Write

"But in its aimlessness, in its desperate commitment to the word, in its primal order of birth and rebirth, a poem remains the most general guarantee that we can still do something, that we can still do something against emptiness, that we haven't given in but are giving ourselves TO something."
-Miroslav Holub

"Poets have been known to be smug about their fine uselessness, but the Vietnam War led many poets of my generation to try to use poetry to make something stop happening. We will never know whether all that we wrote shortened that nightmare by one hour, saved a single life or the leaves on one tree, but it seemed unthinkable to many of us not to make the attempt and not to use whatever talent we had in order to do it. In the process we produced a great many bad poems, but our opposition to that horror and degradation was more than an intellectual formulation, and sometimes it tapped depths of bewilderment, grief, rage, admiration, that took us by surprise. Occasionally it called for writings that may be poems after all."
-W.S. Merwin

In an age of 140-characters and texts and holiday photo cards adorned with pictures, we hardly write anymore. We rarely just sit with pen and paper (and tea and candle) and ramble. Letter-writing seems archaic. Poetry feels obsolete. We want instant gratification and videos on demand and news in snippets. Even reading seems to be going away.

I am incredibly guilty of this. I go through spurts and hesitations with my writing. I took a poetry class where I wrote a poem a week, and that habit has since faded. This blog will go away soon. But I really do believe that writing gives me such unique pleasure, that its work is like exercise, we loathe to start, but we need it. So coming upon this New Year, I resolve to write more. It will be in different forms and forums, different guises and jests, but it will be good for me. Soothing. Nurturing. Healing.

Merry Christmas

"A human being is a part of the whole called by us 'the universe,' a part limited in time and space. He experiences himself, his thoughts and feelings, as something separate from the rest – a kind of optical delusion of consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening the circle of understanding and compassion to embrace all living creatures and the whole of nature in its beauty." – Albert Einstein

It's three in the morning on Christmas Day and I am just finishing up at the hospital. Of my last seven Christmases, I've probably spent about half of them at work. I will admit, it's never easy. There are mixed sentiments; on the one hand, there's a sense of pride in widening our own small lives to encompass those in need, a giving Christmas in a different sort of way. There a sense of duty, almost like filial piety; it is the right thing. But ultimately what I think about is that no matter what negative emotions I have about being here, patients must have so much more. I am here by choice to take care of those without that luxury.

That doesn't make it any easier. How hard it is to spend holidays alone in the hospital when friends and family gather and celebrate. How hard it is on our own spouses and families as they sacrifice with us, when we are not there. What a strain it places on our relationships. What it's like to see everyone else in anticipation of the holidays when instead, we dread the interminable call. How isolating it feels when no one else really understands what it's like to miss half your Christmases. Why scrolling down my Facebook feed of trees and presents and dinners and kids makes me feel a little resentment. And then, ironically, how we judge ourselves bad people for feeling that resentment.

There was recently a great JAMA article on "The Things We Have Lost" by Jennifer Best that describes those sacrifices we make as physicians, things like "absence from 'unique and unrepeatable events' - holidays, birthdays, weddings, and funerals." We feel like we can't talk about these losses because they are minuscule compared to the losses we witness in our work: the loss of independence or health or security or family. But tonight I break that silence. I hold vigil for what I've lost in caring for others holiday after holiday. It is quiet here. Peaceful.

Election

I purposely veer away from writing about politics in my blogs; politics is fascinating to me, but this is not the forum where I want to discuss it. I only write to say that this last election made me think of the classic American ballad "Casey at the Bat" by Ernest Lawrence Thayer. The last stanza really echoes how I feel.

Writing

"Writing is wonderful when you talk about it. It's fun to contemplate. But writing as a daily physical activity is not agreeable. You put on weight, you strain your gut, you get gout and chilblains. You're alone, and every day you have to face a blank piece of paper."
-Norman Mailer, The Spooky Art

I love this quote. There are so many things that fall in this category. Growing up, I loved the idea of classical music and mastering a difficult piece and performing. Oh, but I hated practicing daily. For so many years, blogging also had that same sheen. On occasion, I'd have that perfectly formed idea, pre-packaged and ready for delivery. But most of the time, it was sitting down to an empty screen and forcing myself to write. Now, I'm taking a class on poetry writing, and it's the same thing all over again. Sitting around a table with other hopeful writers drinking tea and reading blank verse is really fun. There's a lot to explore, wonder, learn, and imitate. But then you go home and you sit with idle pen and blank slate. It becomes a narrative of captivity (rather than a captivating narrative) (a quote from a long-time friend of mine, Revati). The daily exercise of writing is a lonesome and individual activity, intimidating, grueling, and challenging. But it is also necessary to get better, to capture those fleeting moments of illumination, and to become more than a dilettante. In part, this is why I am simplifying my life and obligations, to focus on passions I would like to cultivate, and I think I want to give writing a go.

Oxytocin

"There are no events but thoughts and the heart's hard turning, the heart's slow learning where to love and whom. The rest is merely gossip and tales for other times." - Annie Dillard, Holy the Firm.

"Life is not about writing great books, amassing great wealth, or achieving great power. It is about loving and being loved. It is about savoring the beauty of moments that don't last." - Sue Suter.

Love is perhaps life's greatest mystery. Where does it come from? Where does it go? What do we talk about when we talk about love? It seems so simple and yet so large both at once. It can be such an overwhelming life-force and at that same time curiously irrational. It feels so important, and somehow different from all the other things we think important.

Philosophers sometimes talk about "emergent" or "second-order" properties, things that characterize a system but cannot be found in the components of the system. A baseball player doesn't have "teamwork" per se, but when you group a bunch of them together, "teamwork" emerges. A single neuron may not think, but a network of them might have the novel and irreducible property of consciousness. I have not yet read a philosopher bold enough to tackle love as an emergent property, but that is what fascinates me most. We live in a physical, deterministic world. How does love fit in?

Poets and writers love to ponder the transience of love. The unrequited love, the love lost, the entreaty of love, the many masks of love - these inspire libraries of literature. We don't know what it is. We don't know why it exists. We vow to love endlessly. We decide to move on. "All things come to an end. / No, they go on forever." (Ruth Stone, "Train Ride"). We struggle with the feeling that love is so powerful, so irrefutable, and so out of our control. We try to reconcile the pure, perfect love from poetry, pop songs, and promises with the dingy sheen of practical love, love that fatigues and confuses and leaves us wanting.

I don't have a particular direction in this post. It comes from being at the most beautiful wedding this last weekend and also thinking about dear friends who may, someday, part. In seeing the many manifestations of love and thinking about its many faces in my life, I realize I know so little of it and want to know so much more. Love feels simultaneously mundane and magical, perfect and incomplete, ritual and personal story. We make ourselves vulnerable. We become gourds and vessels. We drink and thirst. We invite our friends to dance madly into the night. We invite our friends to hold vigil. There is no greater mystery.

Settle

“Our worst fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, ‘Who am I to be brilliant, gorgeous, talented and fabulous?’ Actually, who are you not to be? You are a child of God: your playing small doesn't serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We were born to make manifest the glory of God within us. It is not just in some of us, it is in everyone and as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.” – Nelson Mandela (1994)

Should you settle? Should you settle for a job that doesn't maximize your full potential, a relationship that leaves you wanting, a meal that is lukewarm? Should you settle for getting three wood for your two sheep when you really want wheat? (Should you settle for a half-hearted pun when you know you could write better?)

It's so easy for us all to say do not settle. You have this one life, this limited set of opportunities, all heart and ambition, so carpe diem. Who wasn't inspired by "Dead Poets Society"? We all remember being teenagers and thinking we could achieve anything, everything. Isn't that the American Dream? Work hard enough and life will be "better and richer and fuller" (James Adams, 1931).

Does it ever scare you that we will chase dream after dream and find them ephemeral, fleeting? That we will never be satisfied (still listening to "Hamilton"), that we will keep following the rainbow but emerge empty handed. I can always dream bigger dreams. I can always imagine something that just might make me happier. We live in a society where we always want more: the bigger house, the spiffier car, the latest phone. We want to show off our relationships, our kids, our jobs, our diplomas, our connections. We are always looking for the next big thing, trying to trade up, pursuing the unknowable, unattainable, and yet unspeakably coveted.

I worry about this. I worry that I want too much, that I have passed or will pass over something perfect in pursuit of a mirage. That settling isn't bad. That being content is more important than being fulfilled if by our very nature, we cannot be fulfilled. There are no bounds to human want, no bounds to human curiosity. "I burn, I pine, I perish" ("10 Things"). It is our obligation to ourselves not to succumb to the hubris of Greek tragedy. It's not to say we should want no more, but to say that in some facets of life, we accept the cards we are dealt with gratitude and find happiness in what we have.

I worry about the opposite as well. A life without purpose is like motion without moving. I should not settle to live in a world with injustice, suffering, immorality. I should not settle to live a personal life plagued by injustice, suffering, immorality. Idealism, even if I know it cannot be fulfilled, has a place. Humans were meant to dream.

