Columbia^2

Yesterday found me walking home at 0730 in the frosty sunshine of a cold December day. I had finished a laparoscopic appendectomy around 0130, and wasn’t called again after that.

My lazy morning consisted of a nap on the couch, an episode of Frasier, and a bowel of oat bran with honey and raisins, not necessarily in that order.

My main goal for the day was to purchase a couple “Angel Tree” gifts for two kids whose fathers are are in prison. When selecting my “angels”, I’d steered clear of the kids asking for an MP3 player. For one, an MP3 player is hard to find when one tries to stay within the $20 limits. And when I saw a couple other children asking for a warm coat and long underwear, those were hard to pass up.

I thought Target would be a good place to find such items. Unfortunately their paltry kids’ clothing section meant I would soon wander next door to Marshall’s after an unsuccessful hunt. The girls’ underwear section of the store was a new and strange place for me; I can’t say I felt entirely comfortable there.

Alas, Marshall’s did not have long underwear, either. In a bind since this was the only day I could really get shopping done before Sunday, I settled on a set of feminine blue flannel pajamas (Liz Claiborne; ordinarily $59, mine for $19.99). I hope the thirteen-year-old likes them. She gets some little gourmet chocolates too.

There was a large selection of boy’s coats, but surprisingly many had fake fur lining the hood. Is this a new trend? Polyester coats with fake fur? The boy is 9 and had asked for a black or navy coat. I found a black one for $20, but it seemed awfully thin. I pictured him trying to stay warm in the blustery New York winter as he gathered his flimsy coat around his thin body, and passed on it. It wouldn’t do.

And then I found it! Navy blue. Down lined. Rugged Columbia brand. It was perfect! There was even one the right size! Only it was $40. Reminded of The Office episode where Michael buys a $200 iPod for the $20 Secret Santa gift exchange and feeling slightly guilty, I bought the coat anyway. Can’t I buy a coat for a child at Christmas?

After that, it was coffee with William at Columbia, where the late afternoon sun slanted across the campus and shone radiantly on column and green copper-clad rooftop. Early morning and late afternoon sunlight is amazing. I sat in on William’s undergrad “Great Texts of Western Civilization” seminar where he led the discussion that evening on the Gospel of John.

I finished the day with the anesthesia department’s holiday party at an Irish pub close to the hospital. Good food, a lot of my new anesthesia friends, music that was too loud, and a glass of champagne…guess it was a success.

A few unconnected thoughts

The other day at church, I was impressed by two things. One was Reyn’s appropriate use of the word comprise. “Washington Heights comprises several ethnic groups,” is more or less what he said. A lesser speaker might have been tempted to say, “…is comprised of…”

Secondly, during a question and answer session, Clifford, a young man who can wear a bow tie and get away with it, rose to ask a question. There was something rather old-fashioned yet dignified in that simple gesture. And practical too–his voice projected easily without a microphone.

I like to preface adages with, “Grandmother always said…” even if it’s not something my grandmother always said. I guess I do it as a nod to past generations’ ideas of civility and respect. Clifford’s gesture fits the model:

• “Grandmother always said to rise when you ask a question.”
• “Grandmother always said to rise when a lady enters the room.”
• “Mother always taught me to write thank-you notes.”
• “Grandmother always said that if you haven’t accomplished half of your day’s goals by 10:00 AM, then you’re in danger of not accomplishing any of them.” (Actually, I think that one is from Wuthering Heights, but I always think of it on a lazy Saturday when I have a hard time doing anything productive before noon.)
• Any others from my readers?

And the other week, I was delighted to catch a verbal nuance when my friend William was talking about presenting a paper to some other grad students. He said–approximately– “My perspective is both originally and ultimately different from theirs.” He was speaking not of uniqueness or degree of difference, but rather was referring very precisely to the source of his ideas and their necessary conclusions. In a handful of words, he said that his ideas are different not simply in static nature, but in direction past and future. Without even trying, William is cool.

One final story. I laughed so hard I nearly cried when watching an episode from the first season of Frasier the other day. “It’s funny, sophisticated, and very white, Jonathan. You’d like it,” my friend Clint said of the show.

Frasier: “Well Niles, people can get set in their ways. Remember when you used to think that the 1812 Overture is a great piece of classical music?”
Niles: (dramatic pause) “Was I ever so young?”

"A place in Boston"

Have you ever noticed that when you meet someone who went to undergrad or law school or business school or medical school at Harvard University, and you ask that person where they went to school, the usual response is, “A place in Boston.”

