Monthly Archives: July 2005

Another post-call morning

The sky is clear as I look out the windows on the 10th floor of the hospital this Sunday morning. Another call day is gone by, and I got a few hours’ sleep so I can’t complain.

I was called early in the morning (~4:30) for a few issues in the ICU, so after taking care of those, I decided I should go ahead and round and write my notes. Since I’m finished with my work early, I hope to grab a bite of breakfast and make it to church after checking my patients out to my cross cover.

As we ate dinner last night, Clay and I talked about a few of our patients, and the sad situations we’ve seen. I know my friend DoctorJ has addressed this in his blog, but it’s weird how we learn to separate ourselves from suffering. It’s not that we’re callous or uncaring; rather I think it’s more out of ncessity. For instance, I could enjoy my chicken picatta, mashed potatoes, and broccoli while we discussed a patient who’d been placed on “comfort care,” which means all therapeutic medical intervention had been withdrawn, and the patient was simply being kept as comfortable as possible while she died. And this is one of many. There’s the 20-something-year-old girl with a history of physical abuse, rape, and substance abuse who killed her brain with insulin. There’s the 35-year-old man with metastatic pancreatic cancer I met late one night in the ICU as I was covering overnight. He has a wife and young children. And there’s the 45-year-old East African man I recently admitted with aggressive stomach cancer…his family is praying for a miracle.

I’m reminded of my stroke patient early in July. After turning back and seeing her one last time after I’d written the orders to discontinue her feeding tube, I cried as I left the hospital. It can be wearing to be around so much suffering, and yet it’s a blessing. I am paid to relieve pain and suffering, to be a healer, which is an amazing privilege. And I’ll use all God has given me to do just that.

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Things I’ll miss about this city…

Please note: I’ve edited this post to maintain my attempts to protect the confidentiality of my patients.

Arranged in no particular order, I’ve compiled a list of things I’ve enjoyed about living in this city. Ever since finding out in March that I’m leaving in June 2006, I’ve felt a little more nostalgic. There’s still a lot to take in during the next 11 months!

Things I’ll Miss

  1. Great sunsets in a huge sky
  2. My church (especially the organ & Colin, who plays it. And we couldn’t forget the wonderful keyboard work of Stephen and Alex. All three of these men are masters. If they were Japanese cartoon characters, Colin’s special power would be improv; Stephen, phrasing; and Alex, rubato.)
  3. Driving on the major north-south artery through town.
  4. Great local barbecue
  5. The fantatic view of downtown from various places in the city.
  6. The symphony center–all cold metal, stone, and glass outside, but dark blue, rich woods, and warm lights inside. Dozens of great concerts within its walls. A fantastic choral loft which is a small compromise on acoustics, but a great deal on price and visuals!
  7. The mansions on A_____. One of my favorite is an 80-year old home which is stately but not pretentious.
  8. The irony of life in this city. The “pretense” within some neighborhoods, and the readiness to spot & criticize pretense by those without.
  9. Driving through downtown.
  10. Visiting a local exclusive girls’ school as a first year medical student taking “Human Behavior.” We were to observe the way the children interact. This is a place, however, where girls quickly line up in gym class when the whistle is blown, where everyone wears plaid skirts, where any ol’ first grader can tell you the definition of libretto, and where they serve “grilled tilapia,” not “fish” for lunch.
  11. Studying with friends at various Borders and of course the big Barnes & Noble, back when they let you sit at the tables for hours!
  12. The major airport. This airport is extremely well laid-out, making it easy to park to nearly any gate.
  13. Delivering babies at the county hospital.
  14. The crazy experiences in the ~200+ hours I’ve worked in the psychiatric E.R.
  15. Teaching anatomy lab to first-year medical students
  16. Spiced chai at the Black Forest Cafe (at Half Priced Books)
  17. The gargantuan Half Priced Books.
  18. Beautiful churches.
  19. The classical music radio station, especially Adventures in Good Music with Karl Haas, and Sunday afternoon listener requests.
  20. Running on the local running trail. This is where Adam both inspired me and pushed me to the point of nausea.

To be continued…

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It’s a sunny day, and I feel great!