"Harlem"
Langston Hughes

What happens to a dream deferred?

Does it dry up
like a raisin in the sun?
Or fester like a sore--
And then run?
Does it stink like rotten meat?
Or crust and sugar over--
like a syrupy sweet?

Maybe it just sags
like a heavy load.

Or does it explode?

(FYI, being post-call tends to draw these types of posts out of me)

Green

“Never doubt that a small group of concerned citizens can change the world. Indeed, it's the only thing that ever has.” – Margaret Mead

We live in a world of stuff. We are consumers, buying things, using them up, discarding them, acquiring more. As I look at the next generation of cell phones and computers, contemplating upgrades, I start worrying about our preoccupation with having things. It's not that I find this hobby superficial or silly (though in a way, I do), but it's because I worry it's ruining our world. Like health care, our resources in this world are finite. Our consumer-driven culture will end up consuming those limited resources. Even if we recycle all that we buy, the cost of manufacturing the new goods and reclaiming the resources of the old worries me. I've been thinking about carbon footprints, global warming, and other environmental issues recently, and I worry that the legacy we are leaving to future generations is more problem than solution. While reducing waste, improving our commuting routines, eating less meat, and composting all make a difference, I think we need to overhaul our cultural disposition to consume. I also struggle with the itch to use stuff up and get more, but I'm trying to curb that. It is our responsibility to rein in waste, to protect our world.

Anesthesiology and Critical Care

"Love. You can learn all the math in the 'verse, but you take a boat in the air that you don't love, she'll shake you off just as sure as the turning of the worlds. Love keeps her in the air when she oughta fall down, tells you she's hurtin' 'fore she keels. Makes her a home." - Serenity (2005).

This will be my last post about medicine. I might have some lingering thoughts about other facets of this strange life we live, but for now, I think I have accomplished what I wanted to with this blog, and it's time to step back. I started writing here on September 1, 2006, when I knew nothing of this ship I was boarding. It was the day before orientation for medical school. Ten years later, I have written over twenty two hundred posts, most of which are essays on becoming a physician, musings on the inner workings of medicine, reflections on the emotional and subjective experience of medicine, and stories of my life during medical school, residency, fellowship, and (hopefully) the beginning of a career. There is no way to summarize this, and while I want to make grand sweeping statements on what this means with flowery and literary-device-laden language, it's really not necessary. Someday, I might highlight those blogs that I am most proud of, but for now, I let this website speak for itself.

This is the path I chose, from the many I could traverse. It has been harrowing, lonely, exhausting, dangerous, frightful, upsetting, and profoundly sad. But it has also been enlightening, inspiring, heartening, beautiful, transformative, and dare I say it, fun. As a career, I am so happy to be an anesthesiologist and intensivist. My day-to-day and week-to-week work life is filled with moments of sheer wonder, great pride, meaningful connection, poignancy, and growth. I can think of no other vocation I would instead choose.

I thank all of you who have read this blog, and I apologize that it is coming to an end. I hope I have shared some glimmer of the magical and miraculous world I see every day. I hope to continue writing in the future and contributing to the literature of medicine in different forums and settings. Like every other incredibly difficult decision in my life, I have very mixed feelings about this, as evidenced by my lollygagging in saying good night. But here it is: please contact me (you can always post a comment) if you'd like to continue the conversation on medicine. I greatly appreciate your patronage, and I hope you have enjoyed reading. I have loved every facet of this. Good night.

In ancient Greece, the Asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The rod of Asclepius is a roughhewn branch entwined with a single serpent.

With respect, love, and passion,
Craig

Last Words

I make little notations to myself about blogs I want to write. I jot them down on scraps of paper, saved emails, and notepad documents titled "temp." Some of them make little sense to me when I find them again (kind of like trying to write down my dreams). Some feel so big and important that I want to set aside dedicated time to write conscientiously. Unfortunately, the window of opportunity is closing. For a lot of reasons out of my control, this blog is making its last rounds.

One note I wrote to myself was, "Anesthesia is not easy; discuss risk taking and dependence on surgeons." I don't specifically remember what stimulated that idea. There's a great deal that I could say (and have said in the past). Anesthesia is one of the few specialties that depends heavily on the skill of another professional. The doctor on the other side of the drapes affects almost everything I do. For the same surgery, two different surgeons may require very different anesthetic plans. Whether the surgeon is speedy or slow, loses a lot of blood or loses nothing, requires deep anesthesia and paralysis or manages with little - it all affects my decision-making. I have written before that anesthesiology is protecting the patient from the (necessary) surgery and surgeon, and I really believe that. It's no small thing to cut into someone, and my job is to safeguard the patient while that happens.

Of course, the skill of the anesthesiologist affects the surgeon. What I do can profoundly change the surgical conditions from whether there's excessive bleeding to how much the brain swells. I can think of very few other symbiotic medical specialties; perhaps obstetrics and neonatology, but not much else.

It's easy to underestimate how difficult anesthesia is. There is a metaphor of the Stanford undergraduate being a duck; on the surface of the pond, she appears serene and relaxed, but under the water, she is paddling furiously to stay afloat. Sometimes, that's how I feel with anesthesiology. Although we show a calm demeanor above the drapes, we may be working tirelessly to mitigate risk and optimize every single aspect of the perioperative period.

The Impact of Anesthesiology

I hadn't seen this when it came out almost four years ago, but the New England Journal of Medicine for their 200th anniversary (such an impressive milestone) asked the question, "What has been the most important article in NEJM history?" This blog concluded that the first description of anesthesia in 1846 by Henry Bigelow was the most significant report, surpassing even articles on aspirin for heart attacks, tPA for stroke, and development of vaccination. Indeed, the field of anesthesiology allowed advancement of surgery and the surgical subspecialties. Before anesthesia, no one would even consider an elective procedure; it would be terrible to put someone through pain and agony for a disease process that was not life-threatening. But with inhaled ether, and later similar compounds, we made possible so many other advances in improving human health.

2200

On a trip to Prague last year, I saw this building and managed to snap a photo. Ten years ago, when I started this blog, I picked this URL, but I don't remember why. Nevertheless, I've grown to like it.

Personal Identity

When I studied philosophy as an undergrad, one topic that really fascinated me was personal identity. How do we know we are the same person we were yesterday? What defines us? Is it causality, physical identity, some kind of metaphysical "soul," or something else? The philosophical literature on this is quite dense and less interesting to me now. But sociological ideas about identity still captivate me.

Many health care workers, I think, identify very strongly with their profession. If you were to encounter them in the supermarket and ask them what they do, they might reply that they are a doctor or nurse or therapist. We are proud of what we've accomplished, and our jobs have taken up so much time in terms of years of education and our daily lives. Our professions also carry such emotional weight, give us such deep satisfaction, and involve such close interpersonal interactions. It is no wonder that our profession, role in society, and vocation are tied to our sense of personal identity.

Over time, I have found that my sense of identity is less and less tied to my profession. This surprises most people, even those close to me. At work, I am very much a physician, anesthesiologist, and intensivist. I enjoy my work, I take pride in doing it well, and it defines me for sixty hours of the week. I am really quite present.

But once I leave the hospital, that part of me fades. My identity is only loosely tied to being a physician. I spend most of my time, energy, and effort pondering other things - writing, books, music, dance, cooking, travel. So it always surprises me when friends (and family) tell me that I'm a good doctor. I'm glad for such affirmation, but it feels strange to me to hear that from the world outside the hospital.

Part of this dissipation of a medical identity, I think, is the reason why I'm winding down this blog. It has always been my firm intention to keep this blog medical in nature. I think focus is important in writing, and writing broadly about medicine has yielded me thousands of posts. I think it's also earned me a reputation of someone who thinks, reflects on, and writes about medicine all the time. Perhaps that was true in medical school and residency when medicine was the whole of my life. But as that part of my identity softens a bit, I am less wont to continue blogging.

In any case, this is a rambling post that stems from me pondering my own identity, who I am, and who I'd like to be. As a doctor, I am proud of what I have become and where I'm going, but I tire a little of all those who assume that is mostly who I am. My departure from writing regularly here is a personal stimulus to broaden my sense of personal identity. I am understanding how much people change, and how important it is to discard the detritus of identities past.

The Cost of Medicines

One of the biggest challenges we face in the coming years with regard to health care is reining in costs. I recently read a great synopsis on why prescription drugs cost so much in the United States. This JAMA article is definitely worth perusing. It explores concisely and clearly why normal supply-demand economics don't apply to prescription medications. By looking at protected monopolies created by patents, restrictions on government negotiation for Medicare drugs, tactics used by the pharmaceutical industry to delay generic drugs, and physician prescribing practices, it sheds a lot of light on why we are here now. The article also addresses a lot of counterarguments relating to the cost of medications in the U.S. such as research and development investments and cost-sharing with patients. It proposes several reasonable and well-supported measures to decrease the burden of prescription medications on health care cost in America. I don't often write a blog that points to a separate article, but I really believe this paper summarizes the problem in a more comprehensive, accessible, and thought-provoking manner than I could ever achieve.

