Pets, Posts and Medical Mysteries

Pop Wuj Clinic

2011-06-25T12:55:00.003-04:00

Here I am, back from my first shift as a doctor in Guatemala!

I had a ton of fun working in the Pop Wuj Clinic. I got to do what I love -- medicine somewhere totally new. All the staff (ie- med student volunteers, a guatemalan doc and one nurse) were super friendly. I have to say, though, the gem of the experience yesterday was the patients.

These are people from a wide cross-section of guatemalan life. I had a 24 year old woman who hasn´t had a menstrual period in a year and is desperately trying to find out why however she can´t afford the neccessary lab tests.

An 11-year-old boy who looked about 8 was brought in by his school teacher for concern of malnutrition. The school was concerned and had been saving for 2 weeks to have enough money to pay the 20Q ($2.50) fee to be seen in the clinic. His family did not know the school was bringing him.

An affluent woman who refused to take the free meds from the clinic -- she said to keep them for those who need them. She would buy hers at the pharmacy if I would write down what she needed.

My favorite patient of the day was my last. At the end of the morning a single couple still sat in the waiting room -- an old woman in tradition al Mayan dress accompanied by a younger woman in a T-shirt and Jeans. It would be difficult to exemplify the changes Guatemala has undergone in just 1 generation better than these two did.

My patient was the old woman. She was weatherbeaten and deeply tanned with dry, leathery skin. Her face was beautiful -- wrinkled and wide open with bright, laughing eyes and a constant smile. As soon as I call her into the exam room, she smiles, hugs me and kisses my cheek. She is tiny -- barely 4´6" and was wearing the traditional layers upon layers of brightly colored mayan dress and her hair was in long pigtail brains with ribbons hanging down her back. She should have been on the cover of a National Geographic.

Despite the differences in their appearance, the woman and her daughter were the same. Smiley, laughing, open people with significant caring for each other and those around them. They were a pleasure to muddle though my spanish with.

Fortunately her complaints were simple -- I diagnosed her with arthritis and a corneal abrasion. Ibuprofen, eye drops and out the door. I asked her to return in 2 weeks for a check of her eye -- I look forward to seeing her again. Her memory is one of guatemala I will cherish always. My beautiful laughing mayan grandmother.

http://www.pop-wuj.org/medical-spanish/medical-spanish.html#PopWujMedicalClinic

Destination: guatemala

2011-06-23T20:13:00.003-04:00

Hi all! (or no one considering how long it has been since my last post)...

I decided that it was time to re-visit this whole blog concept. Lots of things happening in my life. Getting married, becoming a senior resident (scary!) and currently spending a month working in a clinic in beautiful Guatemala.

At the last minute in a five-week rush I managed to arrange an away elective at a medical clinic in the city of Quetzaltenango (Xela). The clinic is located at a spanish language school called Pop-Wuj. Xela is a city located in the mountains of Guatemala about 4 hours by bus from Guatemala City.

In fact, let´s start there. THE BUS. My introduction to life in Guatemala. A smoke-belching old-style greyhound. Comfortable enough to sleep on, yes? ... until you put it onto a guatemalan mountain. And give it a driver who doesn`t like to shift gears. As we went careening up sides of mountains and down into valleys around classic 180-degree turns there was no sleeping, just lots of falling over. On the few and far between straightaways rather than shift up and then down again, the drive just ploughs ahead and the whole bus shakes. Not a little tremor. You know that dance move where you shake your shoulders so your boobs fly back and forth? The boobs, they were a flyin´. Halfway through the trip I also discovered that the seat part of my seat was not attached to the back part. Added entertainment. However, we got to Xela in 3 hours instead of 4.5, so no overall complaints.

The bus ride was also amazingly beautiful - driving through little town and small cities, up into the clouds and then back out again. Women walking along the side of the road in brightly colored mayan dress. All beautiful.

Xela itself is a city known as the cultural capital of guatemala. There are literally innumerable spanish schools here as well as the two largest Guatemalan universities. Overall, the people who live here are very well off- no chickens or goats in the yard, cars, electicity, hot water, extra rooms in their houses to put up visiting spanish students such as myself. There is even a Wal Mart here in Xela (more evidence of america poisonning the world).

I am staying with a family which is... interesting. We`ll leave it at that for now. They are very nice and have been nothing but extremely hospitibal. The matriarch of this three-generation family was quietly waiting for me in the kitchen upon my arrival and promptly sat me down for a meal of rice, beans and tortialls. She also immediately noticed that I don`t like beans when I barely touched my half-plate full. Since my arrival the bean portions got smaller and smaller to the point where she doesn`t even put them on my plate anymore. Smart grandma :-). In fact, most of the time I interact with my host family is with grandma over meals in the kitchen.

