brain fog

i was in LLBean this afternoon and the salesperson asked me for my zip code.

i could see the numbers in my head, only they were really fuzzy.

finally, i retrieved the numbers from the haze by stating the town, then the state, then the zip code.

it's amazing what tricks a tired brain will play.

but i have to say, it was an incredible night. i love picu call. i intubated an 8yo kid with pneumonia who was breathing 70 times a minute, started a central line, and then proceeded to play with a dopamine drip all night long.

was that me?

the RRC and work hours revisited

in a series of interesting and somewhat humorous comments on my last post, an anonymous reader brought up the topic of work hours and the RRC:

"You signed up for this no? Good thing you have the RRC to wipe your nose (and your butt). God forbid you might actually stay up all night. Jeez you are going for a post-call hike. You really think that's what happened before the RRC held your hand? No you were a DOCTOR and worked post call. Tell me, what do you think is going to happen when you get to the REAL WORLD, you are on call all night and then spend the whole next day working? The RRC won't be holding your hand then. ... The present work hour rules have turned the present crop of residents into wussies. I know this from experience. Medicine is not shift work. You don't walk away from the patient when the bell rings. You don't know what I am talking about. In 1 and 3/4 yrs you will...."

for those of you who don't know, RRC stands for the Residency Review Committee. it is the part of the ACGME (American Council of Graduate Medical Education) that oversees residency programs. every few years, all accredited residency programs have a site review to make sure that they are up to standards.

recently, the ACGME instituted restrictions that limit residents to working 80 hours per week, averaged over 4 weeks, no more than 30 hours in a row, no less than 10 hours between shifts and at least 4 days off in a month. these rules echo the Bell Commission reforms that have been in place in New York since the late 1980's after a patient died (Bertrand Bell's daughter, Katie) due to resident fatigue.

anonymous' opinion, it would seem, is that the work hour restrictions have made an entire generation of doctors into "wussies". i'm curious what opinions people have about this, both medical and non-medical readers. does it positively or negatively affect patient care in your experience? if you are a resident currently, is your program in compliance? what are non-US training programs doing to address the issue?

songs to play at my funeral

blogMD started quite a morbid meme. list 5 songs that you would want played at your funeral. here's his list:

"Now, I will admit to both having thought of what song I would want played at my funeral and I’ve also discussed it with my wife. I told her that I wanted a traditional Jewish funeral … with bagpipes. And Guinness. All that being said, I’ve not yet composed a top five list of songs to play. And so, without further ado, I present to you the Top 5 Songs I Want Played (Over My Dead Body):
“When the Levee Breaks” by Led Zeppelin: Because “Stairway to Heaven” is so obvious.
“Dies irae” from Mozart’s Requiem: This piece speaks for itself. I’ve loved it for years.
“A Love Supreme” by John Coltrane: I consider this to be one of the greatest pieces of music ever composed. Coltrane’s “humble offering to God” in the “Acknowledgement” converted this tired agnostic.
“Steppin’ Out” by Joe Jackson: A fitting way to say adeiu.
“Non, je ne regrette rien” by Edith Piaf: No regrets. None."

this was actually quite a fun distraction, not that i like to imagine my own demise. here's my contribution, which is, oddly, not that melancholy:
1. "shine on you crazy diamond, parts 1 & 2" by pink floyd. according to wikipedia, the album, wish you were here, was written as a tribute to syd barrett who i can only assume was the crazy diamond.
2. "serenade" by emiliano torrini. it's hauntingly beautiful.
3. "sweet thing" by van morrison. "we shall walk and talk in gardens all misty wet with rain. and i will never grow so old again."
4. "wond'ring aloud" by jethro tull. one of my all-time favorite songs. "we are our own saviours. ... it's only the giving that makes you what you are."
5. cello suite #1 in G by yo yo ma. i just love it and it's beautiful and peaceful.

as for who to tag...the usual suspects. you can blame sam for this one. :)
sister smile
fat doctor
workinprogress
megan
juniper

the music meme

so flea tagged me with the 7 songs meme.
"Seven songs you are into right now. No matter what the genre, whether they have words or even if they’re not any good, but they must be songs you’re really enjoying now".
thanks flea.
really. thanks.
seriously.

iTunes doesn't lie.

to figure out my top 7 songs, i looked in iTunes and found the most frequently played tracks.

it was a little scary.

here's how it broke down.