Quality of Life II

I feel that relationships and passion are at the center of quality of life. When I meet with a family of a dying patient, I often ask them to tell me about the patient. They almost always tell me about the patient's personality, his relationships with others, or his passions in life. In our conversations, these characteristics seem intertwined in creating meaning and value for that person (or least, the family's interpretation of it). And indeed, when it becomes clearer that the patient is losing his personality, unable to maintain his relationships, and will never recover to pursue his passions, the conversation about the end of life follows.

For me, at least, many of the decisions I make stem from my relationships with those around me and the values, interests, and commitments I have. I am proudest of these things, most creative with them, and happiest when I delve into them. Whether it is holding a board game night or learning a new dance or reading "Harry Potter 8" or crafting a new poem, I am energized, sometimes exuberant. When I reflect on curtailed relationships, lost hobbies, disinterest, I find little substance and joy. My mood and indeed my quality of life follows the robustness of my relationships, the devotion I give to my passions.

Although medicine is not aimed at such lofty goals, I do think we can make small differences in helping patients achieve these goals. We center our patients in their universe of relationships; we ask about their spouse, kids, friends, family. We help them bridge estranged relationships. We encourage their support network to buoy them up. We ask them what they love doing. As they recover from illness or cope with disease, we orient them in their world of passions, helping them engage as best they can in the things that give their life meaning, quality.

Quality of Life I

Although quality of life feels incredibly fuzzy and subjective, I think it's important to contemplate. It is perhaps the truest and least-spoken goal of medicine. And along with passing on our genetic makeup, it may be our most fundamental want as people. We don't talk about it enough. In all the lectures of medical school, studies and articles in journals, and posts on this blog, it represents a tiny fraction of what we discuss in medicine. In the same way that death and the dying process is glossed over, the ephemeral phrase quality of life usually earns only hand-waving and idealism.

Although there are quality of life measures taken with psychometric tools and surveys, I like to think it is in the "I know it when I see it" category (originally attributed to Supreme Court Justice Potter Stewart). Yet I'm not sure it really is. Outsider (physician) impressions of the quality of a patient's life often differ greatly from the patient's assessment of his own life. We all have our own ideas of whether we would want to go to dialysis three times a week or be wheelchair-bound or not be able to eat or suffer constant pain. But if any of us were actually in any of those situations, we might change our mind.

Nevertheless, I will talk about quality of life as if we knew what it was. The reason we allow surgeons to cut into people, prescribe medications with side effects, and hospitalize patients is because we think it'll improve their quality of life or length of quality life. But we never think of it that way. It's almost a rote reaction; we diagnose a patient with hypertension and prescribe hydrochlorothiazide; we find appendicitis on CT scan and book the operating room; we witness a suicide attempt and place the patient on an involuntary hold. We do so hoping or imagining that as a result, the patient will live longer and/or have a "better" life.

Why is it that medicine's boundary stops there? Should we actively participate in enriching a patient's quality of life? Or is that out of our scope of practice, someone else's responsibility? Sometimes, I think our social workers who find shelters for our homeless patients, reunite families, and help patients cope with their illness have a more direct impact on quality of life. I think of our physical and occupational therapists who help patients get back to their sports or climb the stairs in their house or use a prosthetic limb. Why is it that doctors are concerned only with the disease and its treatment? Is medicine nearsighted this way? Or is it simply a division of labor; we cure disease and defer a patient's happiness to someone else? I'm really just rambling, but I figured this is an important topic of conversation, and I wanted to open the door.

The Future of Medicine

I was asked recently what I thought the next breakthroughs in medicine would be. I have no idea. Although I like to read about where science is going and although I used to participate in research, now my career has greatly diverged from that. Nevertheless, sometimes you get asked a question and you just have to hypothesize.

We've been talking about personalized medicine for (it seems like) forever, but I think it's going to happen. President Obama launched the Precision Medicine Initiative and that helps funnel NIH funding to those areas of research. We are definitely getting more knowledgeable about how all the "omics" (genomics, proteomics,, metabolomics, gut microbiomics) affect disease and health. Despite this, it hasn't translated to everyday clinical application. For example, though whole genome sequencing has become cheaper and more readily available, genetic testing is not widely used by physicians to make clinical decisions. Only a few tests are standard of care (such as testing for an HLA gene before starting someone on the HIV medication abacavir). I believe physicians are just late adapters of technology. Once genetic testing becomes a more commonplace clinical tool, I think personalized medicine will really hit its stride. This will almost certainly increase costs. We just await to see if that translates to better outcomes.

To me, personalized medicine comes in flavors beyond the interaction of genetics and diseases. One form of personalized medicine is the use of feedback loops and technology to achieve our health goals. For example, insulin pumps for type I diabetics can almost work on autopilot. They can test a person's sugar, adjust the dose of insulin, and check to see if it worked in an entirely automated algorithm. Will anesthesia move in that direction? Will we end up having machines that can detect the level of anesthesia for a patient and automatically adjust the medications to achieve a target? (This was attempted with a robotic sedation system which never caught on; it's now off the market). To me, these individualized therapies also represent a kind of personalized medicine.

With regard to areas of medicine that will blossom, I think immunotherapies and treatments for neurodegenerative diseases will become a big focus in the coming decades. We must focus our resources on diseases like Alzheimer's which currently doesn't have effective treatments but will become a growing burden on society and our health care system. These are, at least, my predictions; who knows where things will go in the next few decades.

Youth and Resilience

We see two kinds of youth in medicine: the invulnerable and the sick. The classic young and invulnerable patient is the trauma patient. He is drunk and foolish and thought himself a superhero. He is recalcitrant and won't change his ways. He'll be back with new broken bones or head trauma or stab wounds. It's a terrible story but all too common in trauma centers everywhere.

Then there's the chronically ill person in her twenties or thirties. At that age we see diseases like inflammatory bowel conditions, schizophrenia, pregnancy-related problems, and even chronic pain. It's hard for me to fathom how it must feel to deal with pain, symptoms, or medications every day for the rest of one's life. How it must change one's dreams, for better or for worse. I've met patients whose experiences have motivated them to pursue incredible art, service, and academic achievements. But I've also met patients whose diseases have broken down their resilience; they struggle every day to survive.

What determines our resilience and reserve? Why do some people fly through adversity while others struggle? Is it one's fortitude, genetics, and upbringing? Or is it one's social support, medical care, and environment? Can we arm others to succeed through hardship? Can we arm ourselves to succeed through hardship?

There's always something. Whether it is a job transition, an elective surgery, a parent with cancer, a newborn whose growth curves are worrisome, divorce, financial trouble, miscarriage, or any number of stressful life situations, there's always something. It may seem way smaller or way bigger than what others struggle with, but it's relative. For the one in it, whatever it is, it's a big deal.

We must all find resilience. We depend on our family and friends. We look to our communities, our faith, our values, and our principles to guide us. We go through anger and rage and moping and sadness and denial and escape and acceptance. Sometimes we are able to reconcile and repair the situation, and sometimes it is out of our hands. In the same way, we must help our family and friends through their own struggles. We must provide for them what measure of strength we can, the patient ear, the kind shoulder, the word of resolve. Together, we overcome the ebbs and tides of everyday life.

(The wonderful thing about writing blogs is that when I start, I have no idea where they are going to go.)

Blogging

"When power leads man toward arrogance, poetry reminds him of his limitations...when power narrows the areas of man's concerns, poetry reminds him of the richness and diversity of his existence." - JFK, 1963

Dear Reader,

One of the challenges I struggle with daily is the limited time and energy I have. So much of myself is devoted to the people I love, the projects I'm trying to cultivate, and my personal well-being. My work and personal life have been really stressful as of late, and trying to eke out more creativity, energy, and productivity has been really hard. I feel spent. As I ponder my priorities and restructure my life, I've become more and more certain that creative writing should and will take up more of my time. As JFK pointed out, I have certainly become more arrogant and more narrow; it is time to allow poetry to expand my perspectives. With writing, I hope to salvage balance in my life. 

This blog, of course, has been a project and adventure that has taken me far beyond where I imagined I'd go. It's been a wonderful exercise in creative writing, commitment, responsibility, and exploration. I've really appreciated everyone who has come across this, commented to me about it (in person or online), and spent a little time on this website. As I think about my life and its transition points, though, I am becoming more certain that this blog will finally come to an end. I'm planning on winding this down over the next few weeks. 

Commitment is such an important thing. It's a strange idea for me that I will part ways with this quasi-daily activity. I spend a lot of my time finding things to write about, refining ideas, and planning my entries. I've learned a lot of what works and what doesn't, and indeed, I have much more to learn. But I started this journey ten years ago, in September of 2006. It seems only fitting that I will say goodbye a decade later.