Pop Wuj itself is a very interesting place. Currently it is overrun by medical students between their first and second years of medical school looking to get some clinical experience as well as improve their spanish. Other than the hired doctors (2), I am the only physician here. As a result, I was instantly asked "can you cover the clinic on Friday?" I have my army of medical students to oversee.

Pop Wuj as a school firmly believes in community service in all different forms in addition to learning spanish. In fact, all of us "newbies" have been in Cultural Competency class all week where we have been recieving lecures about guatemalan history, philosophy, mayan mysticism and traditional medicines from an AMAZING anthropology professor from one of the Universities. These are the kinds of phenomenal lecutres I wish I had in undergrad -- and they are all in spanish! With a little fuddling through and help from each other, the entire class is able to understand lecutres which jump from spirituality to quantum physics to botany all within a few minutes.

Tomorrow morning is my first shift in the clinic (as supervising physician, no less), so more on that at another time. For now, good bye!

http://www.pop-wuj.org/

Delivering babies

2010-09-12T12:11:00.003-04:00

Let's see... what is going on in my life since last time I wrote?... I did a month of Toxicology at Bellevue hospital which was fascinating as always. I did two weeks in the Columbia ER where I got pretty effectively bitch-slapped once or twice (can always count on Columbia for that) and I caught babies for 2 weeks up at the Allen Hospital (Inwood) on Labor and Delivery. Basically, life has been good.

I wish I could regail you with "The tales of labor and delivery!" I basically walked away from my time on L&D thinking "wow, what a wasted, boring two weeks! I saw about 2 patients a day!" However, upon further reflection, I realized that I saw some very important things.

An eclamptic mother in status epilepticus seizing uncontrollably all the way to the operating room to emergently c-section her baby. She has since been in and out of the ICU twice for further complications of eclampsia.

A woman who I now have the highest respect for who did the entirety of labor and delivery without ANY pain control (and let me tell you, it was NOT an easy delivery by any means even if she would have had pain control). I'm actually not entirely sure if she deserves an award or a brisk shaking and an exclamation of "why in the world did you DO that?"

There was the "day of post-partum hemorrhage" where it seemed that every patient was bleeding uncontrollably after delivery (I got very good at calling for HemeAbate). Those are interesting. Looks like a faucet running red water.

Then there was my last day on L&D. I had a 23-week patient who presented in active preterm labor. There was no way to stop the process. The issue is this: there is a 50/50 chance of survival with all of the modern NICU technologies possibly available if a baby is born at 24 weeks. Younger than 23 weeks, there is no chance. 23 weeks is the grey zone. 10% chance of survival, only 5% chance of survival neurologically intact. As we laid the facts out for a distraught couple whose primary language was not english (we used a spanish interpreter for ALL conversations), the emotional stress began to completely block their ability to understand the situation.

Finally, they were able to make a decision, to rationalize SOMETHING out of the entire situation. The attending who had been explaining for an hour that the two options were to a) deliver the baby and provide warmth until the baby passes away in a few minutes or b) delivery the baby and intubate the baby and do everything humanly possible for a long-shot of survival. Finally the father looks at the attending and says "we want an abortion."

HUH?? Abortion wasn't even an option. The word abortion was never even SAID and yet, this was how they were able to rationalize their desire not to have the potential of having a severely disabled child for the rest of their lives (assuming best case scenario). Our jaws dropped and there was silence where we didn't know how this leap had been made. Then the husband went on to ask for us to just take our instruments and tools and go inside and take the baby out. We went through all of it again... explicitly. Mom was going to have to push the baby out. It was a delivery. She was in labor. We were NOT going to go in and take the baby out, it was coming out on its own. The family agreed to let the baby be born and pass away. No heroic measures.

An hour later we are called into the room. It's almost time. There is a new person there -- an extended family member who is fluent in english. She turns to us and demands, "What are the options? Why are they telling me that they are getting and abortion?" If I ever felt like smacking my own forehead, THIS would be the moment. The attending, however, handled the situation with grace by simply stating, "The matter is closed. We have discussed it extensively with the parents and we have agreed to let the baby pass away after it has been born. This is NOT an abortion. This is early labor." We got the interpreter again and went through it again with the parents. Their faces showed complete confusion. But then it was too late for more discussion -- the baby needed to be delivered.