#1: what i know only as "track 09" by built to spill. it's a great song. it's on my running mix, which is probably why it is the most often played track. yeah. i run a lot.

#2: graduation day, chris isaak. i just love it. what more can i say. his voice embodies McDreamy.

#3: in the waiting line, zero 7. from the garden state soundtrack. the whole soundtrack is fantastic. zach braff's new movie just came out, the last kiss, with a similarly splendid soundtrack.

#4: mushaboom, feist. makes me smile.

#5: i want you, bob dylan. the man is pure genious.

#6: nothing brings me down, emiliana torrini. she has an amazing voice. actuallly, the whole album, fisherman's woman, is amazing.

#7: better together, jack johnson. from the curious george soundtrack. if you're curious why i listen to this, check out some of my previous posts from august.

and coming in a close #8 was a tie between camping next to water (badly drawn boy) and crazy in love (beyonce featuring Jay Z) ... what can i say ... i have eclectic taste in music.

now 7 tags. well, i'm not sure i can tag 7 who have yet to be tagged, but i might come close.

sister smile
fat doctor
blogMD
vitaminKmd
workinprogress
juniper
sid schwab

that was 7, right?

fellowships

so. one of the perks of being in a small residency program is mentors.

i have a great one.

he just came to our fair institution three years ago from a much bigger place. he's the only pulmonologist here. and he has taken me under his wing, so to speak.

i am the guinea pig in a new pilot program that we're trying here. for my continuity clinic, i alternate every other week in his pulm clinic, managing my own panel of patients. CF, asthma, i even have a kid with primary ciliary dyskinesia. pretty cool stuff.

in compliance with the RRC guidelines, i even have my very own set of goals and objectives.

i know, i know...just what you've always wanted!

i still have my panel of gen peds patients whom i love working with, but i really love my pulm clinic. and i'm not a clinic person.

he also set me up with a research project, working with one of the microbiologists here. it's really neat and i now have access to the cf database. i can query searches to my hearts content. i know, i'm a total dork. i can't help it. can any of us? seriously?

during my intern year, ever since he found out i wanted to do pulm, he has talked about setting up a pulm fellowship here, in conjunction with another small, academic children's hospital up the highway a bit, which also happens to be where i went to med school. i always nodded and said, yeah, sure, that would be great. but i never really took him seriously.

until this week.

he basically told me that i should look at other programs because the timing might not work out, but that he was trying to get things started and what did i think?

we're pretty academic here, so research wouldn't be a problem. and certainly there is no lack of patient volume given that there would just be my lone self.

but i guess that's my question. there would just be me.

would i be missing out on having other fellows at the same stage of training? is there some benefit to being in a big institution with lots of fellows in other disciplines?

i'm still finishing my cv and figuring out where to send it. i'll send it to all the programs in big cities. but eventually, this is a place i wouldn't mind working. so the idea of finishing my training here is quite tempting. but also a little daunting.