Commitment wears thin. In an era where young people change jobs every few years, where marriages are perhaps closer to "serial monogamy," where we move and travel and change our identities, I've learned the hard way that the values underlying commitment are mutable. I love this blog so much, and the opportunities it has given me have been tremendous. Through it, I helped a young man change careers, pursue medical school, and choose anesthesiology. Through it, I became involved in The American Resident Project, reaching far bigger audiences. Through it, I have talked to physicians in Canada and India and South America. I've met nurses who've read this blog, medical students who recognize my name through it, and real web presences that have interviewed me about it. It's a commitment that's really paid off. Despite all that, it's time for me to move on. I will miss it and want to linger, but I know new adventures await and new projects are beginning to bloom.

With great affection,
Craig

The Block

Samuel Shem's iconic House of God describes the block with hyperbole. When the emergency department calls for an admission, you try to block the patient and turf him to a different service. If you're an orthopedic surgeon and the patient has a hip fracture, maybe she also has chest pain so she would be safer on a medicine service with an orthopedic consultation. If you're an intensive care physician and the patient is dying of septic shock, perhaps you can dig up an advance directive and POLST saying the patient wouldn't want aggressive medical treatment in this situation.

This is not healthy behavior, but House of God describes why it proliferates; every service is trying to block patients, and if a physician accepts patients indiscriminately, her service will blow up in size. When we are residents and fellows, our clinical volume has no relationship to our salary so there's little incentive to take a lot of patients. Most specialty consultants master the art of the block, and as a result, patients get dumped onto the general medicine or intensive care services. We are the catch-all for any medical problem, so if no one else will admit them to the hospital, medicine will (or the medical intensive care unit if they are sick enough). In general, I was okay with that because the patients got better care, but the idea of blocking always bothered me.

Private practice is the exact opposite. For many of us (but not myself), clinical volume determines our revenue. I was surprised to learn consultants were eager to take on extra work and that there was no push-back when I asked other services to accept patients. A patient's disposition (the medical term of who takes care of them and where in the hospital they go) is determined entirely by medical factors. This is the way the system should be; physicians shouldn't block patients; we should care for them, treat them. Perhaps its not wrong to link this to financial incentives. The goal is to have a collegial and smooth-running system that focuses on the needs of the patient.

Statistics

As I get farther out from school, I start thinking of disciplines I wished I studied more. Some, like English literature or computer science, I think one day I might pick up again. But there's one discipline that I should have studied yet never will, and that is statistics. In the last few years, I've been learning from perusing medical journals (rather than textbooks and lectures which comprise most learning for medical students and early residents). The more I read, the more I realize that statistics matter so much. A study's design is its foundation, and without a solvent knowledge of statistics, I feel like I'm often evaluating the facade of a study rather than its real integrity. Nevertheless, for whatever reason, statistics classes just never engaged me. The one I took in college just passed me by. For me, it is like music theory; growing up, I enjoyed playing an instrument, but never cared for music theory. I guess there will always be a few things where we recognize the importance but just can't make ourselves endure. That being said, I think if we were to rethink the premedical curriculum, statistics is far more relevant than subjects like physics.

Image is in the public domain, from Wikipedia.

Technology and the Cardiac Exam

The stethoscope is the iconic symbol of medicine. There so much I love about it: how it was conceived, the panoply of obscure sounds that indicate specific pathologies, the synecdoche of listening to a patient's heart for the patient-doctor relationship. But I also imagine a time where the stethoscope is relegated to history. Why do we still use an instrument invented in the early 19th century? Physicians are notoriously slow to adopt new technologies, but I can think of two inventions that should replace the stethoscope.

If listening to heart sounds is crucial to medicine, why don't we develop a microphone that we can place on a patient's chest that will record the patient's heart and lung sounds? We have the electronic ability to filter extraneous noises and amplify relevant sounds. Computers can analyze the sounds to dissect out what fledgling medical students struggle to discern. In the same way that the computer reads EKGs, programs can be developed to detect an extra S3 or S4, the type of murmur, or the presence of a rub. Recordings can be saved and compared to prior captures; wouldn't it be fantastic if we could compare today's lung crackles to yesterday's?

And this may be anathema, but I'm not sure listening to the heart offers that much diagnostic value. I definitely think it's important for the patient-doctor relationship and has interpersonal, even therapeutic, value. But it's pretty rare that what I hear on heart or lung exam changes my decision making. This is definitely because of my clinical specialty; in the intensive care unit, I'll often order chest X-rays and echocardiograms, and in the operating room, few heart sounds will cause me to cancel a case. But still, there's less medical utility in the stethoscope than we might wish.

This leads me to wonder when bedside echocardiograms will replace the stethoscope. Handheld echo probes are starting to drop into the affordable range. There's certainly a learning curve, but once bedside echo is mastered, it gives a lot more information than listening to the heart. One day, I think this will become the cardiac exam.

Image is in the public domain, from Wikipedia.

One More ICU Story

It is Saturday midnight, and I'm called by the emergency department to admit a patient who was intoxicated at a party with unknown substances. I ask the nurse if we know anything more about the patient - his identity, other medical problems, etc. She replies, "We don't know too much but we searched his pockets and found a little plastic bag with what looked like crystal meth. But when we gave it to the police, the police replied, 'That's not crystal meth.' I asked, 'What is it?' And he replied, 'That's just crystals. Like decorative crystals.'" That made my night.

Five Days in ICU

Monday

A young man is picked up by emergency medical services unresponsive and hypotensive. He is intubated but despite liters of fluid, his blood pressure remains barely measurable. On exam, his belly is rock hard; I think it's filled with blood. After we start a massive transfusion, we're able to get him to the CT scan, and we find a massive retroperitoneal bleed. He is whisked off to the operating room. On return, his drains pour out liters and liters of blood. The color of the blood coming from the drains is the same as blood drawn from the arterial line. Of course, he returns the operating room and then to interventional radiology for an emergency TIPSS because he has severe cirrhosis. All in all, over a 12 hour period, he gets 25 units of blood, 25 units of plasma, 4 six-packs of platelets, and 2 units of cryoglobulin. Over the week, he goes into acute respiratory distress syndrome with impressive oxygenation requirements (FiO2 100%, PEEP 18), cardiovascular collapse needing pressors, renal failure requiring continuous renal replacement therapy, alcohol withdrawal, continued transfusions, and a return trip to the operating room.

Tuesday

I sign out to the night-time intensivist at 6PM. I finish my notes over the next two hours, clean up pending items, and get ready to go home. On my way out, the nurses flag me down because a surgical patient who was doing fine and planning to leave the ICU had an acute aspiration. After intubating and stabilizing the patient, I sit down to finish those notes as well. I get home well past 9.

Wednesday

I am called by the emergency department to help with an intubation for a cardiac arrest. When I rush down, I see the nurses doing compressions on a child. A three year old previously healthy girl presented with ventricular fibrillation and seizure. Other than accidental overdose of medications, I'm not even sure what causes cardiac arrest in a child. I intubate her, but an hour later when I am admitting a separate patient from the ER, I see that they call time of death. The family is in hysterics. I go home to wrestle with family crises of my own.

Thursday

I see twenty two patients today. We only have 21 beds, but we started with 17 patients and despite sending a bunch to the floor, I get 5 new admits. I'm not even sure if clinic physicians see 21 patients in a day. I make myself a spreadsheet to keep track of notes, orders, and to-do items. The most interesting patient is a person who comes in with torasdes de pointes (shown below). We all learn about torsades in medical school, but this may be the first time I've actually seen a case. It is caused by medications she takes. That first afternoon, she kept having scary episodes of polymorphic ventricular tachycardia, but they finally subside as the medications metabolize off her system.

Friday

I get my most interesting patient on my last day on service. A young woman is intubated in the emergency department because of "bizarre behavior." When I get the call, I wonder how bizarre her behavior was to necessitate intubation and sedation. Apparently, she hasn't been herself for two months. She works at a cafe in the daytime, but according to her boyfriend, she started going out every night to four or five in the morning. She'd sleep for three hours, then go back to work. He wasn't sure what she did at night, but wonders if she was smoking, drinking, and doing drugs. The day before admission, she parked her car on the shoulder of a freeway and ran across the highway. Fortunately, she was picked up before getting hurt and brought to our emergency department. Initially she was admitted to psychiatry, but over the course of the day, she became more combative, even hitting a nurse and harassing another patient. She got 25mg of haldol, an impressive amount, as well as atypical antipsychotics and benzodiazpines. Finally, the ER decided she simply needed to be sedated so they intubated her to get a lumbar puncture and head imaging. She was negative for meningitis, encephalitis, or structural abnormalities. Her toxicology showed benzos and marijuana. I really don't know what was happening with her, but I suspect either intoxication or withdrawal of drugs or a new psychiatric diagnosis with a manic or psychotic episode.