I delivered at 1lb baby boy. He made a single cry and then had no further respirations. He did not move. The room was full of crying, wailing family members. They named the baby, held him, cried and screamed his name, took photos. After all the technical aspects of the delivery were completed and condolences were given, I left. I've never dealt well with rooms full of crying people. I'm a sympathy crier -- not a good trait as a physician. After the parents said goodbye, the baby was taken to the Neonatal ICU and finally pronounced as deceased 3 hours later. I filled out a birth certificate. The pediatrician filled out a death certificate and the matter was closed.

I don't know how those parents will eventually think of the events of the birth and death of their first child. Will they realize what happened -- early, preterm labor -- or will they always rationalize as somehow "choosing" an abortion at 23 weeks? If they rationalize the latter option, how many more pregnancies will they loose because they are passing on incorrect information to future physicians who may be at a different hospital and therefore not have access to our records? It is a terrible dilemma, the stress response of the human psyche.

People Watching

2010-08-14T16:13:00.002-04:00

Something that I enjoy as a NYC resident is the so-called pastime of "people watching." Fortunately, Rob is also a world-class people-watcher and the two of us can go to a park or sit in outside at a restaurant or starbucks quietly and completely comfortable with each other watching the world go by. Occasional comments pass such as "awwww" or giggles and most often, "did you see that??"

I, however, also tend to go on a people-watching tangent. It's called dog-watching. Yes, I watch all the NYC pups go by. Take my walk this afternoon before sitting down to write this post. I was walking through a local park near our apartment and fell into my "dog-watching" routine. There was the adorable Great Dane puppy in the dog run who just didn't seem to understand play with non-litter mates yet. The Golden who, upon realizing that they were near the dog park suddenly jumped to the end of its leash to drag its owner to the run.

There was the gay couple riding their bikes on a beautiful summer afternoon -- each with a tiny chihuahua strapped to his chest. (tiny yippy chihuahuas) ... then I passed a couple carrying their CAT on a leash... kitty did NOT look happy.

One of my favorites is a woman in our neighborhood who owns two HUGE and overweight bulldogs who can barely make it around the block in the august heat. She spends most of her time futilely pulling at the leashes, then coaxing and finally tempting inch by inch with doggy treats.

The point is, new yorkers are a great bunch with hillarious dogs.

Funny stuff

2010-07-05T11:29:00.004-04:00

So, recently I have a had a number of truly fabulous ER quotes. I thought I would share some of them... some may be funny, some may not...

"well, we come here 'cuz you got doctors good here, yo." Patient's primary language: English.

"Why are you putting in a breathing tube? He fell and his pinky hurts."
-- family of a stridorous patient being intubated for respiratory distress.

me: "are you pregnant?"
patient: "no..."
"you're pregnancy test is positive."
"I'm on birth control!"
"well, amazing things ARE happening here."
"huh?"
"Pee in the cup again."

"well, the blood transfusion raised your hemoglobin from 3 to 6."
"great! so you don't need to admit me anymore?""no..."
"so, one more unit and it will double again and then I'm ok?"
"uh, no. It doesn't really work like that. You're still bleeding. Which is generally considered bad."

"Why do I need surgery? It's just a stab wound."
"You cut the artery. That's why the blood was pumping out."
"so, you can't just give me stitches?"
"no."
"fuck."
Charge nurse: "here's your cell phone. call your mother." (patient's scowls, charge nurse raises an eyebrow and shakes the phone, patient takes phone)

In Remembrance

2010-05-20T20:00:00.004-04:00

It has been forever since I last wrote in the blog. Many things have happened -- work, birthdays, vacations, fun times... and I plan to write about all of those, but this post is about something else.

This post is about a being very special to me -- Oscar, one of my family's cats. Born in late 1998, my family adopted Oscar and his brother, Felix from the North Shore Animal League in early 1999 and he was always a wonderful kitty. Being in high school at the time, Oscar and Felix were the first pets my family owned who were pretty solely "my" responsibility -- they lived in my room, their food, water and kitty litter were in my room and I cared for them (and dealt with them waking me at 4:30 in the morning with the now-infamous "double-pounce").

Oscar was instantly dubbed the "purr-box" or "motorboat" for his loud purr heard across the room and incessant demands for attention. Always more outgoing than his brother Felix, he was also the "smart" one of the pair (we missed on the odd couple naming).

Recently, Oscar's health had been deteriorating... he required multiple surgeries to repair problems with his colon. His kidneys were starting to fail. He was loosing weight. 6 months ago a vet recommended we put his to sleep. At that time, my family declined -- he was still running around, purring and head-butting everything as always.

