Sunday, July 31, 2016

What Internship Looks Like X: Studying on the front porch

Studying on our front porch. Today's topic: diabetes mellitus. It's a required online module. I'll also answer 10 UWorld questions and work on the new Teaching Rounds Tumblr while the noisy traffic going by keeps me from falling asleep. Don't mind the sunflower killed by the heat. I'm going to compost it and plant a baby spider plant in its pot.


Friday, July 29, 2016

That's So Pittsburgh: Motor Square Garden

The Mellon family built East Liberty Market c. 1900. It didn't do well as a market and was bought in 1915 by the Pittsburgh Automobile Association for car shows and boxing matches. Then it was a new-car dealership. When it failed as an urban mall, AAA bought the building in 1988. There's a DMV office and also the UPMC Shadyside School of Nursing. This is the dome, three stories up.

Motor Square Garden and Virgil Cabrini's Joy of Life fountain (1969) in S'liberty, Pittsburgh.

Tuesday, July 26, 2016

Clio in the Clinic: A Book Review in Sonata Form

Exposition: I recently finished five weeks on service in the NICU. Upon discovering that I had studied the history of medicine, one of the pediatrics interns asked if I was familiar with a book called Clio in the Clinic-? She remembered reading a chapter in it about the development of the field of neonatology while in medical school. As a matter of fact, I had (finally) gotten around to finishing reading that essay collection last summer and had intended to review it on this blog, but residency interview season descended before I could get around to it.

Then, when another resident found out that the reason I am (even) older than he is is that I earned a PhD in history, he mentioned that I might want to look up the quarterly history of medicine feature in the journal Pediatrics. I took his advice, offering both to write something in the future (when I can get around to it) and to review manuscript submissions. The editor, another MD, PhD pediatrician, was encouraging.

Development: Clio in the Clinic (2005) is the brainchild of Jacalyn Duffin, a Canadian MD, PhD hematologist and a force of nature unto herself in medical history and education. She has written an engaging textbook in the history of medicine for medical and nursing students (History of Medicine: A Scandalously Short Introduction, 2010, 1999), as well as a number of scholarly articles and books. (Medical Miracles: Doctors, Saints, and Healing in the Modern World, 2008, is on my reading list.) Clio in the Clinic is an anthology that unashamedly combines physician autobiography with personal ruminations that cross the threshold between hospital and library, medicine and history, asking clinician historians (most but not all with formal graduate training) to reflect on how their historical knowledge has impacted their clinical practice. The quality of the essays is somewhat uneven, reflecting both the authors' variable comfort with the unusual genre and a light editorial hand.

Jeffrey P. Baker's chapter, "Historical Adventures in the Newborn Nursery," recounts his pathway from pediatrics resident through dissertating while a fellow to attending physician. His thesis explored the first 50 years of the field of neonatology, invented by French obstetricians in the 1880s with the help of chicken incubators turned into baby-warmers. In his Clio piece, he meditates on the temperature of an infant as a medical construct, as well as on the shifting boundary lines between obstetrics and pediatrics. Baker uses anecdotes to teach both professionalism and medical history to the pediatrics residents he precepts now. He goes on to describe a relic of early twentieth-century pediatrics, "inanition fever," an elevated temperature seen in breastfed babies who were a few days old and dehydrated because of the summer heat and/or their mother's milk not yet coming in. The concept essentially disappeared after World War II thanks to antibiotics, artificial formulas, and air conditioning. It reappeared briefly in the 1990s, perhaps due to the resurgence of breastfeeding coinciding with a new practice pattern of early discharge from Labor & Delivery (c. 2 days after birth) and an early pediatrician checkup (c. 3-4 days old). However, he and his colleagues were not able to find a medical journal interested in publishing their case report on the (now) unfamiliar phenomenon. He concludes, "the common thread uniting all the examples in this account has been to call attention to the power of historical awareness as an antidote for medical parochialism." (114)