I haven't worked this many hours since fellowship. Along with these cases, I also had the usual old person presenting with sepsis from a nursing home, cirrhotics with low blood pressure, slow ventilator weans, chronically ill patients who had been hospitalized for over a month, gastrointestinal bleeds, and postoperative patients. What a week.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

The Originally Celebrated Curiously Strong

In an attempt to understand how acetaminophen might help some musculoskeletal pain I have, I tried to conduct a blinded placebo-controlled trial on myself. It wasn't very successful, which might have been for several reasons. First, I'm pretty sure I could tell when I got an altoid rather than the trial medication. Second, the acetaminophen I was using is expired. I'm pretty sure nonsteroidal anti-inflammatories would have been a better intervention. Oh well, this is why I never made it as a research scientist.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Expectations and Medical Decision Making

A pregnant woman at term comes in with active labor. However, she is adamant she does not want her vital signs to be checked, an IV to be placed, or labs to be drawn. She insists on having none of it despite understanding the risks. There's no compelling reason; it's simply her birth plan and preference. It's not clear why she decided to deliver in a hospital rather than at home or a birth center. Nevertheless, she is declining hospital standards of care by refusing an IV and vital signs.

For generations, decision-making was entirely up to the physician. Medicine was paternal; a doctor would tell a patient the plan. In the last few decades, we've recognized the ethics of patient autonomy and shared decision-making. We do our best to inform and educate a patient about the nature of their condition and the risks, benefits, and alternatives of diagnostic or therapeutic interventions. We may give our recommendation but we would never force a patient to undergo something he or she did not want.

I wonder sometimes whether we've reached the other extreme, allowing a patient to dictate everything. One reason to deliver at a hospital over home or a birthing center is the insurance against an emergency. The vast majority of patients do fine, but a few need interventions like an urgent C-section. By declining vital signs, IV access, ultrasound examination, and other tests, that benefit is negated. This patient did not receive prenatal care so we had no idea whether the placenta was normally implanted, whether she had pre-eclampsia, even whether the baby was breech (other than by physical exam). The patient was of "advanced maternal age" and there was a real possibility of needing a Cesarean (fortunately, she did not).

While one could argue that with adequate counseling, a patient can understand that risk and decline those interventions, I think that is ultimately unfair to the providers. In a case like this, unacceptable risk is transferred to me. I am not comfortable in a situation where someone may need emergent surgery but does not have an IV. Even if that's what a patient demands, do I have to acquiesce? (Ultimately I did, but these issues are real conundrums).

Like every relationship, the one between patient and provider cannot be controlled entirely by one party. Biomedical ethics is much more than simply reciting "autonomy, beneficience, nonmaleficence, and justice" (what they teach in medical school). We have to learn and approach real-life ethical dilemmas with care, nuance, and compassion.

Satisfying

In nearly every hospital I've been, when there is a patient who is a difficult IV and everyone else has failed, the anesthesiologist gets called. Usually when I arrive, everyone feels relieved, including the patient who often has two armfuls of bruises. I always get (and still get) a little knot in the pit of my stomach because I'm the last resort, and often these patients absolutely need IV access.

There are a few tricks I've picked up over residency. Most nurses won't try the ventral (inner) part of the wrist (the veins are fragile and tortuous and it is painful). In adults, there are usually visible veins on the fingers (including the thumb). I'll look at the ankles and feet. I'll consider the external jugular in the neck. IV drug users who have scarred every other vein usually miss the back of the elbow. And there's always ultrasound and the central line as a last resort.

It's most satisfying though, when I manage to get an IV with a single attempt after the patient is exasperated, exhausted, and at wit's end. A 7 year old boy comes in with appendicitis. Four nurses have each tried once, and finally I am called. I sit down and we chat about Finding Dory, second grade, and swimming. I make out a bluish tinge along the wrist which we sometimes call the "intern vein" and he doesn't even flinch when I get it.

It's strange how anesthesiology involves so much, so many procedures, so much cerebral decision making, but on some days, the most satisfying thing is a simple IV.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Types of Anesthesia

I was recently asked by a patient, "How many types of anesthesia are there?" It's an interesting yet odd question because I wasn't sure how to answer it. One interpretation might be that anesthesia can be delivered as a general anesthetic, through a neuraxial technique (like an epidural or spinal), through a regional nerve block, through local anesthetic, or as IV sedation. But I'm not sure that's how I think about it. In my mind, anesthesia is a sophisticated art and science where the nuances, details, and decisions matter, and that is what distinguishes each individual anesthetic.

Although the vast majority of anesthetics are performed with a limited number of medications and agents, the tailoring of an anesthetic to a patient, surgeon, and procedure is rarely "cook-book." I was talking to an anesthesiologist at a different institution and we were surprised how differently we do our anesthetics. Most of it is institution-specific; the culture of a place affects the medical decision making. At this hospital in New York, for example, anesthesiologists use a lot more laryngeal mask airways and rarely use long-acting opiates like hydromorphone. When I moved from an academic hospital to private practice, I adjusted my anesthetic techniques to the medications that were available. It's a good reminder that there's no "one right way" to anesthetize a patient, and that a lot of different factors influence our decision making.

Therapy and Socioeconomic Status

One thing about therapy and counseling that troubles me is the cost. I've always been surprised by how expensive it can be, and not all therapists accept insurance. What they do is amazing and certainly worth the price, but the expense means there are be barriers to access. Mental illness is certainly more prevalent in populations that are poorer, though this is correlative and not causative. But even aside from psychiatric disease, many people simply need counseling for itself; we go through hurt, loss, and tragedy, and most of us don't have extraordinary coping skills. 

How can we lower the barriers to counseling? Like medical or dental insurance, I think mental health and personal well-being resources should be available to anyone. Depression, grief, anger, and addiction can be just as life-altering as cavities or a broken bone or a heart attack. No one should have to pay hundreds of dollars out of pocket to address these issues. And I think ultimately, society will benefit. With good counseling, patients may need fewer medications, be more productive, and be less likely to get involved with gangs, drugs, and violence. We need to increase the number of providers, lower the cost of getting help, and expand access to this critical resource.

CRISPR

To be honest, I haven't looked at the scientific papers behind CRISPR, but I've read a lot of lay articles about this genomic editing technique. As I understand, CRISPR stands for clustered regularly interspaced short palindromic repeats and represents sections of DNA that confers resistance to foreign genetic elements. They are found in bacteria and act as a way to recognize and cut out foreign DNA sequences.

The applications of this system are staggering. By using CRISPR and associated genes (called Cas), scientists are able to precisely and easily manipulate the genetics of most cells, including human ones. The technology has been used to knock out specific genes and add specific genetic sequences. Genes can be turned on or off in almost any organism. Most importantly, though, this technology is easy to use and effective.

Various laboratories around the world are using CRISPR/Cas to create disease-resistant crops, mosquitoes that won't spread malaria, yeasts that make biofuels, and animal models of various diseases. The beneficial implications are profound; we really might be entering an age where genetic modification is widespread. But the dangers are clear; such technologies can be used for evil; bioterrorists could conceivably create diseases that are much more virulent and deadly.

One of the most debated controversies, however, is the genetic editing of germline cells. The technology can be used to change the genomes of sperm, eggs, and embryos, and such changes would be permanent and passed onto offspring. This is really close to "playing God." The changes that we make might have dramatic unforeseen consequences. Without close scientific scrutiny, research, and forethought, embryo engineers may cause irrevocable damage to the human genome. We don't yet understand how all our genes interact, and we wouldn't know the implications of altering one gene, even if we did so with admirable intent.

In addition, the ability to have "designer babies" is ethically fraught. If we edit the genome to eliminate sickle cell disease, for example, what does that say about living people with sickle cell? It becomes a slippery slope to social Darwinism and eugenics by saying certain types of people should not exist. What if unethical genetic engineers moved from diseases to other traits like height or intelligence? Such possibilities are really not that far off; the dangers of unregulated genetic editing of embryos really worry me.

I don't pay that much attention to basic science breakthroughs these days; although I would love to stay current with such things, it just doesn't apply to my day-to-day life. Discoveries like this, however, catch my attention because of the widespread scientific, medical, cultural, social, and ethical implications. The ability to engineer genomes is a potential gamechanger in medical research, agriculture, biology (some scientists are considering reviving extinct species), bioengineering, and a dozen other applications. But it can be ethically fraught if we start playing God and exerting our own will on the forces of evolution.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Self-Fulfilling Prophecies

Doctors are a strange bunch. We champion science and evidence based medicine, quoting the latest research journal or study. But we are also a little superstitious, though we don't like to admit it. We talk about our "clouds" - whether we attract business or not when we are on call. I once had a resident who, taunting our superstitious natures, would declare on call, "Not even God can sink this ship." Without fail, those nights exhausted us with endless admissions.

I was telling this story to another physician, and when I started it, she said, "I bet the patient had a C-section." The story starts like this. A woman walks into labor and delivery closely followed by her doula, birthing ball, and yoga mat. She has a typed five page document with her birth plan, a smooth satisfying natural child birth.

Although some physicians roll their eyes, I support mothers like this. In my first year of medical school, I took an elective to see the childbirth process from a patient's point of view, and I trained in one of the most hippie-friendly open-minded areas of the country. I champion patient decision making. Complementary and alternatives approaches to medicine intrigue me.