A few days ago my parents called me to see Oscar -- his health had taken a turn for the worse and the decision was made that it was time to let him go. We all miss him sorely -- especially his brother, Felix, but we are all getting through. And so, I raise my glass and drink in remembrance of one fine kitty.

On Restraint (or Lack Thereof)

2010-03-26T18:55:00.004-04:00

I'm sick.
For the 3rd time in the last month.
It hasn't been a good month in that respect.

So, I'm feely crappy. I sleep, drag myself to the shower and then decide "you know what? I'm going to lie of the couch and listen to some relaxing music." I sifted through my iPod and picked 1) August's Rhapsody from August Rush, 2) Massenet's Meditation from Thais and 3) Ravel's ballet, Daphnis and Chloe.

The Daphnis is actually what spurned this post. Maybe it's just because I was lying with my eyes closed the only task on my mind to listen to the music or maybe it was because I had a headache and had therefore tweaked the settings on my stereo to turn to volume down and flatten the dynamic range so the louds were softer and the softs louder... I don't know. What I do know is that the Daphnis just sounded so controlled -- too much in control.

A few years ago I had the opportunity to hear one of my favorite pieces, Stravinsky's Rite of Spring, played by first a professional orchestra and then the Julliard Symphony in the same month. The Rite is an incredibly challenging piece and is seldom performed by professional orchestras. It is much more common as a graduate orchestra piece -- something for the soon-to-be professional musicians to sink their teeth into and put on their resume. I forget which professional orchestra I heard -- not the NY Phil... maybe the London or the Berlin.

What struck me about the two performances was that I enjoyed the Julliard Symphony significantly more than the professional orchestra! Sure, the professional orchestra's version as technically perfect -- all of the complicated rhythms and counter-themes interlocked exactly. All the dynamics were there, the tempos were accurate and the precision of the performance was incredible. Amazing what a group of professional musicians do when they really concentrate!

The Julliard Symphony was not technically perfect -- a flub here or two. The themes interlocked beautifully, the tempos and dynamics did more than just give a professional orchestra a "run for it's money." They were professional. These were the best musicians in the country playing at the peak of their masters degree education. Here were performances by two groups who should have been on a par but, in my opinion, the Julliard orchestra blew the professional orchestra out of the water!

Why? The Julliard orchestra got excited over the music. You could feel in the crazy, fast, intricate sections that the orchestra was just one hair's breath away from flying completely out of control. The rhythms caught with milliseconds to spare almost like when you have two interlocking cog-wheels but they don't interlock well and there's that second when you say "oooh, it's not going to work" and then the wheels catch and turn to the next cog. The tempos pushed just on the leading edge of the conductor's beat with the conductor holding his students in with the sheer mental will of making them follow him instead of the other way around.

The professional orchestra, as I said, played the piece flawlessly. I cannot find any way to fault the performance but to say that during their performance, I sat back and enjoyed. During the Julliard performance I was on the edge of my seat, gripping the armrests chanting in my head "yes, yes, get that! Yes!! eek eek eek... yes! got it! go!" with my jaw hanging open at the sheer enormity of the performance I was witnessing. My head was reeling with the Julliard performance for days.

That's what classical music is REALLY about.

A sad story...

2010-02-05T10:00:00.000-05:00

I know I just wrote an entire post pretty much criticizing my time on the pediatrics floor, but there is one case the will stick with me.

There was a patient who my service inherited from one of the other pediatrics services because the attending on my team was willing to take on this very difficult patient. Ms. M turned out to be a patient that I had seen around the floor on numerous occasions. I always wondered what was wrong with her because the poor girl was always crying and seeming to be in severe pain while walking around the floor. She looked to be about 12, always was hunched over, face contorted in pain, wailing or, on a good day, snuffling as she walked past with a feeding tube dangling from her nose. While working on the floor, I could hear wailing coming from her room on a regular basis.

When my team picked her up as a patient, I was curious to find out what was making this little girl so sick.... Turns out she wasn't a little girl. She was actually 17, looked 12 and acted 3. She had major depressive disorder, severe fear of abandonment and anorexia nervosa as a result. Ms. M was being force-fed through the feeding tube to keep her alive. She would periodically vomit up her feeds due to emotional distress. Her parents would string her along about visiting and then not visit for days on end adding to her fragile psychologic state. When her parents finally did show up the first week we had her, they asked if they could just take her home to let her die. Needless to say, they were sharply reprimanded for that statement by the senior medical staff. Unfortunatley, they had said it to Ms. M as well, which caused two days of the worst wailing and crying I have ever heard -- it was horrible to bear.

