Monthly Archives: July 2006

My guest book

I have one now. With many friends promising to come visit me in New York City, I thought it would be fun to keep track of my visitors, and also to gve them a chance to write me a thoughtful, meaningful note in exchange for my warm and gracious hospitality.

My first visitor was my own brother, who was in town for only a couple days. The first evening we had dinner at the Boat Basin on Manhattan’s Upper West Side. This is a seasonal restaurant situated beneath a solidly constructed roundabout and looks out over the Hudson River.

David’s friend Justin, who studies at the Jewish Theological Seminary, joined us, and Carrie met us briefly to deliver a wedding present back to Texas for me.

My second and third visitors were my good friends from college, Emily, and her husband Seth. They live in Maryland where Emily works with the Princeton Rev…wait, no, Kaplan, and Seth coaches football & track as well as teaches biology. I met them in the West Village and planned to ride with them directly to my house where I had a brined chicken* roasting in the oven. However, my plans for a quick trip to my apartment and my intentions to demonstrate my subway prowess disintegrated when the E train didn’t take the route I thought it should! We still had fun catching up & visiting on the subway, and Seth even reminded me of the distinction between xylem and phloem.

The chicken was nearly done when we arrived, which we ate alongside arugula & gruyere salad and steamed broccoli. (I need not mention the appetizer plate of smoked gouda, white cheddar, dried apricots, and walnuts in this post, as that would be needless detail.)

Regrettably I forgot to take a picture with Seth and Emily, but I did get a chance to show them nearby Fort Tryon Park just as twilight was easing over the river. Here are a couple pictures of the area during daylight.

* Stuffed, naturally, with carrots, onion, and celery.

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A trip to the market

After a couple days which were good, but with a few harrowing moments, I was pleasantly surpised to find my operating room finished at 2:30 with no cases to follow. I ran upstairs and saw my two patients from the day before. Back at the anesthesia office, the list for tomorrow had already come out. One case was assigned to me: a healthy elective donor partial hepatectomy. (A young patient giving part of his liver to a relative in need.) Because the patient was only 27, he had no real medical problems that I could find in the computer. Thus, by 3:15, I found myself on the streets of New York.

I have a distant cousin, Johanna, who lives in Brooklyn but works in Manhattan at Union Square. We made an impromptu appointment, and finally met for the first time 40 minutes later after an express subway ride and a transfer at Times Square.

It was a great New York summer afternoon with sunny skies and temperatures in the 80’s. Johanna and I got smoothies and got to know each other sitting on a park bench overlooking the famous farmers’ market. Children played nearby, and the square was a beehive of outdoor activity.

After Johanna returned to work, I picked up some fresh, organic zucchini, peppers, and red onions. And then I saw the peaches! Samples were set out–beautiful, moist, succulent, sweet, sticky-juice-dripping-down-your-chin-but-you-don’t-care-these-things-are-so-good good! I got four which should ripen nicely over the next few days.

I finished the evening by exercising, running in the park, showering, and making a big pot of zucchini soup with the above ingredients (sans peaches), cheese, and cream. Ate dinner while watching an episode of Lost on DVD (I’m diligently working through the first season) and went to bed at 9:30.


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Atropine, please!

On one of the last days I worked with Dr J, we had a couple cardiac cases–revision of a defibrillator, and a permanent pacemaker insertion. The first case went smoothly, and as was his habit, Dr J left me in the room alone for long stretches of time.

Between cases, I wrote post-op (post-op = after the operation) orders for the first patient, gave report to the nurse, returned unused medicines to the pharmacy, got new drugs for the next case, and interviewed & examined the next patient. He was an inpatient so he had an IV already.

At this point I called Dr J to let him know I was ready to bring the patient back to the OR. “Oh, I thought you were in the OR already,” he replied. He instructed me to go ahead to the OR. He would see the patient later.

In the OR, I attached a slew of monitors to the patient: pulse oximetry probe, EKG leads, blood pressure cuff. I realized his IV wasn’t running, so I started a new one. I arranged my medicines, and had my airway equipment ready in case the need to intubate were to arise.

And then I waited. The surgery resident was fiddling with a fluoroscopy (real-time x-ray) machine. I waited…and waited. At last, some covert signal was given that the surgeons were ready to proceed. The nurse began cleaning the patient’s skin. I realized that a little Versed would be nice to relax the patient, but I didn’t want to give it without my attending’s having seen the patient. So I paged him. “Oh, I thought you guys had started already,” he said. “You’ve done this before; go ahead and do your thing!” 2mg of Versed and 100mcg of fentanyl later, we were on our way. I was still flying solo.

Well, there are things I hadn’t yet learned about pacemaker insertions. One is that the surgeon or cardiologist induces ventricular tachycardia (or “v.tach,” a fatal heart rhythm) during the procedure. For this reason, the patient had defibrillator pads on. Still, I felt more than a tad uneasy when wavy lines began appearing on my EKG monitor! They quickly resolved, however, and since the surgeons were expecting the v. tach, I figured that was a normal part of the procedure.