Because this answer is so common, I’ve put some thought into it. At first blush, it seems to show a good deal of modesty. Folks at most other universities consider Harvard to be the pinnacle of education in the United States. Instead of announcing it to the world, these alumni show a bit of discretion.

On the other hand, perhaps it’s false modesty. “A place in Boston” certainly begs the question, “Which place in Boston?” Besides, it’s not even Boston. Harvard is in Cambridge, which, owing to the nominal connection to that renowned English university, might add an air of haughtiness. “Oh, a place in Cambridge.” Then again, “A place in Cambridge” could be MIT for that matter, but–sorry Louisa–we’re just not that impressed. So naming “Boston” rather than “Cambridge” or “Harvard” adds a sense of vagueness which could be argued to be dismissive.

In further support of my false modesty theory, I wonder what these people would say if they were talking to a known Stanford or Duke or Vanderbilt grad? Would they just go ahead and say “Harvard”? If so, does that mean they are simply shielding those of us who went to State U from encountering the devastating transcendence of belonging to such an alma mater? There’s nothing condescending about, “I went to Ohio State.” But, “Oh, a place in Boston”… Well, to that I say, “Sorry that I had no interest in majoring in gender studies, and–oh dear–I never signed up for the lacrosse club team, but really, it’s okay to tell me that you went to Harvard!”

On a different note, I recently read an article in The Economist about the financial strains of Oxford University. Most interesting was the bar graph which showed top university endowments from around the world. I wish I would take the effort to scan this, because the visual compilation of data is impressive. I’ll simply list the wealthiest universities and their respective estimated endowments (in British pounds, converted at $1.9 to 1 pound). Imagine the bar graph, if you will. Or plot it on a spreadsheet.

1. Harvard 13+ billion
2. Yale 8 billion
3. Stanford 6+ billion
4. University of Texas (!) 6 billion
5. Princeton 5.9 billion
6. MIT 3.5 billion
7. Cambridge 3.3 billion
8. Oxford 3 billion
9. University of California 2.7 billion
10. Columbia 2.7 billion

I was surprised that the University of Texas is so wealthy. Also surprised that the sum of the ancient giants’ endowments (Oxford and Cambridge) is barely more than Stanford’s or Princeton’s.

And one final thought; a corollary of sorts: Are all “Ivy Leaguers” created equal, or are there various levels of credibility to membership? In my mind, Harvard, Yale, and Princeton are the triumvirate of American university education. Then there are schools like Columbia and the University of Pennsylvania which, though venerable, just don’t quite have that zippy instant name recognition shared by the Massachusetts, Connecticut, and New Jersey institutions. And finally, those other Ivy League schools everyone has trouble remembering. Let’s see, Brown, and…I’m going to have to think…Dartmouth! Oh yeah, Cornell. Is that it?

Well, enough said this evening. Enough toes stepped on. Good night, and study hard!

420

Four hundred twenty. That’s the number you get if you multiply the age of one of my patients by the number of times I’ve seen her this week.

Mrs S is a 105-year-old who fractured her hip after a fall. I saw her Monday evening as part of my preoperative evaluation. Her blood on the day of surgery (Tuesday) was too thin, so she got some vitamin K intravenously, and a repeat lab showed her blood just barely met the threshhold for the surgeons to operate. (I still wasn’t happy about it; the case wasn’t emergent, and I didn’t think we should risk excess intraoperative bleeding when she wasn’t really optimized. I wasn’t happy about the I.V. vitamin K either. Strangely, this can rarely cause a life-threatening anaphylactic reaction, whereas intramuscular vitamin K is pretty safe. I warned the orthopedic resident to give it I.M., but the attending internist wanted I.V. (!) And so, for a non-emergent surgery, they stood by her bed and pushed I.V. vitamin K, ready to resuscitate her if needed.)

Anyway, the case was the last one of my day, and after we’d gotten her to sleep and I placed the breathing tube, I started off by sending off some baseline labs and pumping in four units of donor plasma to help her blood clot. By the time the fourth unit was in, I noticed there had been significant blood loss, so I sent another set of labs and started transfusing. (Good thing I didn’t wait for the labs to come back before transfusing; her blood count had dropped significantly.)

When it was all said and done, the orthopedic surgeons had lost nearly a liter of 105-year-old blood. However, we were able to get the patient breathing & extubate her before transferring her to the unit.

I saw her again yesterday for my post-op evaluation, and then again today since another patient of mine was in the same room. She is an adorable, if slightly demented, lady; and it’s amazing to think that she was a teenager during World War I. She was in her 60’s when JFK was shot. And Sept 11 happened in her 100th year of life.

