A Bad Neighborhood

To paraphrase Anne Lamott my mind has become a bad neighborhood. It is not someplace I want to go into alone. I realized this fully when I noticed I hadn't posted anything for a week and a half. I knew I was working hard. I knew I was stressed and worried about a lot of things but I didn't realize I'd shut down completely until yesterday. It's not that I haven't been playing with my blog. I've been fiddling with the template etc, but I haven't been able to write anything. I don't want to hear any of my own evil thoughts so why should I inflict them on anybody else? Thus, blog silence. Today I presented my gloomy self to the salon for a haircut. The haircut helped a little bit, and I got some sympathy and understanding from Susan as she transformed my head into something much more stylish. As a small business person who deals with the public in a service industry I always appreciate Susan's wisdom. You might think that a salon owner/hairstylist and a physician wouldn't find much common ground but go back and read that last sentence and just try and tell me that doesn't describe medicine. I have always believed that part of what makes an effective physician is good acting skills. I don't mean to say I'm a phony but that I am aware of how I interact and speak with people. I consciously arrange my face, select my words and choose how to intone a statement. All day long I channel Marcus Welby or some Norman Rockwell doctor when House( I tried to give you a link here but it seems their website is in trouble)is closer to the truth a lot of the time. When the day is done. I pull the plug on that freak and I am back to the exhausted, depleted bits of regular old me. None of this is as well written or insightful as I'd like it to be but it's the truth.

Smidgen

The kitten has officially been named. Her blog name was harder to come up with than anything else. We considered "Pinball" and "Ricochet" as these names convey something of her personality. "Milk-Fiend" and "Slasher" were candidates for a while. I thought about referring to her as "Dogzilla's Kitten" which she has truly become but that seemed cumbersome. Since "tiny and perfect" is how I usually answer inquiries about the state of the kitten we moved on to names like "lil'Bit" etc but finally it is Smidgen.

Dogzilla and she like to play "run and chase" in which Dogzilla runs really close and makes a loud "clomp" with his jaws right next to her and then runs off. Smidgen runs after him all offended and bats him with a tiny paw then turns and runs. Now it's Dogzilla's turn again. Dogzilla lets her lie next to him while he's sleeping and doesn't even Grr. She is trying very hard to make friends with the big cats. Killer's nose is still rather out of joint about her presence but he will give her a cursory sniff now and then. I think he is waiting for Princess to give her okay before he lets on that he likes Smidgen fine. Princess, being a princess, is adamant that this interloper remain utterly subservient. Smidgen obliges by rolling over and showing her tummy to the Big Boss whenever they end up a little too close together. Smidgen follows the big cats around although from a safe distance just to remind them that she wants to play too and that she really is harmless. She's only been a member of our family for 3 weeks but we can't imagine our little family without her.

Goodies from Patients

pastries cropped
Originally uploaded by still just me.

I don't know if this is a perk or a drawback.

fff jjj

Everyday I sit down to work at my grandmother's old desk. It's nothing special really. She bought it used in probably 1950. It is a big grey metal battleship. I have her filing cabinet, her adding machine and her check embosser, too. Grandma and Grandpa had a restaurant they opened when Grandpa came back from the war. For a long time they lived in the back but when they could finally buy a house Grandma needed some space at home to "do the books". She made a little room in the very far corner of the basement into her office. Whenever she had to go work in her office my sister and I would go with her. We each had our own desk. Tables actually. We had little spindles for our "memos." We had staplers and tape and lots of pens. We wrote pompous business letters to one another drew stamps on them and mailed them across the room. Sometimes we stood next to her elbow and when she was ready we could pull the levers on the big adding machine or the check embosser. I liked the bumpy Braille feeling of the embossed checks. She also taught us how to type.

She had an electric typewriter that took up an entire table all by itself. There was barely room to stand up the book of typing exercises. You were supposed to turn your head 45 degrees and face the book. Without looking at the keyboard you were to type what you saw on the page. Many of grandma's hours at her desk and quite a few tornado warnings were spent with us taking turns typing: fff fff fff and then the next exercise which went jjj jjj jjj. When you got to the end of the line you had to reach all the way over with your pinkie finger to press return and then freeze with your fingers hovering over the keyboard while the carriage clunked back into place. I don't remember ever getting past ffj ffj ffj. Maybe my sister got more advanced.

I did take a typing class in junior high. This was back in the day when all girls took Home Ec. and it was understood that typing skills would be essential to our careers. The machines were manual so you really had to pound on them. Worst of all you had to lift your hand off the keyboard and reposition the carriage with a lever. You weren't supposed to look to put your hand back because by removing your eyes from the page you would loose your place in the exercise. I was forever typing hjkl; or kl;' when I meant to type jkl;'. I don't know how the teacher could stand the clatter. He did seem like a pretty miserable guy. In college (yes I took a typewriter to college) we girls could make extra money typing the boys' papers for them.