There was little enough history of medicine in action when I was in the NICU, although the elderly physician who used to teach it in the medical school apparently gave a full impromptu lecture on Ignaz Semmelweis, Joseph Lister, and handwashing to the other team. Instead, there was a lot of managing "the numbers": corrected gestational age, weight (both absolute and daily gain/loss), milliliters of formula or breastmilk, rates of IV fluid or TPN delivery, ventilator settings, laboratory results, alarms, and of course, the temperature of both infant and incubator. There is in fact a method to this madness, which takes a little time to catch onto, and then it is a matter of adjusting variables up or down based in part on protocol, in part on the preferences of the attending physician, and in part on the clinical picture of the child itself. (Of course, the protocols are largely observational and empirical, as there are numerous ethical hurdles involved in research on children, much less such fragile ones as preemies.) Parents sometimes challenged these protocols, wanting us to feed their child more or less, or wanting to hold their baby more outside the incubator. As the French obstetricians discovered, the incubator is a life-saving technology for premature babies. But a developing infant inside its mother's body is close and accessible in an intangible way, and the incubator separates them bodily in a way that somehow seems cold. One of the most poignant comments I heard came from a father who marveled at the perverse pleasure in being able to watch his tiny daughter grow and develop in that glass womb, an experience that would have been hidden from him and her mother had she been carried to term. It reminded me that neonatology is in some ways less pediatrics--medicine for children--than it is a branch of obstetrics--medicine for pregnant mothers and their fetuses.

Recapitulation: As the community of clinician historians is relatively small, I know (of) half of the authors in Clio in the Clinic--either from reading their published work or from interacting with them at our annual conference--and was able to read their essays in their voices. So when I sat down this morning to revisit this chapter on the NICU and to write about my experiences there, I was pleasantly not very surprised to discover that the chapter author and journal editor were one and the same.

Thursday, July 21, 2016

What Internship Looks Like IX: Bathrooms, Take 1

Okay, I know I said I wouldn't be posting from inside the hospital, but I am just so taken by these handwashing stations that I had to share. Behold, the hands-free three-in-one sink you didn't know you were waiting for: the spigot on the left is for soap, the middle one squirts water, and on the right is an air hand dryer. Unintended consequence: there still need to be paper towels in the bathroom, because the door opens inward, and otherwise your hands-free clean hands would get dirty as soon as you touched the door handle to leave. Being stuck in this bathroom with no paper towels would be a germaphobe's worst nightmare.


Monday, July 18, 2016

What Internship Looks Like VIII: So you want to order some TPN

Hello, enthusiastic Intern. I understand you want to order Total Parenteral Nutrition (TPN--basically liquid formula that can go in a vein). Let us describe the ways in which you can fail to do this properly:

Did you remember to call the pharmacy to tell them this patient needs TPN? No? Better do that now. Then you'll have time to run to the bathroom or check Facebook or something while Pharmacy freezes your access to their electronic medical record for five minutes so they can enter some necessary information.

...I see you're back. Good, do you have laboratory results for this patient? No? Are they coming today or did you forget to order any? The latter. I see. We'll just order the basic TPN, so log in. No, not that password; use the other one. The other "other one." The program is loading...okay.

What rate will it flow in the IV? Do you know the patient's Total Fluid Goal? Multiply by their most recent weight, unless they are less than 10 days old and have not regained their birth weight yet, in which case use their birth weight anyway. Good. Are they eating by mouth or tube, too? Make sure you subtract that amount from their TFG before calculating the TPN rate. Don't forget to order the right dose of heparin for their line.

Now we'll tweak the lipids and electrolytes. First, ----REDACTED----REDACTED----REDACTED----REDACTED----REDACTED----REDACTED----. Then, ----REDACTED----REDACTED----REDACTED----REDACTED----REDACTED----REDACTED----. And finally you'll want to ----REDACTED----REDACTED----REDACTED----REDACTED----REDACTED----. [This information appears to be a state secret and cannot be shared on the Internet.]

Done? No, not yet. You still have to print the prescription. Oh, I'm sorry, did you use the Resident Computer? That one doesn't print. Here, you can log on and print from my computer. What? No, that's the printer to the wrong pod. Go get it and scan and email it to the pharmacy. Oops, you just spammed the whole pharmacy list-serv; just send it to the NICU pharmacy account next time.

**RING** Pharmacy's on the phone. They say you forgot to sign and date the prescription. Please use the year "2016," not "2013." Good. Then put it in the patient's room. No, don't make the nurse come find you in the workroom--just give her the script now.

Congratulations! You have now ordered TPN (aka Total Pesky Nuisance).

An intern's tools in the NICU: clipboard, bili charts, glucose-regulation algorithm, calculator, sticky notes, phone, stapler, white out (SO MUCH WHITE OUT), water or other provisions. Seen on the left of the image is a COW (computer on wheels) for morning rounds. Now get out there and order some TPN!