But alas, the superstitious of us might believe that she sealed her fate with a self-fulfilling prophecy. Over the next few days, she needed induction with escalating doses of oxytocin and became more and more exhausted when the process of labor dragged out. Finally, after several days without sleep, she decided to get an epidural. By now, the idealistic and lofty goals of the perfect delivery were out the door. She struggled with her pre-formulated plan, asking the obstetrician whether she should get a Cesarean (which, on a totally separate note, would be a great spelling bee word; I never get it right).

Of course, she ended up going to C-section for arrest of descent, and of course it was at three in the morning. Because of her prolonged labor, her uterus would not contract after delivery and she had massive bleeding. We activated the massive transfusion protocol. Of course, her IV access was poor and I was under the drapes putting in extra IVs so she could get fluids and blood. She required everything we could think of: oxytocin, methylergonovine, prostaglandins, misoprostol, a Bakri balloon. We almost called interventional radiology.

Fortunately, she had a healthy baby and her anesthesia was well maintained with her epidural. She never needed to go to the intensive care unit and got through the whole ordeal just requiring a few units of blood. We go through our lives trying to plan as much as we can, certain we know what would make us happiest. But the superstitious among us know that sometimes when that patient with a doula and birth document comes in, it might be prudent to plan for the worst.

Studying This Week

Hello, and thank you for reading my blog. I am gearing up for my (hopefully final) set of board examinations (for about a decade at least). Critical care medicine boards are in less than a month so I'm going to take this week off from blogging to focus on reading. I'll be back in a week.

Craig

Separation and Globalization

The "Brexit" movement is fascinating to me because of some parallels with the medical world. Those who voted for Britain to leave the European Union were mostly older (59% of those 65+ voted to leave compared to 19% of those 18-24), who experienced England before the E.U., who were hurt by globalization. I don't pretend to understand the complex political milieu, but I sense parallels in medicine. There is a globalization of medicine that has been occurring and will continue to change the way we practice. Several generations ago, in a simpler time, medicine was provided by independent individual practitioners. The physician made all the decisions unfettered by the wants, desires, influences, and decrees of other entities. Over time though, more and more of medicine is being structured. We have coalesced into groups that standardize care. Hospitals introduce protocols and pathways to reduce variability. Insurance companies limit the medications we can prescribe. Consumers rate us on how we're doing. We make fewer free decisions. And in return (or perhaps this takes the analogy too far), doctors, hospitals, and health care institutions develop a common language, a shared set of expectations, and better cross-talk and communication. A lot of older practitioners don't like this; "we know better," they think (and they certainly might). But the newly minted physicians, used to this, appreciate the advantages of common standards and practices. We don't want to separate. We like globalization. And we see it to be the future; the world is more and more interconnected. There are fewer pockets of local isolation and provincialism. To practice medicine, we must meet a global standard. We don't discount that history and legacy that got us here; we look forward to see where things are going.

ICU Nursing Care

The intensive care unit isn't just about ventilators and pressors and invasive monitors. Some patients go to the ICU simply because they need the nursing care provided there. Our specially trained critical care nurses are the ICUs greatest asset. I rely on them a lot as they know their patients incredibly well, spending all their time with just one or two. They also develop sharp clinical acumen and great familiarity with the hospital system. I never discount the contribution of our nurses, respiratory therapists, physical and occupational therapists, nutritionists, and pharmacists in the care of our critically ill patients.

Some patients, like those who get a carotid endarterectomy, go to the ICU simply for close nursing monitoring. These patients who have their carotid vessels cleaned out are at high risk for postsurgical strokes. Only our ICU nurses are able to do complete neurologic exams every hour. If the patients do well, they go home straight from the ICU. Other patients come because our nurses can give medications that are restricted elsewhere. I admitted a pre-eclamptic patient to the ICU after her delivery because she needed aggressive blood pressure control that could not be achieved on the regular postpartum floor. Other patients who have complex plastic surgeries may come to the unit for wound care and free flap checks.

Although I enjoy caring for these patients, they are in the ICU more for the nurses rather than the physicians. It is another reminder of the central importance of nurses to our health care systems.

Violence and Tragedy

Over the last few weeks, there have been several appalling and unbelievable acts of violence. Incidents like Orlando, Dallas, Baton Rouge, and Falcon Heights have become terrifyingly common. Our emotional responses to them are becoming muted. Our communities are battered. Our values are becoming fractured. Our nation struggles to understand race, sexual orientation, poverty, law enforcement, protest, and anger.

I think it is a medical epidemic. There are outbreaks of violence; each act of violence can infect others to crave retribution. Each act of violence decimates a community. The physical, mental, and emotional scars persist. Physicians, who care for the health of a community and its constituents, ought to respond. We care for those who are victims of child abuse or domestic violence or elder abuse. This kind of violence is not so far off.

In 2011, a Florida law stated that medical professionals should refrain from asking about firearms and not put such information in the medical chart unless it is relevant to the patient's medical care, the patient's safety, or the safety of others. There is no doubt in my mind from what has happened in the past few weeks that this information is entirely relevant to the safety of our communities. We ought to know. We should also know the resources out there to mitigate the risk of gun violence. We ought to educate, support reform, and be role-models to avoid such tragedy. The world cannot go on like this.

Always Learning

In a community hospital with a high volume of deliveries, it's easy to get complacent about obstetric anesthesia. For the most part, the procedures are straightforward; we do hundreds of epidurals for labor and spinals for Cesareans a year. There are certainly red flags for those that might be challenging - the patient with severe scoliosis or multiple back surgeries - but the vast majority of women are otherwise healthy, and getting an epidural or spinal is no problem.

I'm always learning though. Several months ago, I was doing the anesthesia for a patient getting a repeat C-section. Her prior C-section happened in a different country and she said she had a spinal which "didn't work." She had so much pain, they had to "put her out." Nevertheless, spinal anesthesia is still the preferred anesthetic for a Cesarean, and after talking to her, we decided to attempt it.

I placed the spinal smoothly in my first attempt; I got back clear CSF, which in nearly all cases, confirms the placement of the medication and the efficacy of the anesthetic. Her response, however, was unusual. She developed a patchy spinal block; there were parts of her leg and abdomen that were completely numb, but other parts that retained normal sensation. This occurred on both sides and at multiple levels; I could not explain this anatomically. We did not have adequate coverage for anesthesia, so I offered to do an epidural. I did not want to do a second spinal because overdosing someone with a spinal can be life threatening. Placing an epidural catheter, however, would allow me to carefully titrate the level of the block.

Again, the epidural went smoothly; the procedure itself suggested it would work well. Nevertheless, as I bolused medications into the epidural, she continued to have a patchy block. After speaking to her and the surgeon, we decided to convert to a general anesthetic. Fortunately, it was in well-controlled conditions; the baby was delivered within two minutes of intubation, there were no problems, and at the end, she awoke to the sounds of a healthy baby's cries.

Even if 99.9% of anesthetics are simple, straightforward, and easy, we will still run into that unusual presentation or odd case that baffles us. Nevertheless, we draw on our education and training, our problem-solving and critical thinking, our knowledge of anatomy, physiology, pharmacology, and medicine, and our skills developing a strong patient-doctor relationship in order to tackle these challenges when they present themselves.

Sugar Sweet

One thing that occasionally interests physicians is seeing the extremes of human physiology. The body can generate and withstand really remarkable perturbations, and from time to time, I am simply amazed by the patients I'm caring for. The last time I was in the ICU, I saw a diabetic patient with a glucose of 1700, 17 times normal. He had hyperosmolar hyperglycemic nonketotic coma, which we like to abbreviate "HHNK" (with various spellings). He had been unconscious for days, likely from an infection, and meanwhile, without his insulin, his glucoses became completely out of control. He came in extremely cold, profoundly dehydrated, and unresponsive. Yet after a day and a half in the intensive care unit, by the time we got his glucoses down to 200, he returned to his usual normal self. He left the unit the next day and returned home several days later.

This is by no means an unusual or even difficult intensive care unit case. But when I think of it, I pause because there is something simply ineffable about the resiliency of the human body. Most of the medicine that we practice is aimed at getting the human body back to its baseline homeostatic state.

The Capacity to Change

We underestimate our capacity to change. When I talk to a lot of my friends who are physicians, I hear stories about those who frustrate us: the parents who don't believe in vaccination, the uncle who continues to smoke, the roommate who "doesn't believe in taking medications." We see patients who are addicted to drugs, who drink themselves into liver failure, who won't check their blood sugars, who ride their bikes without helmets. But I think we underestimate the human capacity to change.

We do this for ourselves too. We don't think we can adhere to a new diet, we give up on our exercise goals, we let our projects waste away. And we think that's par for the course. We encourage others to change without meaning it. We make resolutions we know we won't keep. We go through life half-hearted and unmotivated.