The other thing that will stay with me about this case is how irritating I find some surgeons’ mindset. I feel like half of what I do is protect my patients from their surgeons. Especially in situations like this, where some rather unwise decisions were made.

Surgeons can sure be annyoying…

…like when they hurry me to get a patient into the room. One would think that it wouldn’t be too hard to figure out that if some patients’ surgeries take longer than others, then the preoperative assessment for some patients will take longer than others, especially those with congestive heart failure, coronary artery disease, cerebrovascular disease, hypertension, diabetes, multiple past surgeries, etc. And it should also be common sense that an add-on patient (a patient I find out about immediately before the surgery) will take longer to evaluate than one whom I’ve known about and have read about the night before.

Any good suggestions for responses to when surgeons complain about “turnover time” given the above? Maybe I should just point blank ask them, “Are you complaining that I took too long to evaluate this patient?”

Even worse is interruptions. This has got to stop. At least three times this last week, I was interrupted by surgery residents or attendings as I’m visiting with a patient. It seems the height of rudeness to break in and start speaking while a physician is evaluating a patient. I need to have a good line ready; maybe something as simple as, “Excuse me, you just interrupted me. Could you please wait for me to finish?”

The nurse in the recovery room, however, takes the cake. A patient for whom I was to provide monitored anesthesia care was tearful even as the I.V. was being put in by another nurse! As high-strung as she was, I tried to be reassuring. At the end of my preoperative assessment, she asked me, “Have you done this before?” I smiled and said, “Many, many times.”

As she was waking up from the sedation after the procedure, this patient kept saying in a cute groggy manner, “Thank you all so much for taking care of me! Thank you!” Then she looked at me and said she hoped I hadn’t been insulted. I asked her what for. She explained she felt bad for asking about my experience.

Before I could answer that if I were a patient I would certainly be interested in my anesthesiologist’s credentials, the recovery room nurse broke in, “It doesn’t matter. He just does anesthesia.”

Gems from The Economist, part 2

As I’ve said before, I love the writing in The Economist. Smart, witty, often quirky. Some examples follow.

From the Sept 30 issue in an article about Brazil’s presidential incumbent Lula, the writer notes some issues which now face the country. “Brazil’s dismal standard of public education suddenly seems intolerable, prompting the president to campaign on the clunky slogan ‘development with income distibution and quality in education’.”

And in same issue, the obituary for former Texas governor Ann Richards begins, “Not much about Texas is becoming or demure. The coast is muddy and malarial; the west, seen from the air, is an immense brown mat of desert; the centre is scrubland munched by cattle. The state’s history is one long tale of men imposing their wills on the landscape; and, much more rarely, of big-haired weather-beaten women imposing their wills on the men.”

From an Oct 7 article about the cool relationships between China, Japan, and the Koreas, “Most Chinese profess contempt for ‘little Japan’, and young people with no experience of the war often jeer more stridently than their parents. But few appear to let patriotism get in the way of shopping.”

The Economist editors know when to use forcible and when to use forceful. And they make abundant use of the comma, as seen in this sentence: “On October 3rd, as the five permanent members of the UN Security Council steeled themselves to think about imposing sanctions on Iran for failing to suspend its uranium-enrichment programme, the Iranians proposed, out of the blue, that one of the five, France, lead a consortium to enrich uranium on Iranian soil.”

And a final example of knowing eactly how to get a point across: “If the question is to secure the oil-rich Gulf against Iranian adventurism, insist America’s Arab friends, a good first step would be to deny Iran and its rejectionist allies moral traction, by doing something about the festering Palestinian issue.”

Gems from The Economist, part 1

I have a stack of 8 copies of The Economist beside my desk with dog-eared pages and circled quotations, saved, of course, for the blog. Without further ado…

From the Sept 9 issue, a leader entitled, “Welcome aboard.” This mock speech by a flight attendant reveals how airlines are often less than forthcoming with their fliers regarding airline safety.

It opens, “Good morning, ladies and gentlemen. We are delighted to welcome you aboard Veritas Airways, the airline that tells it like it is. Please ensure that your seat belt is fastened, your seat back is upright and your tray-table is stowed. At Veritas Airways, your safety is our first priority. Actually, that is not quite true: if it were, our seats would be rear-facing, like those in military aircraft, since they are safer in the event of an emergency landing.”

It continues in witty fashion, including, “Your life-jacket can be found under your seat, but please do not remove it now. In fact, do not bother to look for it at all. In the event of a landing on water, an unprecedented miracle will have occurred, because in the history of aviation the number of wide-bodied aircraft that have made successful landings on water is zero.”

