixed" with a toothpick, the word "creepy," and a uterus (by the ob/gyn resident in attendance).

The next weekend Dear Husband helped me spread spiderwebs on our front porch, complete with a giant hairy arachnid on the door, and plant skeleton parts in the ivy along the front walk.

Neither of us was home for Beggars' Night, DH having left town to visit his family, and I coming home late-ish after the first day on a new service. Besides which, our jack-o-lanterns had succumbed to fungus the prior weekend, so I didn't even put them out. Here they are in their glowing glory with some of the other carvings. Mine is the free-handed bat; DH made a traditional face. The other ones were made with stencils.

If you look closely, you can see that mine had stripes of green and white mold growing in it, while DH's had developed fuzzy white cataracts, because "It's Rotting Decorative Gourd Season,"

What Internship Looks Like XVII: Partnership

"Welcome back to Mike's Deli[.] I'm Pierre-Bear, your server. Tonight's repast is Turkey Club Sandwich with chips, plum and gherkin. It's in the refridgerator. Enjoy! Pierre Bear."

Seems like Dear Husband left the Bear in charge of the kitchen while he went to choir practice.

It's nice to have a partner to grocery shop / cook while I'm at work, to register our cars, to be at home when repair people come, and so on. I feel guilty about working long days at the hospital, only to come home for a half-hour dinner before writing notes or studying until I collapse into bed. So I've tried to prioritize my days off: more chores and fun things together, less studying (and less time to blog about it!).

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What Internship Looks Like XVI: Tiredness

Sometimes after you've worked 13.5 hours, you come home to eat dinner and video chat with your parents, but really your husband's shoulder makes such a nice pillow...

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What Internship Looks Like XV: Encouragement

Sometimes internship looks like treats from a senior resident who knows you're having a rough week month.

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Are You Out of Your Gourd?

Friday evenings the Phipps Conservatory is open late, so Dear Husband picked me up after signout for dinner at the cafe and to enjoy the displays. We got lucky: the rooms were already set up for the Fall Flower Show: Bask in Nature's Bounty, which opened officially the next day. DH and I were not impressed by the baskets of fake apples, but there were also wicker squirrels and sheaves of corn stalks, scarecrows, pumpkins, and all manner of what DH called "haunted vegetables."

We got even luckier that there were performance artists in homemade costumes that evoked the gardens at the Conservatory that night. (I assume they were from one of the local colleges or universities.) Two wearing branches did interpretive dance. Two hid under an umbrella of fabric strips that gave the impression of being a giggling, shaggy plant-creature and interacted with the museum-goers. Two posed in the various galleries (I thought the one below was the best costume, being most representative of the gardens). DH's favorite two appear to have been modeled on an Asian legend, with one representing an evil spirit (with a head like a squash) and the other a good spirit (who struck a bell as if to drive the other one away). We could hear the clang all night, reminding us that the spirits were never far away.

Another exhibit was set to open the next day, the Garden Railroad: 200 Years of Pittsburgh. Little dioramas showcased famous parts of Pittsburgh history such as KDKA, the oldest commercial radio station; Three Rivers Stadium, with tiny football players lost in the real bed of grass on the "field"; and of course Mr. Roger's Neighborhood. I liked the rubber ducky floating near the replica of the Point, where the rivers converge. Many of the displays had buttons to push to make the trolley go up the Mount Washington incline, for instance, or to turn a model of the first-ever ferris wheel.

DH and I are particular fans of Dale Chihuly's glass art, of which there are at least four at the Phipps. Here were my favorites: a spiky yellow sun suspended above cacti and other succulents; and this assemblage on the right, which suggested underwater tropical plants to me. They have done a good job pairing the plants with the artwork, and with the lighting.

Honestly, it hadn't occurred to me until we arrived that it would be dark inside--because of course, most of the greenhouses' light comes from the sun. Once it sets, the interiors had the perfect mood lighting for spooky viewing. It really was perfect (almost) by accident. We enjoyed our hour-long visit so much that we went ahead and purchased an annual membership. It not only allows us unlimited visits for the year, but if one of us is busy (::cough::) the other one can bring a guest. Our next trip will be for the Winter Flower Show and Light Garden: Days of Snow and Nights Aglow. I can't wait for the schedule of live performers to come out for the Candlelight Evenings. And I look forward to the pictures I can take when the halls are lit with sunlight...


Editor's Note: If you liked this edition of That's So Pittsburgh (TSPGH), you might also like this post about the Regatta, this one about an iconic piece of Pittsburgh architecture, or this one about a centuries-old cemetery.