Monthly Archives: December 2005

Decisions, decisions…

Now that I’m due to move to New York City in less than six months’ time, I’ve started thinking about where to live. It’s entirely too early to reserve an apartment given the quick housing turnover rate there, but it would be nice to have the plans firmed up in my mind at least.

For a person who has difficulty ordering in restaurants because everything looks good, choosing between Manhattan neighborhoods can be a challenge. When it came time to rank anesthesiology programs, I had a list of my top five programs, each with something unique to offer. In the end, it came down to choosing a city: New York, besides being close to my extended family in Philadelphia, is a city that has more to offer than perhaps any other American city and is a place where I hope friends will want to visit!

Now it’s time to decide on Manhattan neighborhoods. On the cardinal-directionally-correct map below, I’ve listed a few advantages of two of the main contenders.



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Parking lot code!

So there are two types of “code blue” at this hospital:

  1. MET, which is a true medical emergency (Medical Emergency, True???)
  2. ART (I have no idea what this stands for) which is not a medical emergency. We, the code team, do not have to respond to them.

On a recent code, I was paged “CODE BLUE: MET, PARKING LOT 5.” Part of me wondered if this shouldn’t be an ART…was there really a nurse around to determine that this patient’s heart had stopped? But then glamorous images of me intubating the patient in the middle of the parking lot on this sunny cold day compelled me to hurry downstairs.

After consulting a map of the hospital campus, I determined which one was parking lot five and jogged over to the adjacent professional building. There, in a stairwell, an elderly man had tripped and fallen. He had a couple lacerations on his forehead, but a passerby had stopped and given him a napkin. I quickly made sure the bleeding was controlled and did a brief neurological assessment. He was fine. It should have been an ART. Actually, they should have just called 911 rather then going through the hospital pager system.

The code at 7:45 AM the following call day was a little more legitimate. I had decided to take a quick nap after seeing my ICU patient. (Since the team on call the day before my team only has one intern, my call room goes unused, and is ready for napping virtually the moment I arrive.) Being awakened by my pager, I stumbled downstairs to the eighth floor and met my resident in the stairwell. There were a few nurses in the room, but that was it. Since the respiratory therapist hadn’t arrived yet, I dug through the “crash cart” and found an appropriate laryngoscope and endotracheal tube.

We did the usual thing: chest compressions, a few medicines. Intubating the patient was surprisingly easy, given that he was such a large man. I always feel much more comfortable in codes once we have an airway, and I’m not sure if it’s because I’m a budding anesthesiologist, or if others feel the same way too. A few people congratulated me on the smooth intubation, which made me feel a little guilty because it was so easy…but sometimes it’s best just to accept the compliment.

The rest of the code wasn’t so smooth…four times we got a pulseless ventricular tachycardia which meant four shocks with the defibrillator, each one bringing back a regular rhythm at least temporarily. In the meantime, he got bicarbonate, calcium, lidocaine, vasopressin, multiple doses of epinephrine, and two boluses of amiodarone. Finally after thirty minutes, we were still in pulseless v tach. My resident “called” the code, that is to say, we had done everything we could do, and it was time to stop.

Like a machine being powered-down, the room quickly grew quiet: the humming faded, the activity stilled, the oxygen flow was cut off. And then, much to our amazement, the patient’s jaw moved–he was trying to breathe! And then, slowly, his right arm lifted off the bed! “Uh, resume compressions!” my resident ordered.

Shortly after this point, the cardiologist showed up. His first question was how long we’d been coding the patient. Thirty minutes. “Have you thought about calling the code?” was his second question! When we explained what had happened, the cardiologist tried a couple shocks with the manual paddles (like you see on TV) rather than the sticker pads. Maybe the cardiologist believed the extra pressure would do some good….maybe he did it just for style points.

In the meantime, both of the patient’s arms were rising. Given that the unfortunate guy didn’t have a perfusing rhythm, the cardiologist informed us he was simply “posturing”, that is, having involuntary muscular reflexes. We decided to try one last shock and one last amiodarone bolus. (Even though one amiodarone bolus is usually sufficient, this would be this patient’s third.) Wouldn’t you know, that did the trick! He had a pulse and a blood pressure after a grueling 45-minute code. We wheeled him to the ICU (rather than discharge him, as the primary team had been planning to do that day) and let the specialists take over from there.

As if that weren’t enough about this remarkable code, the story doesn’t end there…by the following afternoon, the patient was ready to be extubated! Evidently he’s had full–and rapid–recovery with no neurological deficits after being dead for the better part of an hour!

I also learned a lesson about napping. Right after I’d intubated the patient, my resident turned to me and asked, “Jonathan, were you asleep in the call room? There’s a line on your face!” (The lesson is to sleep on my back during my daytime naps.)


