Monthly Archives: June 2008

Concert in the Park

Last week I got to visit Central Park with several friends to hear the New York Philharmonic perform on the Great Lawn in Central Park.  The orchestra, as is its habit, is playing in a park in each of the five boroughs this summer.  Despite a light rain earlier in the day, the weather was absolutely perfect.  The temperature, with resolute balance, could not be accused of being either warm or cool.  A light breeze swished through the leaves as people gathered a couple hours before the concert, and the growing crowd soaked up the late afternoon sunshine on picnic blankets spread with cheeses, wine, and berries.  At least, that was what was on my neighbors’ blanket.  I’d had a quick peanut butter sandwich before leaving the apartment, so all I brought was an orange and some water.  Who likes cheese and berries anyway?

In the festive atmosphere, the music (a Mendelssohn symphony) seemed more of an afterthought, the icing on the cake of a city-wide picnic on an early summer’s evening.  Cocooned Swadled in a perfectly air-conditioned concert hall with tree trunks for columns and a sweeping canopy of deep blue, and bathed in the refreshing after-rain scent, our bare feet burrowed in the soft leafy carpet, we rested in the pulsing green heart of the island-city of Manhattan.

Here’s a view looking north toward the stage.  This picture reminds me of last year’s movie, August Rush, which has a pivotal scene of the New York Philharmonic performing in Central Park.

This photo gvies a better sense of the crowds.  This was about one-third of the way back.  As the time drew closer to eight o’clock, the seated crowd grew so thick that it was difficult to walk between picnic blankets.

This picture is taken from the same spot as the second picture, only it’s looking south toward the back of the “concert hall.”  One can easily see the buildings facing the park along Central Park South, nearly a mile and a half away.

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Guilty pleasures

I had an epiphany of sorts on the train today.  I was riding in relative peace–as much as was possible wedged between two strangers in a car whose air-conditioning was a bit like a gentle breeze in Death Valley–when a nearby two-year-old began to cry.  This was no “I’m scared” cry, or “I’m hurt” cry.  No, it was an angry cry, one whose screeching pitch rose and fell like the tides, one whose tantrums crested with piercing squeals as the child arched his back and kicked his legs in convulsive fits.

A pleasant middle-aged black man riding across from me smiled at the struggling father and asked, “How old is he?  Two?”  The father nodded.  In that moment, I could think of no other age that so deserved the modifier “terrible.”

In fact, the cries brought me back to my time doing pediatric anesthesia.  For those rare children whose parents refused oral premedication on their behalf, a trip to the operating room may have well been like checking into a nice stay at Abu Ghraib.  And for these children–a particulary wiry and surprisingly strong eight-year-old getting a questionably medically necessary circumcision comes to mind–gently inducing anesthesia was a two-, or sometimes three-man job.  More than once, I’ve stood behind a child who sat on the operating room table facing his mother and wrapped my boa-long arms around his body, pinning his arms to his side, while the attending held the cherry-flavored mask to the little head which was frantically flinging itself left to right, left to right.  With every deep, visceral shriek, I could just imagine the little molecules of sevoflurane being whisked from lung to capillary to heart to brain.  No child can withstand a compelling inhalational induction of anesthesia.  Grisly, but strangly satisfying.

And so it was, as the cries brought me back to the rattling subway car, I slowly opened my bag and pulled out the pink bubble-gum mask.  The father, seeing this, grimly nodded and handed the child to me.  His dark, confused eyes surveyed the new face before him while his shallow panting afforded our ears a brief reprieve before the fierce wailing resumed, the back arched, the little fists pounding against the orange plastic seats.  As I pressed the mask against the child’s face, the sobs became muffled and shorter, and then, eyes rolling back, blessed, quiet sleep came.  I handed the little one back to his father as the subway ground to a stop and the doors opened.  A last glance at the car before exiting showed every beaming face raised, every mouth upturned in a thankful smile.

