Sunday, November 27, 2016

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.

Friday, November 18, 2016

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."


Tuesday, November 15, 2016

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.

Thursday, November 10, 2016

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, 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.

Monday, November 7, 2016

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.


Tuesday, November 1, 2016

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.