So I realize that lately my posts haven’t told much about my life, and I guess that’s really what this blog was meant for. Things have been about the same up at the hospital. Every fourth night call, admitting patients, discharging patients, sipping capaccino in medical records. While most of my colleagues on “wards” this month will change to specialty electives (e.g., heme/oncology, ER, ICU, cardiology), I will have another medicine ward month in August. And my second paycheck comes today! It is much needed, as rent is due soon, and I have the usual credit card bill for my extravagant Uptown lifestyle.

One encouragement is that this morning, several little things look better with my ICU pancreatitis patient. He’s certainly not out of the woods, but I hope this is the first step of many on the road to recovery.

Took the time last week to make some home-made bread. Used my favorite bread recipe: asiago-rosemary bread. One of the best things for relaxation is spending ten minutes kneading bread. This is what I’ve never understood about the fancy Kitchen Aid mixers that do the kneading for you–the machine does the best part!

Overall I’ve been pleased with the balance I’ve reached in residency. Despite working right at 80 hours per week, I’ve been able to exercise a little, attend church, read for work, and do some fun reading, as well as spend time with friends. As I look out the window I see blue sky with cumulus clouds (see picture below, but substitute urban sprawl for the idyllic countryside).

I can’t help but be in a good mood looking at this picture!

Oh, I watched Finding Neverland last night. (DISCLAIMER: Skip the rest of this paragraph if you haven’t seen the movie.) While it was impressively done and had a great story, still I found myself disappointed with the fact that the marriage kinda fizzled. I was hoping for some sort of redemption there, but I guess Hollywood values the romance of James’ emotional intimacy with the Davey family more than the boring task of restoring a marriage. However, the movie did reinforce number 7 on my “Things to do in Life” list: Live in the countryside of Scotland for a year. During that year I plan to drink a lot of tea, do some gardening, go for daily strolls, attend a little Presbyterian church, and read plenty of good books. In fact, this may have surpassed number 6 on the list: Be a small-town volunteer firefighter.

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Answer to "Ask Marilyn"

* If you haven’t read the post from 7-26-2005 and you’d like to try a little puzzle, take a look at the “Ask Marilyn” post before reading on.

So this puzzle was evidently designed to lead the intuition away from the cold, hard facts of statistics. After she explained what I’m about to explain, I’m told Marilyn had angry college math teachers and statisticians writing in telling her it was time to admit she was wrong. However, I stand by Marilyn.

To properly analyze this puzzle, we must first realize it is all about probability and statistics. It is just a little more complicated than asking, “If I flip a coin, what’s the chance of getting heads?” but to understand the puzzle we have to remember the difference between an independent event and a dependent one.

Two independent events are, in fact, independent. I might ask, “If I flip a coin and roll a die, what’s the chance of getting a heads and a six?” The chance is 1/12, which is equal to 1/2 chance in flipping heads, and 1/6 chance in rolling six. These probablities are multiplied as they are independent events.

So going back to our goat & Porsche problem, the chance that the Porsche is behind any particular door is 1/3.

~ Door A~Door B~Door C
1. Porsche ~ goat ~ goat
2. goat ~ Porsche ~ goat
3. goat ~ goat ~ Porsche

Each of the three rows are equally likely, given what the game show host has told us. At random, the contestant picks a door. This is another independent event which, when multiplied by the first three events, yields nine equally likely combinations. To illustrate this, I’ve taken the three rows above which represent the three distributions possible of the Porsche, and expanded each row times three to show the chance of choosing any particular door. The selected door is bolded.

~ Door A~Door B~Door C
1. Porsche ~ goat ~ goat
1. Porsche ~ goat ~ goat
1. Porsche ~ goat ~ goat

2. goat ~ Porsche ~ goat
2. goat ~ Porsche ~ goat
2. goat ~ Porsche ~ goat
3. goat ~ goat ~ Porsche
3. goat ~ goat ~ Porsche
3. goat ~ goat ~ Porsche

All should agree that each of the nine rows above is equally likely. If you were to count up the chance right now of picking Porsche, you’d see it’s 3/9 which equals 1/3.

Now here’s where it gets tricky. For simplicity’s sake, let’s assume that door A is chosen. What I illustrate next is door A selected. This is the first row of each group of three from the nine equal possibilities above.