Okay, so I made up that last paragraph.  But oh, what I would have given to knock that little kid out (anesthetically, of course).  It was startling, though, to realize that I wouldn’t have done it only for the sake of my hearing.  No, when those situations arise–not that I would ever choose to be in them–there’s also some element of primative power struggle, and it’s gratifying to win…even against a two-year-old.

Addendum–ethical analysis

In my defense, I don’t believe I’m a horrible doctor and a horrible person.  Just reflective.  The same essay could probably be written about law-enforcers, or CEOs, or even a flight attendant dealing with an unruly passenger…  With many (most?) jobs, there’s a difference in power, and when individuals’ goals are in conflict, that power advantage–be it physical, mental, social, or rhetorical–can be, shall we say, compelling.  The intentions and the circumstances may determine the moral and social acceptability.  Anyone remember Rodney King?

What I realized is that unpleasant as it is to put a fighting child to sleep (“Disgusting,” I remember my attending muttering after the aforementioned eight-year-old was anesthetized, referring to our brute force, not the child’s lack of cooperation), it’s generally regarded as necessary in some circumstances, and it accomplishes a greater good, so it’s okay.  But if I’m honest, I have to say that a primitive part of me actually finds it satisfying.

Obviously, the hypothetical scenario I described on the subway would have been a display of power not out of necessity or because it was accomplishing a greater good for the child, but simply because it would have given our ears a rest from the painful cries.  The epiphany was that I would have definitely enjoyed putting that child to sleep for the good of everyone on the subway.  Clearly this is ethically indefensible, and so those motivations were filed away to some hidden part of the consciousness, and I continued reading my magazine in a socially acceptable manner as other nearby riders rolled their eyes and the wheels continued clicking along the steel rails.

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Final Jeopardy

In lieu of grand rounds this morning, we held our annual Jeopardy contest which pits the somewhat aggressive attendings (and CRNAs) against a coterie of anesthesiology residents.  The attendings were the defending champions.

The anesthesia trivia came fast and furious.  Julia, one our our chiefs, was our team captain, and she did a great job being nimble with the buzzer.  Our star team member was Al, who, if not known for his reticence, is encyclopedic in his knowledge of trivia, both useful and otiose.  Our strong performance in the first round elicited a rather whiny jeremiad from the attendings which addressed the faulty score-keeping, the glare on the screen, and the inequality of the buzzers.

The faculty came back strong during Double Jeopardy.  My only contribution in this round was the confident pronouncement, “Who is Sir Christopher Wren?” to question the anwer, “This person took time off from designing Saint Paul’s Cathedral to experiment with intravenous injections in dogs.”

After being neck in neck, we pulled ahead at the end and led by a couple thousand points.  A strong lead, but by no means indomintable coming into Final Jeopardy.

Both teams made their wagers, and then the prompt appeared, “This year Virginia Apgar published her APGAR scale for neonate evaluation, and Watson and Crick published their evidence for the double-helical structure of DNA.”  In a move meant at least partly for intimidation, I instantly jumped up and whispered in Julia’s ear.  She nodded, wrote down our question, and submitted it.  The attendings, meanwhile, deliberated for a couple minutes before turning in their question.

“1952…wrong,” read the moderator. “The attendings lose 3000 points.”  And then, to my relief, 1953 turned out to be correct.  Thank you, college genetics professor who made us read The Double Helix!

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Pain and palliation

Today was a rewarding day.  I was called by a primary care team to assist with the care of a 25 year-old girl who is dying of cancer.  This was a situation that, as unfortunate as it was, had been made more complicated by growing distrust on the part of the family.  As the resident told me her story, he mentioned that the patient was being seen by the Palliative Care Service.  This was unusual, since the same pain specialist oversees both the Palliative Care Service and the Chronic Pain Service.

I agreed to come, not as a formal pain consultant (since my boss was already technically on the case), but as someone that might visit with the family and offer another perspective.  This was mainly a psycho-social consultation.  I did meet briefly with the patient, but spent most of my time in the family room with the father, the rabbi, and the primary care physician.  When I arrived, they were on the verge of signing Do Not Resuscitate/Do Not Intubate orders, and the father wanted to make sure that in spite of signing the paperwork, the family would still have a voice in the medical care.