So Grandma's desk sat in the basement unused for a long time until my Dad used his Super-Dad powers to bring it to me from Iowa. It looks much the same way it used to. Most of the drawers open and the extra writing surfaces pulled out. I think it was neater when Grandma worked at it. I remember she had a big blotter with a calendar. If I had one of those you would not see it because it would be buried under the very important piles which occupy that real estate. My diploma and various other credentials hang over the desk now but I can still see Grandma sitting here in my place. Sometimes I imagine how she would chide me about these piles of paper and then how she would commiserate with the endless amount of work I face as a small business person. And, I always think about her when I type.

The Impossible Will Take a Little While

I'm reading this book of essays and wanted to share this bit out of it. These words are spoken by Benjamin Mays, president of Moorehouse College and mentor to MLK:

"The tragedy of life doesn't lie in not reaching your goal. The tragedy lies in having no goal to reach. It isn't a calamity to die with dreams unfilled, but it is a calamity not to dream. It is not a disgrace not to reach the stars, but it is a disgrace to have no stars to reach for. Not failure, but low aim, is a sin."

Check out Mr. Loeb's website "Soul of a Citizen" for more inspiration.

AM Radio

I heard this on AM radio the other day:
"It's nice to be important but it's much more important to be nice."
Don't ask me why I was listening to AM radio.

July or Breathing II

Most people think the new year starts in January. Confirmed academics believe the new year starts in September. Anybody who has ever worked in a hospital KNOWS for a fact that the new year starts in July. July is when the newly minted physicians, ink still wet on the diplomas arrive in the hospital to actually figure out how to take care of sick people. They are young young young. The smart one's are petrified. If they don't look like they've worn a quarter inch off their teeth in the last 24 hours you should watch them like a hawk. During my residency I worked on the in-patient service each July. July first of my internship year I turned up for "Morning Report" and was assigned my first patient. She had been admitted the night before. She had pancreatitis. I had enough sense to recognize this as a "bad" thing. The rather scary senior resident (later to be widely known as "General Rao") who had worked the night had done her history and physical exam and then over the course of the night had transferred her to the ICU where she was subsequently intubated. There I found her sedated and intubated with a central line going into her neck and a tube coming out of her bladder. Later she would get another line inserted in the artery of her arm and a bag attached to her rectum. I would ultimately care for her for the entire month. I would go to the ICU in the morning and review the night's events. I would always talk to her even though most of the time she couldn't respond and it was questionable whether she was aware of anyone speaking. In my mind pancreatitis went from being a "bad thing" to an absolute nightmare. She developed adult respiratory distress syndrome which makes it hard for oxygen to get into the blood stream even when there is a machine delivering it to the lungs. Next her kidneys failed. Her blood pressure was so low we couldn't do conventional dialysis. Instead she got a special kind I'd never heard of before. While on dialysis her blood sugar went dangerously up and up. I sat at the nurses station near her room and questioned each specialist in turn. Why is X happening and what can be done about it? Why? Why? Why? I understood my role to be that of a large and annoying three year old and I refused to let anyone caring for this patient do so on auto-pilot. I was there to make them stop and think. "What am I doing for this patient and why? If it isn't working then why? What else can be done?" Ultimately I convinced the renal fellow to check what was in the dialysate fluid and we found it was full of sugar. Sugar that was crossing into my patient's blood stream. I pestered him to concoct a custom dialysate to correct this problem until he did so.

One weekend night I was on call. I had taken enough call that I could actually put myself to sleep basically praying: All I have to do is get everyone to morning alive. I was asleep when my pager went off. I recognized the number to the ICU and dialed it. Respiratory had changed the tube in my patient's throat and while taping it in place had accidentally cut the balloon through which air is introduced to keep a cuff around the tube inflated. The cuff is deep down by the larynx with out it the ventilator cannot generate enough pressure to inflate the lungs. The tube had been switched again but now despite all the equipment working the lungs could not inflate. They needed me. Me! I told them to call a code hospital wide so that anesthesia and others would report to the scene. I pulled on my scrubs ran down the stairs and across the hospital and sprinted up two more flights arriving unable to speak. They were having some success using an old fashioned bag mask to keep her oxygen up. There were no breath sounds on the right side of her chest. Keep bagging. I called my second year. "I've never deflated a pneumothorax." That night I watched him stick a needle between my patient's ribs but no satisfying gush of air came out. The air outside the lung was still keeping the lung from inflating. We both knew the next step was to insert another needle in the front of the chest under the second rib. We also knew this was highly dangerous because of the major blood vessels passing under there. Next a senior anesthesiologist appeared and without discussing it proceeded to do just what we had feared to do. He took a deep breath and plunged the needle in. The trapped air gushed out and the lung could re-inflate. I could have cried. (Years later I ran into him and thanked him. He still remembered the case.)

Suddenly the crisis was over and we were back to the previous mere train wreck. At the end of July my patient had a tracheostomy. Her kidneys and lungs resumed working. She left the ICU and went home from the hospital in mid-August while I was on who knows what rotation. To this day I feel badly about a stupid sort of thing. While she was in the ICU I neglected to get splints but on her feet until about the second week. As I learned you cannot bend your ankles anymore after laying there without moving for a month. My patient had to have painful physical therapy for weeks and could only walk with splints after that.

Did I mention she was only 24?

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