I don't think it needs to be this way. I have seen true, genuine change. I have seen people's values, principles, ethical stances, political positions, and convictions change, adapt, and renew with time. I have met that cancer patient who quit their long-time job to write a book about dying; I know the chemical engineer who gave up that life and now meditates for fourteen hour sessions on the weekends; I have treated the investment banker who became an art philanthropist; I have talked to the abuse victim who confronts her abuser.

We need to expect change of ourselves. Change is a natural process of the self-aware life. When we live an unexamined life, when we stop questioning who we are and why we do things, we get into a rut and wither a little. When we need others to change, we are right to expect it of them, and we are also responsible for helping them reach it. In reflecting on our lives and what we expect from ourselves, we hope to become clearer and truer to our convictions, our goals, our values, our friends, our family, our community, and ourselves.

Losing Hope

This is not an uncommon ICU story. A patient with cirrhosis has been on the transplant list for years. He develops progressive hepatic failure, and the sequelae of liver disease start manifesting. He becomes confused, develops varices, builds up fluid in his abdomen, starts bruising and bleeding. The blood pressure starts dwindling and the kidneys start failing. He needs a new liver or he will die.

About 6000 liver transplants are performed in the U.S. every year, but there is still a big organ shortage; approximately 1800 people on the transplant list will die because they could not get an organ.

This patient presents with encephalopathy, pancytopenia, and hypotension. I admit him to the ICU, hydrate him, start him on norepinephrine, begin lactulose, and hang antibiotics. His MELD score, which determines liver transplant priority, is quite high and I talk to his hepatologist; both of us agree he needs to get to a transplant center. Transferring him earlier is probably safer because things will only get worse. I contact nearby tertiary hospitals and tell his family this may be his best chance.

Then the labs come back. Unfortunately, he is septic with E. coli growing in his blood. In my head, in my experience, I know this is it. He won't survive a systemic infection, and no one is going to give him a liver until he clears it. He doesn't have time. I've already started a third pressor, and I know intubation is just around the corner.

I am still learning to deliver bad news. It's one of the hardest things I do. How do you walk into the conference room knowing that hope is all that is sustaining the family but that the hope is ephemeral? How does the pendulum swing from one extreme where you are scrambling to transfer a patient to a transplant center to the other where you believe the best thing is comfort care? Is that my goal? If I am certain he will not survive to transplant, should I recommend stopping aggressive treatments and heroic measures? I don't want to intubate him. I don't want to dialyze him. I don't want him to suffer without a prospect of getting better.

Hope is tenacious. Even when something is doomed, we ache with hope. Even the most rational of us find ourselves in situations where we pray, wish, bargain, yearn. Ultimately, after hours of discussion with the family, we ended up transitioning to comfort care; he was never intubated and could communicate until the very end. No one would say the situation was good, but I have seen so many worse deaths and I'm glad he was pain-free, talking to his wife, and surrounded by his children in his final moments.

Opiates

The epidemic of prescription opiate overdoses is a really complex issue. It's gotten a lot of press in the popular media especially as President Obama declared this a national crisis. But I'm afraid this is a much more nuanced issue than most people realize. There is no doubt that the number of emergency visits and accidental deaths from prescription opiates has skyrocketed. We are seeing less heroin, methamphetamines, and cocaine, and a lot more oxycodone and morphine. But the solution is not clear to me.

Recent guidelines strongly recommend avoiding opiate prescriptions outside of cancer pain and palliative care. In particular, there are recommendations to avoid long acting or slow release medications. Alternative pain medications including drugs normally considered for neuropathy, inflammation, and epilepsy are highly recommended. Indeed, I've read several recent research studies supporting de-escalation of opiates outside of cancer and the end-of-life.

These guidelines are quite reasonable, but for me, they highlight the difficulty in treating chronic pain. In anesthesia residency, we spend only a little time in the chronic pain clinic, but it is still more than family practitioners get. The few months I worked with pain patients taught me that treating pain is a highly specialized practice requiring advanced training. Of course, there are hardly enough pain specialists out there to care for the epidemic of chronic pain and its resultant epidemic of prescription opiates. But it does shine a light on the fact that complex patients should be referred to a pain practice.

I've met drug-seekers and malingerers, and I've also met patients with real chronic pain. In treating chronic pain, I believe (and have been taught) that long acting or slow release medications are crucial. They provide a foundation of effective pain relief in the same way that long acting insulin provides a background dose. Short acting medications help with spikes of pain in the same way that short acting insulin is given for meals or snacks. Avoiding long acting opiates can create big swings in pain management where the patient gets behind and then takes too much to catch up; it can disrupt sleep and impair function.

I definitely agree with multimodal management of pain, using non-opiate alternatives such as antiepileptic, antinflammatory, and neuropathic drugs. But in seeing patients on these complex regimens, I realize the risks of polypharmacy. It can be challenging for patients to keep track of their different medications or physicians to manage their side effects and interactions. When I read the geriatric literature, all of it suggests paring down on medications. How do we balance these conflicting recommendations?

I guess in the end, I chose not to be a pain specialist for a reason. But when I see the lay media, medical journals, and CDC recommendations on how to curb prescription drug abuse, I question how simple they make it sound. Like any other epidemic, tackling this is not easy. I hope that pain management physicians will step up to engage the public, educate physicians, and research ways of reducing overdoses and accidental deaths.

Gap

Sorry for the big unexpected gap in blogs. The end of June is always an interesting time. In academic hospitals around the country, senior residents are graduating and new interns are orienting. Soon, new teams of residents, bright-eyed and bushy-tailed, will start on the wards. Clinic patient panels will be handed off to the next practitioner. My wife starts a new job. My brother begins an orthopedics internship. Even at the community hospital where I work, where there are no residents, we feel the change. The summer is when new hires, fresh out of residency or fellowship, begin their first jobs. We see new faces among the hospitalists, surgeons, consultants, and even the nurses and technicians. With this, I hope there comes a since of renewal, of emergence, of new goals and resolutions. Oddly enough, my calendar has always been organized this way; I count my first work anniversary soon. I reflect on what I have done this past year and what I hope to accomplish in the year coming up. Starting in private practice has been challenging in its own ways. I learned how to be flexible, how to adapt to changing circumstances, how to walk into call prepared for anything. My anesthetic techniques changed to accommodate the speed and efficiency of private practice. I honed my skills and my judgment, integrated myself into a system, got to know a wonderful cohort of partners, surgeons, nurses, and staff. I tackled problems, surgeries, and intensive care patients that I had never seen before. I started acquainting myself with billing. It was a really busy year; many of my mentors told me the first year of practice is one of the hardest, and I am glad I made it.

Personality

One of the most fascinating aspects of neurology for me is the idea that parts of our identity can be altered by illness. It's easy to imagine that diseases can change our memory or our sensory perception or our balance. But I've always been so curious of the idea that illness can affect parts of ourselves that seem so intrinsic and fixed. When I first read Oliver Sacks' The Man Who Mistook His Wife for a Hat, I was most drawn to the stories where personality changes with illness. There are bizarre diseases that can make patients hyper-religious. In my psychology course, I loved hearing about Phineas Gage who had an iron rod pierce his brain's left frontal lobe in a railroad construction accident.

He survived the accident, but his personality changed dramatically. How can an injury change who we are?

That last time I was in the intensive care unit, I saw terribly sad example of this. A young woman presents with several weeks of subacute altered mental status. Her sense of smell and taste change. She becomes less interactive, more withdrawn. Eventually, she has a seizure at home and is brought into the emergency department. She is intubated for recurrent seizures, and her head imaging shows enhancement of the temporal lobes. A tentative diagnosis of HSV encephalitis is made, and she is started on acyclovir. However, during this hospitalization, she starts exhibiting extreme behaviors including suicidal behaviors that her family says she's never had. What a terrible and strange disease that can make someone suicidal. I wonder how this happens on the level of the neurons and neural networks.

Image is in the public domain; from Wikipedia.

Beauty in Everyday Life

I've been pretty worn down lately: long days at work, stressful cases, insomnia, fractured relationships, family tension, difficulty motivating myself, overwhelming emotions. I anesthetize a patient for a bronchoscopy and biopsy of a lung mass. Under the microscope, it looks like small cell lung cancer. Her imaging shows disease outside the lungs; when I realize she likely has metastatic small cell lung cancer, I am greatly saddened that she may only have months left to live. The day before, in an orthopedic surgery with unexpected blood loss, I am splashed in the face with blood and irrigation. Glasses covered in blood, I pause the slightest bit but then continue to transfuse products and place an arterial line. A couple days later, a surgeon requests a central line in the middle of a surgery and I have to place it in a terribly un-ergonomic position; my shoulders still ache. On my way home, I realize I have been remiss in calling back friends, working on my projects, tidying up the household.

On weeks like this, I remind myself to slow down. I try to curate more art in my life. I've been filling the house with music when I get home. I've been changing the wall art. I make time to go to the SFMOMA, which just recently reopened. I cook. I write a poem or two. I cherish deep conversations with those I love. I take a walking meditation. I find beauty in the books I read.