I always tell people that there are cases you come across that bring home the severity of a disease for you. Those are the cases that make you respect a disease entity. A prime example is Asthma. So many people have "asthma" (there is a theory, actually, that many who are diagnosed with asthma may not actually have it). There is so much mild asthma out there that it can be easy to brush it off as "not that bad." After seeing my first case of truly life-threatening Asthma, I will never underestimate the disease again.

For me, Ms. M is my bar -- my disease-defining entity for anorexia. To say I was shocked when I learned that she was 17 is an understatement. To watch her suffer with the psychiatric burden to the point that her parents were willing to let her die to relieve her suffering was jaw-dropping. Not only were those things amazing to me -- but to watch how a firm hand, a set of rules, absolute 100% structure could turn a patient around was one of the most interesting things I watched on Pediatrics.

Immediately after the "can't you let our daughter die" conversation, the attending on our team decided to structure absolutely every aspect of M's life -- including demanding and holding her parents to a daily visiting schedule with set arrival and departure times. She had a daily schedule posted in her room with shower time, school, nap, everything written in. She had rules about where she was allowed to do what -- she had to vomit in the bathroom, she was not allowed to have the vomit basin in her bed. There was much more the the elaborate plan, and somehow it worked. I returned from a weekend off to discover that M was eating of her own accord. Another week later, she was smiling as she walked the halls. Another week after that and she had befriended one of the much younger patients and we would seem them laughing as they walked. It was a different person from the one who had caught my eye my first days on the ward.

She has been transferred to a long-term psychiatric care facility specializing in adolescent eating disorders. I hope they can continue the work that was begun in the Children's Hospital and that someday Ms. M can go home to her family.

It's been a while

2010-02-03T19:30:00.002-05:00

I know, I know, I'm a horrible blogger. I go for long stretched of time without writing anything!

Let's see, I was noticing that my last post was about Jason's wedding in Oklahoma. What have I done in the past month?? I've been on the Pediatric in-patient floor in the Children's Hospital of New York at Columbia. This is a rotation that has gotten fairly unanimously panned by my co-residents. I am pleased to say that it was more enjoyable than I was expecting!

As part of training for emergency medicine, we do a number of "off service" (ie- out of the ER) rotations. The goal is multifactorial. First, the foster relationships between the ER and other services. Second, to give us some compassion towards our colleagues when we wake them up at 3am to admit a patient. Finally, to hopefully teach us a bit about the specialty.

Here is the problem: (mostly, it's reason #3). Interns in places outside of the ER and pretty much overqualified underpaid secretaries without any responsibility to make clinical decisions. In fact, on the peds ward, the intern is the equivalent of a trained monkey. Clinical decision making is actively discouraged. I wrote notes, I put in orders, and I answered mundane questions. That being said, I had a good month. I got in a 6am, got my work 90% done by 7am, rounded until noon, had an hour off for lunch (!!!!!), rounded from 1:30-2:30, finished the last 10% of my work and then went home generally between 3-4pm. In-between I played lots of solitaire and had all my decisions made for me by my seniors.

Did I just say 3-4 pm?? yep. I did. I was like being a normal person!! And with Rob currently working from home, he was there! We got to eat dinner together, go out with friends, meet other people for drinks... sigh. We've never seen more of each other than we did this past month and that was worth all the frustration and solitaire-playing that occurred while on Peds. The number of game apps on my iPhone doubled over the past month... I kid you not.

What else did I learn from peds? I'm not going to have kids anytime soon. I can do the little babies, their cute and not that bothersome. I can do the teenagers -- despite the attitude at least you can talk to them (even if logic probably doesn't apply). Everything in-between I can do without. I am sure that when I do have kids someday I will be all about every phase of their lives... just hell no, not yet.

Sum up: it was a nice, relaxing month where my days were filled with an hour and a half's worth of work spread out over 10 hours and I got to enjoy having a wonderful relationship with a fabulous, handsome man. ;) siiigh... back to work (yessss!).

Ooooklahoma, where the wind comes sweeping down the plains...

2010-01-03T16:39:00.002-05:00

Yep.

In the past 72 hours, I have visited 2 new states for me -- Texas... and Oklahoma. "Why?" you might ask. Rob's good friend from his childhood, Jason, got married this past weekend in Oklahoma City to a very cool gal, Cathy. Rob had the honor of being a groomsman.

When we first got the invitation, we just assumed the wedding was in Philadelphia. Or the midwest, where Jason used to be. Careful scrutinizing of the invite showed address, address, address... Oklahoma City. eep. Two hard-core northeastern city-ites had already RSVP'ed "yes" before realizing where the wedding was. So we sucked it up and went to Oklahoma.