musings on a sunday

i have a relatively new housemate, since August, really. he's quite nice, quiet, respectful. it's been sort of fun to live with someone after having been on my own for awhile.
well, he went to his brother's wedding this weekend, leaving me with the apartment all to myself, which was sort of nice. i spent the weekend catching up on things that had been piling up during my picu month...bills, laundry, journals, etc.
there was an article in the most recent Pediatrics (Pediatrics 2006;118(3):888-895) about screening for cystic fibrosis with the newborn screen (NBS). they looked at a cohort of children in northwestern Italy diagnosed by NBS between 1997 and 2004, looking to see if there was a difference between the NBS children and the historical controls in the time to infection with Pseudomonas aeruginosa, a bacteria that is associated with a decline in pulmonary function and an increase in morbidity and mortality.
interestingly, they found a shorter mean time to P. aeruginosa infection in the children diagnosed by NBS (183 days for NBS children vs 448 days for historical controls), suggesting that newborns are more readily infected with nosocomial bacteria than older children diagnosed at a later point based on clinical symptoms. this would sort of fit with our understanding of the newborn's evolving immune system.
what this study brings up is that the NBS is not an entirely benign intervention. one could assume that earlier diagnosis and access to treatments and resources would be a positive thing for kids with CF. theoretically, it is. however, we as practitioners need to be vigilant about infection control, with the recognition that our adherence to CF precautions is profoundly important in protecting these vulnerable infants. in our clinic, we see a mixed population of pulmonary pathology, including asthma, CF, PCD, complicated pneumonias, etc. we try to segregate the CF patients to the CF clinic days, but this is not always possible. in addition, the allergy/immunology clinic is run out of the same clinic hallway, increasing the chance for more nosocomial infections. makes me want to carry around lots of alcohol swabs.
coincidentally (or perhaps not), the next article (Pediatrics 2006;118(3):896-905) in the journal was about the cost-effectiveness of various methods of CF NBS in the netherlands, where they use several different methods to confirm the diagnosis. cost-effectiveness studies sort of creep me out a bit. i guess that's the clinician in me. how can you boil a child down to "life years gained" and "willingness to pay values per life year gained"? and whose willingness to pay are we talking about?
another topic this article addressed was parents who chose to terminate the pregnancy if they knew the fetus was affected. in the abstract, i can understand this. however, having met so many kids with CF who lead lives full of happiness and normal kid experiences, albeit punctuated by more frequent visits to their doctor, i struggle with this on a personal level. it is akin to the debate regarding terminations for trisomy 21 fetuses in a way.
i don't pretend to have any answers. just food for thought.

little miss sunshine

if anyone is in need of a good laugh, i recommend little miss sunshine . it's dark in parts, but i like that sort of thing. my friend who always falls asleep in movies, no matter how interesting they are, didn't fall asleep in this one because she kept laughing. you'll find yourself thinking, 'how can i be laughing at this?' but you'll laugh nonetheless.
isn't laughter the best medicine?

recovery

so i did it.
i ran in a charity half-marathon for the hospital yesterday afternoon. outrun the sun, if you will, which i did.
my goal was to finish without walking (except at water stations, three of which i slowed down for).
13.1 miles. 9:30 min miles (i know...not impressive for you marathoners, but consider for a first-time half-marathoner who trained whilst doing her picu rotation)
$1,006.
the pain i feel now is worth it. it was all for the kids.

i was severely impressed with c.j.. he's a medicine resident whom i was chatting with before the race. he had not trained specifically for this race. he decided to run on wednesday, with the race being saturday. he non-chalantly told me that he used to run track and cross-country in college and that he would have been a professional runner were he not 6'8". maybe if he were 6'2", he said. or 6'5" at the most. i nodded my head, thinking that the last year as an intern, if not the grueling 4 years of med school, would have gotten him slightly out of shape. nope. he placed in the top 20 overall, 3rd in his age group. why does being 6'8" disqualify you from being a professional runner?

today is about recovery. i slept in. brunch at lou's with my brother, who drove up with sister-in-law to cheer me on.

i did do one productive thing...my laundry, which in my new abode means going to the laudromat.

note to self: never do laundry on a rainy sunday afternoon.

you know you work too much when...

...the most amusing event this evening was when the a-la-mode scoop of ice cream slid off your friend's molten chocolate cake and she said,

"i SCFE'd my cake!"

and the table full of peds residents burst out laughing.

it probably would have been funnier if it were actually an ice cream cone.

transformation

there have been a lot of changes in my life of late, many of which have not made it into this blog. some have been good changes. some have been more challenging. most, actually, have been more challenging. i'm still struggling to find the good in those changes.

suffice to say, i've been wearing a little thin.

picu has been a whirlwind of sadness and stress. we've had several kids die over the last few weeks, including a little boy i've known almost my entire residency and his entire life and a little girl with a brain tumor whom everyone adored.

in an attempt to de-compress after a stressful night on call and the events of the early afternoon (see previous post), i went for a run. i told my roommate, who was making pizza for dinner, that i probably wouldn't be more than 30 minutes and that was being optimistic.

i was gone for an hour.

the first mile was a little painful. but then the runner's high kicked in and it was like i could suddenly fly.

have you ever felt like you were filled with strength that was not wholly your own? that's how i felt today. it was incredible and i felt, for the first time in a long while, that things are going to be good again. different, but good.

so now i'm sitting at my new kitchen table, eating really good pizza and listening to yo yo ma's cello suites, watching the sun set over the hills across the river, feeling peaceful. it's a nice feeling.