The article concludes, “We appreciate that you have a choice of airlines and we thank you for choosing Veritas… Cabin crew, please make sure we have remembered to close the doors. Sorry, I mean: ‘Doors to automatic and cross-check.’ Thank you for flying Veritas.”

From the Sept 23 issue, a brief article about the hTAS2R38 gene in humans. What this means to you and me is that different people have different types of taste buds. The research seems to suggest that broccoli really does taste bad to some people, okay to others, and good to still others–including me.

The same issue continues the food theme with a snippet about meat grown in vats rather than on animals. This meat could avoid bacterial contamination and could also be modified to include healthy omega-3 fatty acids. Eating cultured meat “would allow vegetarians to have their meatloaf and eat it too.”

Stuyvesant Town

It was big news around town recently when Met Life sold Stuyvesant Town and Peter Cooper Village in the biggest residential real estate deal to date in this country (something on the order of a few billion dollars). These two apartment complexes sit on Manhattan’s East Side, and they were developed on land aquired through eminent domain and given to Met Life for the purpose of providing housing to soldiers returning from World War II.

On the one hand, it seems they’ve served their purpose, and the real estate eventually should feel the tug of market forces. (Why should retired people pay 1/2 market rent in Stuyvesant and own a second home in Florida, while young people struggling to make it in the city pay much more for a smaller apartment?) On the other hand, I see some legitimacy to the protection of poor folks and those on fixed incomes, which is provided by rent stabilization. It’s a complex social and economic issue.

My favorite part of the issue, however, is this photograph which appeared in “AM New York: Manhattan’s Largest Circulation”. The paper is popular only because they hand it out free at subway stations, not because of the thoughtfulness or scope of its writing, and certainly not because of its journalistic integrity.

Need I explain the humor in this picture? Clearly they wanted a shot of a Stuy resident, but why only half his face? And this is no passerby. He is Samuel Lichtenberg, 80, a long-time resident. Thanks for the smile, AM New York!

Friends in town

Nearly two weeks ago, three of my good friends from medical school clame to visit. Dave & Louisa live in Cleveland where they are in surgery, and Alison does OB/GYN with the military in Washington D.C. New York City, therefore, was a practical and fun place to meet in the middle. (The true geographical mean would have been somewhere in the countryside west of Harrisburg, Pennsylvania. I found this spot by finding the midpoint between D.C. and NYC, and then going 1/3 of the way from that point to Cleveland. As satisfying as a true “meet in the middle” weekend would have been, NYC worked quite well.)

Fort Tryon Park overlooking the Hudson River

I met Alison at the train station, and then we had some tea at my apartment while we waited for Dave & Louisa to arrive, which they did around midnight. Thankfully, 1:00 AM is not too late to get a bowl of noodles for a late dinner near Columbia. (We were, however, warned at 1:15 AM that the restauarant closes at 2:00, and then at 1:45 we were hurried to slurp up the last of the noodles since the restaurant was officially closed. I could comment on the quality of service at Asian restaurants, but will wait for another post…)

The South Street Seaport. Very Navy Pier-esque (Chicago)

On Saturday we hung out at the South Street Seaport, bought discounted tickets for a show, ate cupcakes from the Magnolia Bakery, toured and had coffee at the Time Warner Center at Columbus Circle, stopped by Rockefeller Center, and then saw The Producers. At another late dinner at the Chelsea Grill on Ninth Avenue, I had one of the best burgers I’ve ever had.

The big window at the Time Warner Center overlooking Columbus Circle

I ushered for the first time at church on Sunday. Fairly unremarkable, only more bulletin-folding than I expected. That, and people would look timidly at me when it was their time to go forward for communion. All I had to do was give a subtle nod and a smile, and people knew to go up! I bet one raised finger and a direct stare would slow down those attempting to go forward while the line was too long!

The cupcakes were worth the 30-minute wait at the Magnolia Bakery!

We finished the weekend with Dim Sum and then relaxed at my apartment while waiting for the appropriate time to leave for the airport. As fun as the weekend is, it was this last lazy hour or two of doing nothing at home that reminded me most of spending time with these friends in med school! It was great!

A two week hiatus

Well, I’m back. Again. These past two weeks have been good ones, though very busy. I think part of feeling busy, of course, is the long days of residency, though certainly another part is life in New York City. Its denizens become accustomed to spending 30 minutes getting to a nearby neighborhood, or up to an hour traveling to another borrough.

I will try to share some highlights of the last two weeks in posts to come. First, however, a picture of my cousin Lucia, whom I visted a month ago in Washington D.C. I thought this was a great picture!