This, of course, was easy.  I assured him that these measures simply meant we would not take aggressive measures to unnaturally prolong his daughter’s life.    They absolutely would not change the quality or quantity of their interaction with their physicians.

I spent the next thirty minutes asking about their goals and expectations, listening to their fears and frustrations, and assuring them that we would in no way abandon them in the face of the daughter’s rapidly deteriorating health.  I say “them” because in this case, my role of physician seemed to explicitly extend to include the patient, her parents, and the rabbi.  We clearly definited several goals: comfort & pain control, avoiding sedation, tolerating oral medications, being able to go home.

Tangibly, I was rewarded by being able to accomplish what the primary team and the regular Palliative Care Team had been unable to do, that is, to adjust the pain regimen that might facilitate comfort and be a step closer to home.  I attribute this not to any special skill, but to being willing to take the time to build a “therapeutic alliance” which involved the family’s trusting me that I had no interest in pushing the patient out of the hospital.  I clearly expressed that in the setting of rapidly progressing cancer, avoiding sedation might conflict directly with comfort, but that we would do everything possible to accomplish both.

Practically, this meant increasing the transdermal fentanyl dose, changing the intravenous pain medicine to avoid some untoward side effects, and supplying some potent non-intravenous medications as a trial run for out-of-hospital care.

But I felt most satisfied when I rose at the end of the conversation and the father and the rabbi both stood and eagerly shook my hand and, with damp eyes and choked voices, emphatically thanked me.  Here I was, telling them that yes, the daughter was dying, and that I could keep her comfortable but maybe not awake and she may never leave the hospital, and they were thanking me.  That’s ironic.  But I also told them that I would walk with them, that I wouldn’t abandon them, that I cared about what was important to them, and that I understood them; and they responded to that.  It was here, in practicing the art of medicine, that I connected with the family’s experience at the same time that I connected with physicians who, through the millenia millennia, have eased suffering and done no harm.  And that made my day.

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…stays in Roosevelt Island

To send Clay off (again) to China with his Sound of Music tour, Mauricio, Mavis, and I decided to celebrate with another trip to Roosevelt Island.

Our original plan was to meet at Columbus Circle at 1133, disguised in sunglasses and scarves, complete with password.  However, to be more practical, this plan was modified to simply convene at the tramway at 3rd Avenue and 60th Street.

Clay, Mauricio, and I were coming from Morningside Heights.  Mauricio instructed Clay and me to leave the apartment promptly at 1330, walk to the 125th Street station, and get on the first subway that comes, third car, middle door.  Mauricio would leave the lab at 1330, walk to the 116th Street station, and wait for the subway at the middle door of the third car.  (Strangely, this is typical for New York City.) Clay suggested that we could just walk to 116th Street and meet Mauricio there.  “No, that’s too easy!” Mauricio replied.

Boarding the tram

The four of us rode the tramway over to the island.  This time we were pros and had quarters ready to board the bus that took us up Main Street.  As Main Street seemed to be the only street on Roosevelt Island, we mused that maybe it should just be called “Street.”

Clay appears sinisterly delighted that we’ve arrived.

We dined once again at Trelli’s.  The restaurant features an absurdly expansive menu, featuring everything from sandwiches, burgers, and salads to pasta, chicken or fish entrees, and steak.  We had…

  • Mavis: Grilled chicken salad with roasted peppers.
  • Clay: Quiche with side salad.
  • Mauricio: Chicken topped with fruit and a couple sides.
  • Jonathan: Philly cheese steak sandwich with onion rings.

We split some German chocolate cake and ice cream for dessert, along with coffee.  Afterward we walked along the East River (not a river; actually a tidal strait) and admired the Manhattan skyline.  (n.b., Roosevelt Island, though distinct from Manhattan Island, is part of the borough of Manhattan.)

Manhattan skyline with the Queensboro Bridge

Strange sculptures in the water

Pondering the strange sculptures

Ready to go home

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Beware, the interns have arrived…

The last couple nights on pain night float have been complicated by the fact that the new interns have apparently begun taking call.  It doesn’t seem like that long ago I was beginning internship, but it’s already been three years.