We get off the plane and look around at the wide expanse of flat. Trees here and there, but mostly flat. Meh, it's the plains. (by the way, we had to look up WHERE Oklahoma was on the map in the airport). The airport was empty even though it's 3pm. Walking outside the terminal at the "taxi" sign we could almost hear the crickets. Not a car in sight. Fortunately a passing security guard showed us where the single taxi was hiding, behing a giant pillar in the outermost lane. He was a friendly guy, instantly chatting away with Rob (I don't handle "interested" cabbies very well -- too much paranoid new yorker in me).

By the end of the cab ride, Rob and I were giving each other the "oh dear god, what have we gotten ourselves into!?!?!" look. Fortnately, the cabbie was the only scary interaction in the trip. He did have one good line: He reminded Rob, "now, we here in Oklahoma are nice people. It's not Vegas. What happens here will get back to that pretty lady there."... I think I might have snarled at that point.

The city was dead quiet over the weekend. The downtown skyline is 3 buildings about 20-30 stories tall. However, the people (other than the cabbie) were great! The group at the wedding were highly educated, highly intelligent and very interesting people. Jason is in the Air Force, so a number of guests were in the armed forces or married to people in the armed forces -- mostly engineers. Cathy is a trained pilot and flight instructor who now sells private jets for mucho bucks whose friends were mostly aviation people. Both bride and groom are avid fencers and they actually met at the local fencing gym (this is how Rob knows Jason). It was a fun, friendly and eclectic group of people which made for a very nice wedding. Rob stood out a little as the one groomsman not in uniform, but Rob always takes all of that in stride.

Would I go back to Oklahoma as a tourist? No. Would I go back to visit Jason and Cathy? Definately! Am I still scared of Oklahoma (total state-wide population 3 million)? nope =). Just to note that there are over 3x the number of people in NYC alone than in the entire state of Oklahoma. Just for perspective.

'

Recap

2010-01-02T15:47:00.002-05:00

Half way done with Intern Year!

how in the world did that happen!?! and why don't I feel like I've gotten much better and what I do? (in defense of that statement, I did ask one of the attendings one night when the feeling like I know what I'm doing thing starts happening... the answer was half way through NEXT year, so... )

Maybe it's just a "the more you know, the less you realize you know" phenomenon. I have had 2 successful intubations now (of 6 attempts), put in my first femoral line on my first try (yay for anatomy class), have seen cool stuff, have seen some sad stuff, have had patients drive me crazy and have had patients I really liked. I have figured out which Cornell attendings I like, which I love, and which one (singular) I could really do without.

by the way... I survived surgery. 'nuff said.

Now it's a new year and, for me, a new hospital. My entire second half of the year will be spent up at Columbia -- time to re-learn an entire hospital system, 100% new ER staff, new ordering systems and a different chart. Not to mention almost double the patient volume, at least half of whom don't speak any english. Columbia is the place where you don't bother to call the primary doctor because 90% of the patients don't have one.

wish me luck! (I'm gonna need it...)

Snowstorm!

2009-12-20T04:39:00.002-05:00

... I would like to thank this snowstorm... for keeping the ER quiet... and only creating a few Saturday night drunks instead of a ton (although the one I'm taking care of is particularly vomit-y)

ER entrance, midnight.

And The Moral of the Story...

2009-12-12T16:32:00.002-05:00

So, last night in the Cornell ER was a steady stream of interesting cases, notifications (EMS giving us a heads-up they are coming in with someone sick) and some unfortunate events.

There was the woman who tripped at a holiday party she was hosting. Turned out that she hadn't tripped -- she had had a massive stroke. Apparently there was some debate at the party as to whether she was just stunned from her fall or actually had something seriously wrong. One of the woman's friends basically said "I don't care what all of you think, I'm calling 911." Minutes are brain with strokes. The patient had tPA (the clotbuster drug) on board within 1 1/2 hours of onset of symptoms. For those of you who are non-medical, that's damn good. I later overheard the friend on the phone with other partygoers saying "See? I told you!! I saved her life tonight!" The patient's future is still very unknown (strokes are horrible and take months before a prognosis can be made), but that friend drew a line in the sand and as a result the patient has the best possible chance of making a meaningful recovery she could have.