Sunday, July 17, 2016

That's So Pittsburgh: Churches

Until Dear Husband finds a church job, we have the freedom to "church shop" Sunday mornings. Here are some places I/we have visited:

Swissvale Presbyterian Church
MAIL (My Awesome In-Laws) took us to this church our first Sunday in town, as it was the recipient of a significant bequest after the death of an extended relative of my MIL's. The sanctuary is lovely, but it was hot, and the service was sparsely attended. The young pastor gave a very moving sermon about God being present in our time of need--it may have hit a little too close to home for DH. Afterward we wondered whether the bequest wasn't propping up a dying white church in a now-black neighborhood. I wanted to stay for the peach lunch, but DH wanted pizza and a nap.

South Avenue United Methodist Church (above)
My mother stayed home with DH while I biked to this church. We met in an air-conditioned "John Wesley Room" with a satisfactory grand piano to accompany the small choir. I was a little late, but I tried to be social by sitting next to an older man by himself. Whoops, I chose poorly, as I apparently took his wife's seat. Should have chosen the single older gentleman two rows ahead. The pastor was gone at annual conference, but the rest of the small congregation could not be accused of being overly friendly. The wife didn't even introduce herself. The only reason I met anyone after the service was because the 90-something-year-old man who was celebrating his 75th wedding anniversary came up to me standing alone in the back to show me a magic trick and photos of himself and his wife from the 1940s. Totes adorbs. Then, when other people came up to congratulate them, they had to greet me, too. When I told him my husband is an organist, at least he let me see the organ in the sanctuary. What I learned from the sermon: the 10 commandments can be reduced to an acrostic: I AM THE LORD: Idolatry Adultery Murder Take Honor Envy Lie One Rest Disrespect. (No to idolatry, adultery, murder, stealing, --, envy, lying, --, --, disrespecting one's neighbor by coveting his things, wife, etc. Yes to honoring one's parents, acknowledging one God, and resting on the Sabbath.)

East Liberty Presbyterian Church aka "The Cathedral of Hope"
Dear Husband had heard that the music ministry at this church was all the rage, so although the cisplatin was still causing problems with his hearing, we packed a pair of earplugs, and off we went. Unfortunately we missed the prelude, but the soloist who sang the special music was a-MAZ-ing. Parts of the service were even in Spanish. The sermon addressed the massacre at The Pulse, the gay nightclub in Orlando, FL. The sanctuary was reasonably full, but DH didn't want to stay afterwards to meet anyone. I would go back. It seemed like an active congregation trying to do good in the community.

Mifflin Avenue United Methodist Church
Another congregation meeting in an air-conditioned "John Wesley Room." Attendance was even poorer than the last UMC, and the upright piano was not quite in tune. The (self-appointed?) head of hospitality apologized that the congregation actually had several families, but it was in the process of rebuilding. This pastor was also gone (on vacation?), but the guest speaker was pretty good. There was no parking lot, and no bike rack, either. But the sanctuary has obviously been remodeled recently and is probably very nice in the winter. Love those big red doors in an old stone church.

Church of the Redeemer (Episcopal)
DH had heard the organist here, Nathan Carterette, on the radio during one of his (DH's) 24/7 radio marathons while recovering from chemotherapy. NC is a young pianist/organist, very personable and innovative--a surprising combination given how High Church the Episcopal service is. We meant to meet my parents here, but their GPS steered them wrong, so it was just the two of us trying to figure out which book to sing from and when to kneel. Afterward we stuck around for snacks, met the very friendly priest, and NC asked DH to substitute for him one Sunday he would be gone(!). We've been back once for DH to take notes before he subs next weekend.

Hilltop Community Alliance Church
I had to stay home, recovering from gastroenteritis, but DH and our houseguest drove over with our neighbor to the church where he (the neighbor) plays guitar in their praise band. DH even jammed on the piano, and I.C. played tambourine. I.C. gushed about the friendliness of this little congregation, which would love to have DH back, but I suspect their theology is too conservative for him.

Saturday, July 16, 2016

Happy Birthday, Dear Husband!

Action shot! R.M.'s lilac ball flies into the hole
overseen by a ceramic frog.
For Dear Husband's birthday, we went putputting with some new friends at Kniess Miniature Golf. We chose the "green and brown" classic course (the other course has a transportation theme and moving parts). The holes were sufficiently difficult to keep the game interesting for over an hour, and the landscaping is beautiful and well maintained. Each hole had what I think is supposed to be a vacation theme--they were very essentialistic: a "Maya" station, a "Mexican" stop, an "Old Cowboy West" hole, a cabin in the woods with "Native American" decorations, a fishing boat, etc.

Water feature at the first hole.

Dear Husband watches a ball down the three-stages of the homesteading hole.

Some "wildlife."
The "East Asian" zen garden.