broken heart

i've lost a friend today.

to those who knew him, he was and always will be the bravest, strongest, most courageous of souls.

for those who will never get the chance to meet him, my heart breaks for you that you will never know this boy.

this boy has the most amazing smile. every time i walked into his room he would hear my voice and his whole face would light up. i could have been having the worst, most stressful day and one trip to his room and seeing his sweet little face would erase all the irksome things in this world.

this boy has the most infectious laugh. it was so wonderful to watch him grow up. when i first met him, he was not one for talking. but over the course of my time with him, he learned to coo. the coo eventually became a babble. the babble turned into a laugh. sometimes, i'd be standing outside the room of one of his neighbors and hear a cheerful squeal. i'd poke my head in his doorway and see him in his crib, grabbing his favorite green hippo and laughing to himself.

this boy had good taste in music. early on in his life, someone gave him the soundtrack to curious george. if ever he was fussy or agitated or not feeling well, all you'd have to do is press play on his cd player and listen to the first song, upside down, and he would calm down.
"And as my mind begins to spread it’s wings
There’s no stopping curiosity
I want to turn the whole thing upside down
I’ll find the things they say just can’t be found
I’ll share this love I find with everyone
We’ll sing and dance to mother nature’s songs"
i kept telling him that the lyrics were right, that nothing could stop curiosity. that he could change the world with his two pudgy hands.

one afternoon this spring, he was out of sorts. no one could settle him. it was a slow afternoon, so i took him in his room, sat by the window in the rocking chair and held him, rocking him until he fell asleep. he slept for two hours in my arms, rocking back and forth. every once and a while, he would let out one of those quivering breaths and then settle somehow deeper in my arms, his pudgy little hand resting over my heart. it was the most peaceful i've ever seen him. i'll always remember him that way, snuggled in the crook of my arm, watching his eyes flutter beneath the sleepy lids, dreaming some wonderful dream where he could do anything...even pee his name in the snow.

this boy came into my life for a reason. his life has been too short, but it has been full of every happiness we could give him. of that, i think we should be proud. i will always count myself lucky for knowing him. i will always wish i had more time with him. but i also am thankful that he will not suffer any more, that he won't have to endure any more hardship or pain. he has suffered enough. if there is a heaven, he is there, watching over us as we watched over him.

"...and flights of angels sing thee to thy rest."

books and such

for all those who think i'm mysterious ...
not so.
really.
an open book, i tell you.

the book that changed my life: to kill a mockingbird
hands down, the most amazing book. i read it when i was little and it's always stayed with me. atticus always reminded me of my dad.

a book i've read more than once: wasted
don't ask why. it's just one of those kinds of books.

a book i'd want with me on a desert island: a book about how to survive on a desert island...if such a book exists...if anyone has ever survived a desert island.

a book that made me laugh: thank you for smoking
i read it years ago when it first was published. turns out christopher buckley summers in the town where my parents live and came to give a reading just after i had finished it.

a book that made me cry: lots of books make me cry. several more notable ones are:
the kite runner
no matter how loud i shout
Baby ER
cry the beloved country
savage inequalities

a book i wish had been written: central lines for dummies

a book i wish had never been written: my organic chemistry textbook ...gawd that was painful...but it made a good doorstop once i passed the class.

a book i am currently reading: at the top of the pile currently is the history of love

a book that i am meaning to read: appetite for life, a biography of Julia Child.

five bloggers i'd like to tag:
sister smile
fat doctor
blogMD
vitaminKmd
workinprogress

the magical fluid bolus

a little girl came in to the ED today with a fever to 39.5. i had spoken with her mother several hours earlier about the fever, as well as some bug bites that looked infected and asked them to come in to make sure the bites weren't cellulitic. at that point, her mom told me over the phone that she wasn't too worried, because she was still playing.

by the time she got to the ED, she was no longer playing.

she was, in fact, lethargic.

the dreaded L word that parents throw around willy-nilly without proper respect for the weight it carries. it does not mean they're sitting on the couch all day playing video games or just wanting to watch movies. it means that they are sleepy and very difficult to wake up.

this girl slept through my exam, including the belly exam. even still, this mom did not describe her daughter as lethargic, but, rather, as "a little more sleepy than usual".