Soon thereafter, however, the patient’s heart rate began to slow. He was having the pacemaker put in for an abnormal rhythm called third-degree heart block, in which the chambers of the heart are totally out of synch; however recently he’d been a very benign rhythm called first-degree heart block. Well, not long after the v.tach, the patient converted from first-degree to third-degree heart block. His heart rate slowed from the 70’s to the 60’s…50’s…40’s…high 30’s… My attending still had never met the patient. I thought, “Oh, maybe the surgeons expected this too.”

However, a glance over the drapes* confirmed otherwise. I sensed a feeling of uneasiness as the surgery attending muttered how the pacemaker wasn’t “capturing.” Without going into the details of cardiac brady-arrhythmias, let’s just say that the surgeon’s weren’t in control of the situation, and I certainly wasn’t! And I learned later that the process of placing the pacemaker is likely what converted the patient back into third-degree heart block.

I quickly cycled the blood pressure cuff to see how the patient’s pressures were holding up (they were fine despite the slow heart rate), and reached for the atropine with one hand and quickly paged my attending with the other.

The story doesn’t have a good ending…and I use good in the sense of exciting. Dr J arrived. The patient remained hemodynamically stable (maintaining a normal blood pressure). And the pacemaker began to capture the patient’s heart rate, meaning we could control how fast it beat. Disaster averted.

Although there were no valiant, heroic efforts on my part, this experience was remarkable for a number of reasons…

  1. It reinforced a proper fear (respect, need for vigilance) for the delicacy of human physiology when it’s subjected to the insult of surgical intervention compounded by anesthetic poisons.
  2. It forced me to realize I shouldn’t be afraid to use my “emergency drugs” in emergency situations! This sort of scenario is exactly the reason why I have atropine drawn up every day. Being in denial doesn’t change the gravity of a situation…except, perhaps, to worsen it.
  3. It prompted me to be proactive in being ready for emergencies. In the two weeks that have elapsed since this case, I’ve walked through similar scenarios tens of times in my mind as I sit in cases. The imaginary ending, glamorous as it may be, usually has my giving exactly the right medicine, in exactly the right dose at exactly the right time; or instructing the surgeons to step back while I throw back the drapes to begin compressions and hand-ventilating the patient. Glamour aside, this is useful practice to anticipate things that could go wrong and how to react.
  4. It reminded me that it’s always better to err on the side of calling back-up when it’s not needed, rather than not calling when it is needed. I have a low threshold these days of deciding a situation is beyond my expertise. And at a month into anesthesiology training (I’m finishing writing this post on Aug 2), I think most people would agree!

*Drapes. See comments on the July 15th entry. Drapes commonly serve as a physical and psychological barrier between the anesthesiologist and the surgeon.


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My first two weeks

I’ve already heard some cynicism (thank you, M.G.) about my ability to post regularly! And I admit the posts have slowed down a bit, but I’ll do my best to give at least weekly updates.

My first two weeks as an anesthesia resident (I feel it’s a bit premature to say, “…as an anesthesiologist…”, though I am one who studies anesthesia) were good. I worked with one attending anesthesiologist who I’ve mentioned before, Dr J. Dr J (not to be confused with is a cardiac anesthesiologist who is regarded by several of the residents as “the smartest person I know.” He also tends to do several of the “celebrity cases” at this hospital.

Dr J is also one of the funniest people I’ve worked with! I laughed a lot during the first two weeks. However, his dry sense of humor meant that sometimes I didn’t know if he was serious or joking (what people often say about me). This is a little problematic when he says, “Why you touchin’ that dial?” He’s either serious that I shouldn’t turn it, or just making me justify why I want to turn it.

I feel fortunate that there wasn’t too much excitement my first ten work days. The first day was the most stressful as I was learning how to enter passwords, where to file paperwork, how to give report to nurses, where to get drugs. My first two cases at this hospital were insertions of inflatable penile implants. (!)

My attending was also very laid-back. He left me in the room alone for long stretches, whereas other attendings kept hawkish watch over their first-year anesthesia residents. During one such time–in the middle of one of the penile implant cases done under spinal anesthesia–a CRNA came in my room to see if there’s anything I needed. Around this time, the patient began to “wake up” a bit. This wasn’t a problem since he had spinal anesthesia–he shouldn’t have pain–but people can be a bit disoriented. I reached for the propofol infusion…adjusting the rate upward should put him back to sleep nicely. Unfortunately, at that moment, the patient’s hand flew up, pulling out his only IV! He became more and more restless by the second, and I stood there paralyzed by fear realizing the patient was waking up during the surgery, and I had no IV access to put him back to sleep!

My hero of the day was the CRNA who quickly gathered IV equipment, pulled back some of the drapes, and deftly started the IV, through which we bolused a little propofol. Normalcy quickly returned.