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Christmas gift exchange

Dad Wish List

  • Pedometer

Mom Wish List

Jonathan Wish List

Charity Wish List

Charity Stocking Stuffer

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What I learned from my mother

Another significant part of the week was the theme of death and loss which emerged in many instances. In grand rounds this morning, one of the assistant program directors–Dr S–gave a “Tribute to a Teacher,” which was dedicated to a rather unusual, complex, and challenging patient with Marfan’s Syndrome among a host of other problems. Her many phsyicians (including residents who helped admit her to the hospital 24 times over the last few years) often found themselves mired in frustration. This patient died rather suddenly and unexpectedly not too long ago.

The time since has allowed Dr S a period of reflection. Her tribute was warm-hearted and even sentimental, which contrasted sharply with the frustration I knew many felt with this patient. However, at the end, she reminded us what our job as physicians really was: to take care of patients both in health and as they die. Dr S asked herself regarding this diffcult patient, “Did I inquire into her faith journey? Did I ask her about her biggest fears? Did I let her know that I understood her fears?”

This reminds me of a relatively young patient I’ve taken care of recently (see link) who is now at home on hospice care. I felt the urgency and gravity of somehow meeting more needs of this patient than simply managing hypertension and arranging for hospice care. Much time I spent with the family as they hung tenaciously to hope and faith. And yet I had the feeling that there was something I wasn’t facing head on. This was it. I think I was afraid to delve into acknowledging this woman’s fears. It’s one thing to pray with her for grace and peace; perhaps it’s another to open myself up to sharing in her fears. The least I could do is acknowledge them.

And this is why a poem I ran across this week stood out to me. It is written by Julia Kasdorf, and its title is “What I Learned from My Mother.”

I learned from my mother how to love
the living, to have plenty of vases on hand
in case you have to rush to the hospital
with peonies cut from the lawn, black ants
still stuck to the buds. I learned to save jars
large enough to hold fruit salad for a whole
grieving household, to cube home-canned pears
and peaches, to slice through maroon grape skins
and flick out the sexual seeds with a knife point.
I learned to attend viewings even if I didn’t know
the deceased, to press the moist hands
of the living, to look in their eyes and offer
sympathy, as though I understood loss even then.
I learned that whatever we say means nothing,
what anyone will remember is that we came.
I learned to believe I had the power to ease
awful pains materially like an angel.
Like a doctor, I learned to create
from another’s suffering my own usefulness, and once
you know how to do this, you can never refuse.
To every house you enter, you must offer
healing: a chocolate cake you baked yourself,
the blessing of your voice, your chaste touch.

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Skyscrapers and menus

Sometimes I feel like I’m enjoying life too much to be in internship…this week is one of those times. Last night found me winding through the terminal of the local airport, crowed by holiday travelers. Soon I found friends Phil and Kathleen at their baggage claim; they were on their way back to Texas from interviews in North Carolina.

The night was cool and drizzly, but we were greeted by a warm apartment back at my place. Dan and Kristen joined the three of us for dinner, which I had fun planning.

And where do skyscrapers come in? I’d stopped and browsed at the bookstore on Saturday, where I spent twenty minutes purusing a book about architecture. One trend in the mid-to-late twentieth century was to define the base, mid-portion, and top of these giant structures. (It seems many earlier structures did just so, but then the box-like skyscraper emerged in the fifties.) I had fun patterning the menu after these skyscrapers, with a different drink for each segment.


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New York City strike

See article. This irritates me on a number of levels. Most of all is the fact that the union decided to shut down the daily public transportation for seven million people after they rejected a compromise offered by the MTA, and they did so in flagrant disregard for the law and a recent judicial injunction.

Now, I’m sure there are two sides to every story, but the union’s demands must be put into context. 1. MTA has already offered raises that are above the rate of inflation. The union wants even bigger yearly raises. 2. The union workers get paid more than resident physicians in NYC. Something’s wrong when the bus driver, who makes more than a doctor, is on strike for more money.

And why am I posting at 4:45 in the morning? Let’s just say my irritation extends to my own work. I’m seeing ever more clearly how patients themselves get in the way of my taking care of them. My ICU transfer in the middle of the night: “I don’t want a catheter!” “I don’t want to stay in bed!” “I want to go home!” “I’m really starting to get worked up!”

To this last comment, I was pleased with my off-the-cuff reply: “Well you should be worked up! This abnormal heart rhythm can kill you! That’s why we moved you here to the unit.”

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Good photo

I recently discovered my friend Melissa’s blog. She’s working as a midwife in the Philippines. Here’s a photo I stole from her most recent post…


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