Later in the evening a horrible case came in. A car pulled into the hospital circle and two young guys helped a third unconscious, pulseless guy out of the car, yelling for help. We brought him straight in only knowing that the patient had told his friends that he was having an "allergic reaction." Immediate CPR was started and the patient was asystolic (flatline). We worked on him for half an hour before calling it. It didn't make sense that this very young professional could present after an allergic reaction without any signs of cardiac activity. He never had a pulse, never had anything other than asystole... it was erie, strange and confusing. Young healthy people's hearts don't just stop. And he was young and healthy.

You work longer and harder on the younger patients for a number of reasons. There's the obvious -- the patient has so much left to life. There 's anothe reason, their hearts are more resillient. Let me explain: There was a heartbreaking arrest a few weeks ago in the hospital. A young, previously healthy person arrested on the main units. Every medical resident in the hospital that night assisted with that code. They coded her for two hours and eventually lost the patient. Why? Because they kept getting her back and loosing her again. This is how you expect young person arrests to be. Horrible, full of hope that gets dashed over and over again. I was in one on my surgery rotation. We kept getting a heartbeat back and we would all take a deep breath and feel the pulse... strong... strong... not as strong... moderate... weaker... gone... fuck! Start compressions!

Back to our guy from last night... he never did what I'm talking about. He was the same age as the other examples I gave, but his heart never gave an inkling. Maybe that was the most confusing part. It just didn't fit and it was hard. What were we missing? What was the silver bullet that would make this guy's heart wake up? We threw every drug we had at him -- nada.

Over the hours following his arrest, more of the story of the events of the night came to light. He had severe food allergies. He was at a holiday party for work and started to have an allergic reaction. People wanted to call 911, but the patient wouldn't let them. He and a friend went trekking across the campus of the facility to go to his locker in search of an Epi pen. None to be had. Then back to his office -- maybe it was there. Nope. They decided to drive him to the hospital but the car was in the 3rd sub-basement. The patient got in the back, his two friends in the front. At this point, the patient stopped responding to his friends. They drove... but they didn't know where the hospital was. It took them 10-15 minutes to find us. The rest, some might say, is history.

No one is to blame for any of the events in any of the examples here. The young man's friends lifted him and carried him bodily into the ER for help. They yelled encouragement to him from the other side of the curtain. The older woman at the party had significant slurred speech seeming like confusion.

The lesson is that one of the hardest thing to do is to stand up to your friends. To go against the group decision or against your friend's own decision. To be the "bad guy" who caused embarrasment by calling 911 for "nothing." It might not be nothing. Forget all that "do what is right" bullshit -- I think it is nearly impossible to live a completely morally just life. I would say, if you're scared, do what will make you un-scared -- whatever that may be, I find that it usually involves getting backup.

Happy Thanksgiving!

2009-11-28T16:48:00.003-05:00

Happy Thanksgiving, everyone!

I find myself in Philadelphia with Rob's family for the second year -- something which I enjoy very much. It's always fun to be with someone in their "native habitat"... in Rob's case, this consists of his mother (who has a special place in my heart for putting me up last year for an entire month), the younger bro and lots of family friends. Thanksgiving this year was a big event consisting of 13 people around one giant table in one tiny dining room. The food didn't fit (never does) so it lived on a separate buffet table. There was a wide smattering of ages from high school, college, us 20-somethings, some 30-somethings and, of course, the parentals who were actually the significant minority!

All in all, yummy, warm, excellent wine selections (thank you, Rob) and then a nice long lie-down on the living room floor in an attempt to digest. Good time =).

The gang...
Nan, Lucas, Ryan, Angela, Marcelle, Alex, Nora, Danielle, and Jeff
in line for the buffet =).

Vacation, Part Deux

2009-11-02T14:50:00.006-05:00

Where did I last leave off... oh yeah, in DC, at G's. DC was great -- Genevieve and I went to the National Opera Trunk sale and got great halloween costumes (see bottom of page).

Chicago was tons of fun -- Aileen was slaving away in MICU (ugh) but still managed to take me to FlatTop -- one of my FAVORITE restaurants of all time! FlatTop seriously needs to come to NYC... I say this when they only just arrived in downtown Chicago. Aileen took me to the new location in the Loop that has only been open for a few months.
Ashley took care of me for the rest of my chicago stay, including super yummy oysters at Shaw's Crab House -- live music, fab seafood. Overall, the dinner (with two glasses of wine each, and dessert) was incredibly reasonable!! Not something you would expect from a restaurant just off the Loop, valet out front and the after-work-suits piling in. We opted for the significantly more casual Raw Bar half of the restaurant due to the jeans we were wearing and LOVED it!