The well-traveled golfers.

Afterward DH and I crossed the street for some cold Dairy Queen treats, then took ourselves downtown to find the Five Guys for burgers and cajun fries at Market Square. We spent the rest of the afternoon hanging out with L., S., and R. and eating freshly baked bread. DH worried that he might not see this birthday, but he did, and it's been great to celebrate together.

Wednesday, July 13, 2016

Tuesday, July 12, 2016

That's So Pittsburgh: Frick Park

Within easy walking distance of our house in Point Breeze is one corner of Frick Park, 644-acres of greenery in the southeastern corner of the city. It's one of many Pittsburghers' favorite things, and ours already too. Along a path I found this little lean-to.

Wednesday, July 6, 2016

So Long, Farewell,...

Dear Husband and I received a care package from A.S. today! It contained cards and belated going-away presents: for Dear Husband, a bobble-head statue ("As you bounce Bach, know your friends will always have your Bach."); for me, a Pittsburgh coloring book ("With the hospital monopolizing your time, here's a way to see your new hometown."); and for the both of us, a copy of Chris Ballard's non-fictional account of the 1971 Macon Ironmen, a high-school baseball team that went to the state championship. These are beautiful, thoughtful gifts that blend old and new. We are almost finished with Arthur Conan Doyle's The Valley of Fear and can read One Shot at Forever to each other next.

Tuesday, July 5, 2016

Touring Polymath Park

On the Fourth of July, My Awesome Parents, Dear Husband, and I drove an hour southeast of Pittsburgh to visit Polymath Park and tour three properties ancillary to Fallingwater, which DH and I visited the next spring.

Duncan House (left) is one of only nine extant pre-fab Frank Lloyd Wright homes. It was built in 1957 in Lisle, Illinois, and after the owner's death was moved to SW Pennsylvania to make room for a housing development. Priced at $15,000, it ended up costing $38,000. Duncan House exhibits some classic FLW traits: straight prairie lines inside and out; a narrow hallway opening up into a spacious living room; irregular footprint; and integration with nature.

(The landscaping could use a little TLC.) FLW hated garages (too practical?) but conceded to including a carport.

The home was disassembled and shipped complete with its furnishings.
A lot of the furniture has been replaced, but those are the original appliances and Fiesta pans.

A combination radio and intercom from the dining room to the master bedroom. Take that, Alexa.

The carpet is not original, but apparently they can't find
anyone to make 4'x4' Cherokee red concrete tile.

View down the main hallway that reminds me of a SW canyon.
Got the classic line of prairie windows and built-in cabinets.

When they relocated the house, they added a charming multi-level back patio and a basement,
a pre-fab option that the original owners could not afford. But it blends nicely with the present surroundings.

This one is called Balter House. It was built in 1964 by FLW's first apprentice, Peter Berndston, as a summer home for the Balter family. It has the look and feel of a tree house, with the galley kitchen serving as the trunk and a skylight serving as the main branches. As you can see, it is surrounded by greenery.

This house has the original 4'x4' Cherokee red concrete tile. I was really taken by the sectional sofa.
In the back you can see the screened-in porch. Immediately to my left is a large stone fireplace.

Line of snowshoes in the back hallway.

Master bedroom. Just beyond the trees is a ridge overlooking the valley.
Our guide, Roger, told us that guests who spend the night say the
 morning light creates a beautiful green glow.

Zigzag profile of the back of Balter House.

Finally, here is Blum House. It deviates from the typical "Usonian" style in its simplicity. Also because whoever put in the first set of pipes neglected to insulate them, so over the first winter they burst, destroying the original ceiling. Blum House sits on a small flat area with a lovely view; apparently they often host weddings there. Below are two views of the living room, one of the enclosed porch, and last the back of the house. They always look bigger on the inside than you think.

DH in front of the big picture window overlooking the field.

Notice the line of windows along the angle of the roof. If this is a party house, it's not for dinner parties, as the small round table with yellow chairs in the back corner is the only eating area.

More period furniture. I dig the rug.

Finally, we were treated to a fancy lunch at the Tree Tops Restaurant: crostini, sandwiches with quinoa or red potato salad, and cheese cake or chocolate mousse for dessert. Vegetables were sorely lacking, not even a whiff of lettuce on my chicken salad sandwich. But otherwise it was a tasty meal in congenial surroundings. We left just as it started to sprinkle.

Click here to read a local article about the history and architecture of the houses at Polymath Park. It has more and more beautiful photographs.

Monday, July 4, 2016

Happy Fourth of July 2016!