How do we cope with those intense, confusing, and exhausting emotions in our personal and professional lives? How do we decompress from stress, avoid burnout, and find beauty in each day? How do we go from a work that is technical and scientific to an everyday world which is imperfect yet filled with art, music, literature, dance, and beauty?

Changes in Family Structure

Over time, the composition of family has changed. We moved from living in extended families with multiple generations under the same roof to having smaller nuclear families. Our families are more spread out geographically; it's no longer common for an entire clan to live all in one neighborhood. And now the Millennials are changing things even more. The so-called Generation Y are marrying later, having children later, and delaying rites of passage. It's been described as the Peter Pan effect; these Millennials are living with their parents longer and pursuing longer routes of education. How will this change health care in a couple decades?

I've been pondering this as I've seen a small uptick in the number of people undergoing surgeries unaccompanied by a family member or friend. Most of these procedures are small outpatient surgeries, but it's still surprising when I hear their plan after surgery is to take Uber or Lyft home. (That in itself, is a question - is it safe to discharge a patient from a hospital to a smartphone transportation service?).

But what happens when the Millennials get old? When we are hospitalized in the intensive care unit with a pneumonia or after cardiac bypass surgery or from a car accident, who will make our decisions? The vast majority of surrogate decision makers I see in the ICU now are spouses and children. But with the Millennials, we might start seeing other people take that role. Even those with children are having them later. If a sixty year old man has a stroke and would not want to live dependent on machines, would his thirty year old daughter be able to make that heartbreaking call? What about a twenty year old daughter? Those of us who are unmarried and have no children may depend on our siblings or other relatives more. What if we don't have any? Will we rely on our friends to make life-altering medical decisions? Will we be able to make those for our friends?

When we leave the hospital, who will help us with the recovery? If a third of us are unmarried and have no children, will we lean on those more-distant relatives? Friends? Neighbors? Childcare and elder care has changed a lot now that few households have multiple generations living under the same roof. Will new societal innovations change how we deal with illness in the setting of changing family structures?

Ramblings on Race, Culture, and the Doctrine of Separate Spheres

Race and ethnicity can be touchy subjects to write about. I don't want to make any generalizations, and yet, I've noticed very striking patterns in how culture affects the way people interact. In my experience, this has been most pronounced in labor and delivery.

I wrote a blog several months ago about a husband who dominated a conversation I was trying to have with the wife (the patient). This happens at a surprising frequency. For a specific ethnic group, communication seems to happen via the husband, almost like an interpreter. When I ask a question, the husband will repeat it to the patient. If the patient has a contraction, she will whisper it to her husband who will then communicate it to me. Although I respect this is how they communicate, it is strikingly different than what I am used to (or expect).

It makes me think of the doctrine of separate spheres. In early 19th century Europe (though the idea has been extant in Western thought for much longer), men dominated the public sphere; they were allowed to engage in politics, business, and interactions outside the household. Women, on the other hand, participated in the private sphere of domestic life, housekeeping, and childraising. It was improper for women to cross over to the public sphere; indeed, it would be indecent for a woman to be seen in public unaccompanied. These gender roles permeated the culture and thought of the time; it wasn't until the mid-20th century when feminist theorists began to refute this doctrine (ie., The Feminine Mystique).

This is what that interaction in labor and delivery feels like: some clash between the private sphere and the public sphere, and the husband traverses the gap. This hypothesis may be completely wrong; the ethnic group isn't a Western one, but it's a thought I have in the middle of the night on my eighth epidural. Other ethnic groups also have their own particularities. For example, one group of patients commonly asks their mother or sister to stay for the epidural rather than the husband. The sociology of pregnancy is a fascinating topic.

Happy Memorial Day!

Thanks for reading this blog. I have a lot of things on my plate, so I'm going to take a break from writing this week. See you next Monday!

Craig

Rambling Musings on Memory

Memory is a strange and slippery ghost. How malleable it is, how curious that we can be so certain of what happened and yet so far from the truth. Fascinating that the further we get from an event, the more convoluted things feel, and yet the more sure we are about our own recollection.

I remember in college how I was shocked to learn in psychology that eye-witnesses in crime are so unreliable. How sure I felt that my memories of a moment were pure. I could understand, of course, such an event is traumatic, and that will certainly color things, but what I see or hear or experience is mine and how could that be changed?

I remember, too, in philosophy, debating over the subjective and objective, trying to tease apart what is real. If I remember an event one way, does that make it real? What if two people remember the same event differently, how do those realities reconcile? Or is objective reality external to our experience, and we are simply wrong about what happened most of the time?

For a long time, I thought such concerns were unnecessary, silly even, applying only to a subset of life's happenings. The outcome of a ball game, the plot of a book, the content of a lecture, the rollercoaster ride at a birthday party, lunch with friends, a dance, an ocean swim, a hike, a vacation - what is there to misremember? Sure, recollections become hazy, and there are gaps in the details, but where is the import?

As I grew older, things became more blurry. What was the cause of the friendship that grew distant? Why did this relationship sour? What was the argument really about? Why am I feeling deja vu? Every time I tell a story, why does it change, and does it matter? When I hear someone else tell the same story, how does it influence what I believe?

I subjected myself to years of sleep deprivation, and oh, how it pulls memory apart! After being up thirty hours as an intern, my memories fuzzed. Which patient had decreased tendon reflexes? Was the creatinine normal? How come this patient's story seems so familiar? Was I remembering someone I admitted my last call three days ago? My pager buzzes at 4AM, and I've been up nearly twenty-four hours. I call the nurse, and she says I already answered that page half an hour ago. I wade that terrifying plane suspended between consciousness and slumber. I begin dreaming of patients, of the hospital. I round twice, once as I emerge from the depths of sleep, and again as I stumble bleary-eyed in the hospital.

I started repeating conversations to friends. Did I already tell you about...? I can't remember if you knew... My friendships frayed at the edges. My relationships unraveled. Because sometimes you are expected to remember a fight and a compromise, and memory can be so unfair and unyielding.

(Of course, these are memories I describe, and who knows how accurate they are? What can we believe? What can we trust?)

I float to the surface. I sleep now, not great, not even close, but better, less fragmented. Memories bubble up. Some feel so strong, so visceral. They must be real. I don't know what to trust. This person lied; this person soothed me. This person claims I said, "Good riddance," but I don't remember the conversation. This person who I used to see every week has fallen out of my life. My friends say I encouraged them to get (metaphorical) tongue piercings and tattoos, but I remember the story differently. What I remember from 9/11 is patently different from my friend standing beside me, and what it means to me is so different than what it means to him.

How did so much of my life collide under my feet? Where are the fault lines? I see those critical moments of my life crashing head-on, the many versions of memory subsuming each other, tectonic plates like rhinos. What results, I am sure, looks nothing like reality. But the landscape of my life has been irrevocably altered by this amalgam of what happened, what I remember happened, what everyone else remembers happened, and how we act on these faulty (pun regrettably intended) assumptions.

Where to go now? I think of my philosophy courses in college and my classmates who wore "WWKD" (What Would Kant Do?) shirts. As ridiculous as it feels, reality must be some mishmash of what everyone experiences, remembers, and believes. Our relationships are colored by what we remember of our interactions with that person, whether or not it actually happened that way. We enter a business deal, choose a career, break off an engagement, drop someone from our will, cut a friend out of our lives, and send holiday cards based on our biased, faulty memories of these people. Each person tells a different story of some critical junction in their lives. I have my story and it's completely different from yours but I can only act on my reality and you on yours. We accept these realities to be different for each of us, that our values, motivations, personalities, character, and desires are shaped by different interpretations of the same events. We move forward, understanding, compassionate, forgiving, and accepting.

Book Review: The Water Knife

I guess I really do like books about dystopian post-apocalyptic futures. I was talking to an old college friend of mine the other day, and we realized how much we've changed with what we do during our free time. Before medical school, I would read books like House of God, pursue philosophy treatises, try to understand the movies critics liked. Now, I read and watch a lot more fantasy. Escape is an important form of well-being, of decompression. There was a time when I thought I ought to fill up the entirety of my day with productive work, and sometimes I wish I had that kind of commitment. But then I realize how necessary it is for me to simply retreat into something I enjoy, something apart from the emotional tenacity of patient care. It's not that I need something mindless - I don't own a TV - but I need something that sparks the other faculties I enjoy: creativity, art, movement, wonder, imagination.

In The Water Knife, Paolo Bacigalupi paints a vivid picture of a world without water. This hits close to home as California weathers drought after drought. The world is a cutthroat every-man-for-himself situation where each state and city vies for rights to water. It touches on environmentalism, culture and society, espionage, and technology, but ultimately the story is about a journalist, a spy, and a refugee, all struggling to survive. It's beautifully written and tantalizingly addicting, though the world created is harsh and violent. It's not a must-read, but I did thoroughly enjoy it.

Image shown under Fair Use, from npr.org.