1 IV, 300cc of NS, 240mg of tylenol...and presto!

all better.

up, talking, smiling, asking for apple juice and stickers that were pink.

i gave her all the pink stickers we had, including the one of the bear with a pink bow and the caption, "i'm all better!"

non sequitor(s)

went running today. on a windy, hilly dirt road, i could have sworn i saw a mushroom as big as a basketball. turned out to be a rock. some runner's high.

i have a new housemate who is about to start med school after his first career in computers. he's a total wiz and is, as we speak, figuring out how to transfer all my music on my ipod (that came from a computer that no longer exists) to my current computer. brand new music library for me. well, not brand new. it's all my music. but it's now manipulatable on my iTunes.

my new favorite show on t.v. when i can't seem to wind down from a night in the ED is "Throwdown with Bobby Flay", in which the Iron Chef travels hither and yon to challenge ordinary, everyday people to a cooking challenge. Last night was a Texas Chili cookoff. hey, new yorkers can cook chili, too.

work beckons in the morning. at the moment, i am feeling masochistic enough to get up even earlier and run before clinic. i think i really am nuts.

bad day

ugh.

(post edited)

on a brighter note, i did my long run yesterday and feel fairly good today. minimal diaphragmatic irritation. hills that used to kill me are now an afterthought. could it be that i am actually getting in shape???

when you are sicker than your patients...

so it's never a good omen for your day when you feel worse than most of your patients. there's a lovely gastroenteritis going around and, lucky me, i seem to have caught it. not surprising, considering how many times my face has been sneezed and coughed in over the last few weeks.

here's a tip that i learned the hard way. wear a mask when swabbing people's throats. that way, when they gag and cough, you are somewhat protected.

saw some neat stuff today, though, despite feeling wretched.

a resident came in with a dislocated shoulder from a slip-n-slide incident (presumably involving a lot of alcohol). pretty much behaved like an ass, which is sort of what he's known for. a little boy with a septic joint from a laceration that was sewn up a few days ago. a young baseball player with a nasal fracture from trying to catch pop-up flys with his non-dominant hand who had clear rhinorrhea ever since the injury...didn't turn out to be csf rhinorrhea, but it was good to go through the differential. lots of non-specific viral stuff but overall really pleasant families, which always makes things easier.

plus, i was working with one of my favorite ed docs who totally gets my sense of humor. we have a good time. he wouldn't give me an iv, though, for my own rehydration, but that's ok. i guess i didn't really have mental status changes...yet. i've been working on the ORT. alternating gatorade with emergen-C. if i wake up tomorrow obtunded, you'll know why.

based on the number of parents that i convinced over the phone to wait until clinic tomorrow to be seen instead of coming to the ed tonight, tomorrow is a busy day. off to sleep i go...

a running question

a question for fellow blog-reading runners out there.

i've been training for a half-marathon of late. it's a fund-raising event for the hospital where i work. it's going well, now that the blister is healed. but every day when i start out, i have left shoulder pain, no matter how much stretching i do. after about a mile or so, it stops. why is that?

on a somewhat related note, i was just down in new york visiting family and went running in central park, one of my favorite things to do. i started out near columbus circle and ran up around the reservoir. it was a weekend morning, so the park was full of other runners and bikers and families and couples. it was quite distracting, and still somehow motivating, to have other runners around. not that i was competing with any of them, but it helped a bit with pacing, particularly since it was 11am and 95 degrees out.

there was a musician playing on the grass near tavern on the green, a crowd of people sitting and listening raptly. lots of people having picnics on the great lawn with their coffee and bagels. i absolutely love the peace and quiet of living in a small place, but it was nice to be immersed in the city again, even just for a few days.

blisters and such

i've not been able to run this week due to a nasty blister on my left heel.
it's finally healed. 
well, sort of. 
enough to try running again today on my day off from the ED. 
life on the ED rotation is sort of interesting. it's a little lonely, as i work when most of my other friends are sleeping. but it's also pretty neat. i get to see people who are really freaked out, whether for valid reasons or their own imagination, and help them in a very real way. whether it's getting a kid with an asthma exacerbation a neb and a wopping dose or steroids or sewing up a laceration on a little boy's knee. i always tell them how brave they are, even if they weren't really, because that's as much of a band-aid as anything else i can offer. 
the families whom i've met so far in my short 2 weeks on this rotation have run the gamut from those reeking of cigarette smoke and neglected dental hygiene to the most well-educated with glowingly polished veneers. i have to say that i learn something from each and every encounter. 
even if it's just that i should really floss more. 
here's to healed blisters (and other body parts) and to a glorious, sunny day off.