These "little red girls" (or Sokolettes, so named for their red competition leotards) really got into the spirit of the Independence Day weekend by sticking American flags into their French braids. We were singing "God Bless America" at the end of the field day concluding the 2016 USA Gymnastics Sokolfest.

Sunday, July 3, 2016

Trail, the conquering heroes!

Listen, my children, and you shall hear
of a misadventure of spoke and gear...

Pittsburgh from across the Monongahela River

As luck would have it, I got a three-day weekend for the Fourth of July. My Awesome Parents were in town and staying at the Waterfront on the south shore of the Monongahela River, so we decided to bust out our bicycles and go for a ride along the famous Great Allegheny Passage (GAP) that runs all the way to Washington, D.C. (with the help of the C.&O. Canal Towpath). I proposed the eastern route to McKeesport, PA, which Google Maps predicted would take 45 minutes to go 8 miles. There's not much to do in McKeesport, but I thought it might be nice to stop and snack in Renziehausen Park, whose rose garden is supposed to be one of the top 10 public rose gardens in the country. Thinking it wouldn't be much of a trip, I suggested we ride along the edge of town, for a grand total of about 12 miles and 1 hour in each direction. The only hindrance might be the mile-long hill at the end, but we could always walk that if necessary. The best laid plans...

In the background, the blue Duquesne Bridge into McKeesport, PA.
First, Dear Husband discovered that his bicycle tires wouldn't hold air. But he could rent one next door to my parents' hotel. He couldn't find his helmet, but they would have one of those, too. And I needed to adjust my brakes, but they would surely have wrenches. Mom needed a refresher on how to change gears, and after that we were off!

Unfortunately, it soon became apparent that Google Maps had calculated our trip based on my usual cycling speed, which is twice what DH and Mom can tolerate. The weather was warm but not oppressive, and the bike path alternated between railroad/industrial areas and a cool green tunnel. After an hour we were still riding. I had to pull out my phone with increasing frequency to check the route through McKeesport. I missed the last turn, we doubled back, and the route led us to a major street with businesses (most closed on Sunday). By now we were tired and hungry and still one mile and a large hill from our destination. Mom and I reasoned we could find someplace to sit and eat before turning back, but Dad and DH campaigned for attempting the incline. We got about three fourths of the way up before we had to stop to wait for DH to walk his bike to us. We sat on someone's raised garden bed to snack while we debated how to proceed. Unfortunately, there were no cross streets on this road. Our choices were to go down the way we had come and ride the long way home or, if we could crest the hill, take the shorter way back. We decided to walk the rest of the way up, and boy are we glad we did.

We actually weren't that far from Renzie Park. I snapped the shot above of the fountain on our way to the rose garden...which we almost didn't get to visit. The main gate was closed and locked (despite an optimistic sign to the contrary). Dad finally found an open side gate, which let us into this charming garden. It was a little past the high season for roses, but enough were still blooming.

The ride home was a comedy of errors, from an incredibly steep incline through town, to having to ride on the sidewalk along a major street without a bike lane, to inconsistencies on Google Maps. The piece de resistance was the rear tire of my bicycle popping flat 3.5 miles from the hotel. Mom and I walked most of the way back, until the path intersected with the road, and Dad and DH could pick us up with the car and put the bikes on the rack. We paid the guy at the bike shop to change the tire, but he put it on backwards the first time. We decided we had earned burgers and shakes from Burgatory, but we waited half an hour for a table, and then half an hour for our food, while MUSIC BLARED IN THE BACKGROUND and someone turned down the air conditioning to "freezing." Our little 2-hour jaunt turned into a 3.5-hour (mis)adventure, but we'll always have the stories and the pictures. 

Friday, July 1, 2016

What Internship Looks Like VI

Welcome gifts, practically a catalogue of Pittsburgh: a Terrible Towel, Chunky Chocolate Caramel Pittsburgh Popcorn (aka "PGH crack"), the free hat I acquired at a Pirates baseball game, and a sippy cup full of candy--from the Pediatrics residents, of course. (Actually, I was less interested in the candy than the clicky pen that was attached to the ribbon. It quickly became my daily writing implement.)

Although I made a face and picked it up with two fingers when I opened the gift bag, the Terrible Towel actually supports something I do. No, not the Steelers! The gold-and-black rally rag was invented as a fan gimmick in 1975 by WTAE sports broadcaster Myron Cope. In 1996, he gave the rights to the Allegheny Valley School, which cares for his autistic son, among other individuals with developmental disabilities. I wonder if they need a resident physician...?