As I look back at some of the earlier entries in this blog, I see some rather indignant posts describing my calling consultants who seemed to think we hadn’t done an appropriate work-up.  Even last year, I remember calling a cardiology consult for a stat echocardiogram in the ICU for a crumping patient (because the fellow wanted one), and the cardiology fellow was still a jerk about it.

Alas, I am now that consultant.  Last night found me returning a page from an intern who told me that his patient with a thoracic epidural catheter was having pain.  This was a very reasonable consult, but the intern couldn’t tell me much about the patient’s medical history, couldn’t give me more details about the patient’s pain, couldn’t tell me where the catheter was, how deeply it was placed, which medicine was being infused through it, and at which rate.  He stammered, “This is my first night on cardiothoracic, and I’m just cross-covering that patient.”

I responded, “You are that patient’s primary physician for the night, and you should know more about the patient than anyone else in the hospital.  You should know all these things before you call a consultant.  I wouldn’t dream of calling a cardiology consult if I couldn’t recite a brief history, and if I didn’t know what the last troponin was and what the EKG showed.”  Of course, I said it all in a nice–but firm–tone of voice, and the chastened intern apologized to me when I showed up on the floor.  I told him I wasn’t upset, but that it was important for him to learn sooner rather than later how to appropriately ask for help from a consultant.

This morning I received yet another page.  “This patient had back surgery and is having pain.  Could you come write a PCA?”  Again, I asked for more details, and at first the intern couldn’t tell me the patient’s medical record number, when the surgery was, and what pain regimen the patient was on.  For him, I simply said, “It sounds to me you know very little about this patient.  Please go look up the information and then you can call me back.”

In this case, I was busy and I didn’t have time to wait while the intern looked up every detail I asked for.  Sure, I could easily look up all the information, but it’s inappropriate not to be able to tell a consultant pertinent details.  I felt like this intern just hadn’t really bothered, and that conveyed the message that he felt like his time was more valuable than mine.

Ironically, I’m sure he did have a lot more than me I to do that morning, but I think he still got the idea that he needs to know his patient before calling the consultant.  I think of it as tough love.  You can’t coddle these interns who just spent the last six months skipping through an easy end to fourth year and being told how bright they are.  Better to work hard and to be prepared than to be bright.

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A call in the night

My pager went off at 0030 the other night.  I’d just fallen asleep thirty minutes earlier, so I was rather disoriented when the team captain told me they’d need my help in the pediatric hospital.  As the pain night float resident, I’m also back-up for the adult hospital, pediatric hospital, and labor & delivery floor.  On a good night, I’m not called to any of those services.

I stumbled downstairs and over to the pediatric OR desk.  The attending and fellow were already there; the fellow was going to start a heart transplant.  My case was a child who’d ingested a foreign body.  In common speak, the kid had swollowed a penny.

This x-ray is a similar one I found on the internet.  The penny is oriented side to side (i.e., in the coronal plane) because it’s in the esophagus, pressed against the flat tissue of the neighboring trachea.  If the coin were in the airway, it would usually be rotated 90 degrees, in the sagittal plane.  In the real x-rays, the coin was much higher, in a place where it could potentially flip forward and obstruct the larynx, leading to acute respiratory failure and imminent death unless immediate action were taken.  In a panic, we threw up our hands and ran around the stretcher a few times, screaming as we went.

And then, without too much fanfare, we took the kid to the operating room, preoxygenated him after putting on monitors, and put him to sleep with intravenous medication.  I had some Magill forceps handy in case I saw the coin when I intubated.  It was nowhere in sight, so the surgery fellow took a look with his rigid bronchocope and nabbed the coin with little grabbers.  That was it.  We woke up the child, extubated, and brought him to the recovery room.

I helped out a bit with the heart transplant which was just getting off the ground, but was back in bed by 0230, having done an interesting case and now looking forward to a few hours of sleep.

Below is an x-ray of a sword-swollower, just for fun.

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