~ Door A~Door B~Door C
1. Porsche ~ goat ~ goat
2. goat ~ Porsche ~ goat
3. goat ~ goat ~ Porsche

Notice, you still have a 1/3 chance of having selected the Porsche. What the game show host does next is NOT an independent event. He opens a door to reveal a goat, but he does so knowing which door you have picked (he doesn’t open that one) and he knows where the Porsche is, so he doesn’t open that door either. So in row 1 above, the game show host might open either door B or door C. In row 2, he will open door C. In row 3, he will open door B. Remember that row 1 is as equally likely as either 2 or 3, but in row 1, the host has a choice of doors to open. In my next illustration, we know there’s a goat, so I’ll illustrate only the closed doors.

1. Porsche ~ ~ ~ ~ ~ goat (1/6)
or Porsche ~ goat ~ ~ ~ (1/6)

2. goat ~~ Porsche ~ ~ ~ ~ (1/3)

3. goat ~ ~ ~ ~ ~ ~ Porsche (1/3)

The way I have it illustrated almost makes it look like a 50/50 chance. Two doors closed, one Porsche, one goat. But remember each numbered line is equally likely. Row one has two equally likely possibilities (the host had a choice of opening door B or door C). We can clearly see that as things stand, there is a 2/3 chance that the goat is behind door A. Therefore, it would be to the contestant’s advantage to change his selection to the closed door. There’s a 2/3 chance the Porsche will be there.

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If one is good, then two is better…

My co-intern and resident were down in the E.R. last night admitting a patient, and I, being caught up on my work, was waiting for them to eat dinner. I realized the cafeteria would be closing some of its lines soon, so I went to the workstation in the E.R. and asked if there was anything I could do to help. Clay told me, “Well, I’m almost done writing orders, but we need a rectal exam with a guaiac test, and a tilt test.”

A rectal exam is just what it sounds like, performed with a lubricated gloved finger. It yields information about sphincter tone, the shape and texture of the prostate, and if there’s stool in the rectum. A guaiac test is a cheap and inexpensive way to assess for hidden blood in the stool. And finally a tilt test, which takes about 4 minutes, is done by taking the patient’s blood pressure and pulse while supine, sitting, and standing. The results of this test give a clue to the patient’s blood volume status.

“I’d be happy to do those things,” I told Clay, thinking it would mean we’d eat sooner. After seeing the patient, doing the tests, and bringing him a warm blanket, I dropped off the guaiac card at the nurse station and returned to the doctor station to find Clay and my resident. They were gone! While looking around for them, I noticed the patient’s door was shut, even though I’d left it cracked open. There was Clay, performing yet another rectal exam on this poor patient!

Clay later told me he thought I was kidding when I volunteered to help.

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Ask Marilyn

In the Sunday issue of the Dallas Morning news, there’s a magazine called Parade. Ever since I was a kid, I’ve read a column in Parade called “Ask Marilyn,” in which the woman with the reportedly world’s-highest I.Q. answers questions ranging from word puzzles to politics.

Here’s one math puzzle that I recently came across.

Suppose you are on a game show. There are three closed doors,

A —– B —– C

and the host tells you that behind two of the doors are two goats, and behind one of the doors is a brand new Porsche. If you select the door hiding the Porsche, you leave with the car. If you pick one of the other two doors, you get a goat. You are told to pick a door, which you do. Let’s say you pick A.

A —– B —– C

Instead of opening the door, the game show host, knowing where the Porsche is, opens one of the doors you did not select to reveal a goat.

A —- goat—- C
or
A —- B — goat

He then tells you that you can either stay with the door you originally picked (A), or you could switch your selection to the other door which remains closed.

Unfortunately you’ve already used your “eliminate an answer” lifeline. Your Aunt Nelda, the math teacher, is away from her phone. (Another lifeline burned.) Your last lifeline, the audience poll, shows :50% say to stay with the door A, 49% say to switch doors, and 1% say, “If you randomly pick a shirt and tie from your closet, what’s the chance that their colors would exactly match?”

What do you do, and why? I’ll post Marilyn’s answer on Thursday.

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Colorful captions…

“Sunlight-propelled spacecraft launched, but its fate is cloudy,” from the Dallas Morning News, Jun 22, 2005

“Approaching Heart Failure from a Cardiovascular Point of View,” a talk to be given by Dr Inderjit Anand, Professor at University of Minnesota College of Medicine. This should be much better than that “Heart Failure from a Podiatric Perspective” talk I heard last week.

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