Lessons learned

  • It never hurts to have an extra IV
  • Have a cool head so that I can start an IV in the middle of a stressful situation
  • Appreciate CRNA backup!


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My bridge

So I’ve been doing some regular running lately, and it seems that every time I’m irresistably drawn to the George Washington Bridge. Although newer and not as famous as the Brooklyn Bridge, this magnificent structure has become a favorite part of my neighborhood. In fact, now that I’ve run across it several times, I feel I can almost claim ownership. Since taking photos on the bridge is not allowed in this Post-9/11 age, I hunted down a few on the web.

The interesting structure leads to fabulous viewes & perspectives. Four enormous cables (each 36 inches in diameter and comprising almost 30,000 wires) support the roadway. The running/biking bath lies on the north side of the bridge between these two support cables. Eight lanes of traffic cross the bridge on the upper deck, meaning the bridge is more than 100 feet wide!

At dusk, understated lighting effects appear along the road and the support cables. Unlike in the picture, however, the towers aren’t lit regularly anymore.

26 December 2000 by Nell Dillon-Ermers

Construction on the George Washington Bridge began in 1927, and it opened to traffic in 1931. It has two decks (which can be appreciated in the picture below), giving a total of fourteen lanes of traffic. It’s one of the busiest bridges in the world with more than 150,000 crossings daily.

26 December 2000 by Nell Dillon-Ermers

In this picture (below) we see the Manhattan side of the bridge. The bridge is exactly 0.9 miles long from anchor to anchor. The towers are 600 feet tall (the height of a respectable skyscraper!), and the road is more than 200 feet above the Hudson River. In the distance to the right of the three nearly identical buildings is the Columbia-Presbyterian Medical Center.


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Independence Day

The day started off low-key with some house-cleaning and a run across the George Washington Bridge. I’d never thought of the Hudson River as a major river, but it’s nearly a mile in width and impressive to see how it dwarfs gigantic barges floating far below the bridge.

I spent the better part of the afternoon studying at a coffee shop in Greenwich Village, and then met up with a couple new anesthesia friends, David & Jessica, for dinner at a restaurant on Union Square. An afternoon shower had cooled the air, so we dined outdoors under large yellow striped umbrellas, looking out over the square famous for its produce market. Since I live and work in Washington Heights (but plan to buy monthly subway passes), I’d like to make a regular effort to spend time in other parts of the city.

After dinner, we joined the throngs migrating east across Manhattan. Tens of thousands were watching the fire-works show over the East River. There was of course a strong police presence (this the first time that the reality of terrorism flitted into my consciousness…being in the middle of crowds in New York on Independence Day.) I was amused by the police check-points where we were stopped and asked where we were going. “To 32nd Street to watch the fireworks,” seemed to get us through the checkpoints.

The show was pretty good, but later in the evening I ran into another anesthesia resident in the Times Square station who had some fortunate connections and had watched the show at a garden party at the United Nations. Sound like his view was far better than ours, as we stood in the southbound lanes of the FDR.

Getting home on the trains of course felt like rush hour. And at this point, I’d like to offer a few words to the gentleman entering the far left turnstile, 42nd Street station, southeast corner, at approximately 10:30 PM July 4, 2006….

How strange that we both wound up at the same turnstile–me exiting halfway through after waiting on five people to exit and then seeing a break; you poised to swipe your MetroCard. I apologize for not realizing sooner that when you put your hand on my chest and blocked my path as I was half-way through the turnstile exiting the station, that it was a signal you wanted to enter before I exited.

I regret not reading your aggressive body language sooner. Your corpulence may have obscured some of the subtleties. However, I do appreciate the freely offered corrective etiquette tips with regard to my rudeness.

And when you actually began pushing me, I really wish I could have been more clear that the turnstile only works one direction. Simply to say, “Sir, this turnstile will not go the other way–you have to let me out this way,” is a bit ambiguous. And silly me for repeating it a couple more times, rather than finding a way out over, under, or through the turnstile.

I’m sorry this encounter slowed you down. You seemed to be in a hurry, and that thirty-second wait as we stood in a deadlock was rather excessive.

And as I told you the other night, I really didn’t see you coming (all I saw was the break in the flow). But you know what, if I had to do it all over again, I’d do the EXACT SAME THING! Good night, sir, and happy Independence Day!


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Backtracking II

More pictures…

Dave and me at Louisa’s house in Cleveland.

Uncle Paul & Aunt Betty’s house in Philadelphia. They’ve lived in this small home for the last fifty-five years!

Uncle Paul & Aunt Betty’s small flower garden and compost pile in the back-yard.

Approaching Manhattan. The rain slowed down enough in the afternoon for us to unload the van. The G. Washington Br(idge) on the roadsign is the closest bridge to my house and the only bridge on the west side of Manhattan. More fun facts to come!

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