quiet afternoon

i spent the afternoon sitting on a bench at the edge of the town green reading my latest favorite book, The History of Love. it was an interesting exercise in people-watching, too.
there was the group of girls who all looked the same, as if they had consulted one another before getting dressed that morning. the little boy in his motorized wheelchair who was racing in circles around his nanny and her friends with their young charges, all the while a huge grin on his face. the family waiting for their dinner reservation at the fancy restaurant across the street, all dressed up in suits and high heels. they seemed like such a content family. the youngest amongst them was a 9yo girl who reminded me an awful lot of myself at that age. she was just dancing around on the grass, blissfully un-self-conscious, doing cartwheels and congratulating herself when she did a particular move well. she caught me looking at her at some point and we forged an immediate bond, as if she sensed that we were dopplegangers. when they all went across the street for dinner, she looked over her shoulder at me and waved good-bye. i smiled and waved back. i wish her well, oh so well, in this crazy world. 

independence day

today was one of those amazing days that i want to preserve forever. if only you could put those days in little snow globes so that you could pick them up, look at them and remember why it was that the day meant so much to you at the time.
my sister and i hiked mt. moosilauke with my chief resident and his girlfriend, who also happens to be an old med school friend. from the ravine lodge, we hiked up the gorge brook trail to the summit. it's a steep hike up but so incredibly beautiful. there's something so amazing about how the vegetation changes from tall, dense pines and birches to the wind-stunted dwarfs at tree line. it was not the best day for views, but that didn't seem to matter, as there was a mystical, blue-purple haze that gave everything a somewhat ethereal hue.
we sat on the rocks at the summit and ate nutella and pretzels. there's nothing quite like chocolate at the top of a mountain. french fries might be better, but i've never been able to find them in such a place.
we hiked down the carriage road (beware the poison ivy!) to snapper, re-entering the dense, lush forest. so many wildflowers blooming, growing in the crevices of the rocks that lined the trail. i wish i remembered more botanical names from my undergrad ecology labs, but they have been replaced with the names of muscles and nerves and bones. for some reason, bird calls have stuck in my memory, though. white throated sparrows were in abundance, singing heartily as we entered their territory. i've always loved their call, so plaintive and almost melancholy.
at the convergence of snapper and gorge brook, there's the class of '97 swimming hole. the water as deliciously cold and made my tired feet feel so much better. i splashed the water over my face and head, feeling the freezing rivulets drip down my neck. nothing quite like it in all the world. it was almost torture to put my shoes back on for the walk up the hill to the parking area.
the last time i was at moosilauke was late fall. the lodge was deserted and it had already started snowing. yesterday, however, the lodge was full of summer staff and visitors, the sweet smell of cornbread lingering in the air. there was a man with dreadlocks playing guitar, trying to learn a song before tonight's 4th of July celebration perhaps.
we filled up our now empty water bottles and headed back, stopping at fat bob's for ice cream. to give you a sense of why it's called fat bob's, a baby size is 1 scoop, kid size 2 scoops, small 3 scoops, medium 4 scoops and large 5 scoops. no wonder americans are overweight. i got a twist with rainbow sprinkles. a little girl in line behind us said excitedly to her mother, "she got rainbow sprinkles!" i remember being that excited for rainbow sprinkles once upon a time.
after a late afternoon nap, my sister and i went to watch the fireworks. it was really quite impressive. greens and golds, red, white and blue, pinks and purples all showering over the river, the boom echoing loudly off the hillsides. during the finale, the song "born in the USA" was blasting over the loudspeaker. my sister and i both looked at each other and wondered why they chose that song, as the lyrics are not the most glowing portrait of life in this country. but i guess as long as the chorus is catchy, what does it matter?
all told, it was a cleansing, restorative and grounding day...reminding me of my own, innate independence and strength and also of my inextricable link to the earth and the people in my life whom i love dearly. i think i'll have to make this a new july 4th tradition.