From Chicago, I jetted off to Seattle to visit Dave and Katie. Katie and I spent the day bumming around Seattle with a trip to one of my favorite stores ever -- Fireworks, and then the Seattle Mystery Book Shop which is wall-to-wall, floor-to-ceiling Mystery Novels. Katie was in heaven.

The highlight of the stay was definatley dinner at the Purple Cafe and Wine Bar with Dave, Katie and Nolan!! It was great to see Nolan -- who I hadn't seen in literally 5 years! The four of us caught up, tasted through a bunch of wines and had a fabulous dinner.

I highly recommend the restaurant -- it is a new favorite of mine in Seattle! The wines are great, the food is delicious, but the also have a sense of humor. The wine list opens with "The Book says "the apple tempted eve."... our book says "it must have been the grape."" The entire list is covered with little jokes. I still know next to nothing about wine, but we ordered a few fleets of which each fleet definately had one "looser" wine and one major "winner" wine.

Of the "Bullfighter" flight of 100% spanish wines (we ordered it as a tribute to the absent Rob), Atalya Amansa 2007 was the winner. From the "Pino Noir" fleet, the Erste & Neue Kellerei "Mezzan" 2007 from the sudtirol-alto region of Italy was the clear winner. Rob wrinkled his nose when he heard that, but it was the best of the bunch!

Returning to NYC and work kindof sucked. It was so great to see everyone, but time flies. I'll leave you with a Halloween picture displaying the awesome Kimono costome I picked up with Genevieve in DC!

Rob, Me, Elena and Alex on Halloween.

Enjoying NYC once again...

2009-10-19T16:35:00.008-04:00

Took a while, but I finally got back around to enjoying NYC -- or just enjoying everything in general. I just finished a month on the Acute Care Surgery service at Columbia Presbyterian Hospital. I learnt a lot, I worked hard, did 30-hour call (horrible) and actually had a good time. The Surgery residents at Columbia are a fantastic group of people and I had the tremendous help of someone who has helped generations of NYP EM residents survive surgery -- Voula, the acute care surgery service PA. If most PAs are worth their weight in Gold, Voula is worth her weight in Platinum. phew!

First, there were the 3rd row seats in the endzone at the Eagles game in Philly...
I was going to go SCUBA diving during this time off, but that all fell through, mostly due to the fault of annoying bosses and failure of appropriate planning. Oh well. That's why I live in NYC and can salvage! Then there was taking Deka to the dog park (she was spade and forbidden to run for a month). She was so excited, she ran laps for the first 15 minutes. Deka is now 9 months old!!!

Thursday found me at Carnegie hall with Elena to hear Hayden's "The Seasons" -- a piece I was completely unfamiliar with. Turns out that Hayden drew significant inspiration from Handel's Messiah for this work and it was really beautiful! Full orchestra, full choir, soprano, tenor and bass soloists. Each "season" was unique. Spring was calm and pretty, Summer was a little weird because it had a sad feeling to it, however Fall was fantastic with the "hunt" and the french horns going bells up and balls out crazy and Winter was full of BIG choral stuff with a necessarily rousing finish.

All of this was followed by a weekend in DC w/ my college roommate, Genevieve and her husband, Bren which included a stop by the National Opera Company's Trunk Sale where they were selling old costumes -- both G and I walked away with kickass halloween costumes from Madame Butterfly (Bren stayed home).

Now I'm in Chi-town visiting Aileen and Ashley. Irony of ironies, it's actually warmer here than in NYC (as in, 53 instead of 48, but I'll take it). From here I go to Seattle to see Dave and Katie for the first time in almost a year and a half!

..More pictures later. I kindof forgot my camera charger, so I'm taking pics VERY sparingly. oops.

NEJM does it again!

2009-10-19T11:48:00.003-04:00

So, I'm browsing, killing time (on vacation, I might add) and decide to see what's doing on the NEJM website. I get there and the top story on the website is this: Interactive Medical Case- A Bloody Mystery.

Wait... interactive?? So I click the link and guess what? This is FABULOUS! There is a reason why the NEJM is considered the preeminent medical journal and innovations like this are it. This is a case, presented in pieces (the usual horrible puns apply) with frequent breaks where you "order" lab tests and "create" a differential diagnosis then reassess and "order" more tests/treatments. There are charts, tables, MOVIES, images. Even better, this isn't the "one correct answer" format. It's the "which 5 of these 15 potential diagnoses could this patient have?" There also isn't any sort of giant ERROR buzzer, either. You choose your answers, the green checks and red "x"-es appear and you read an explanation of the answer.

Did I mention the excellent explanations? Sometimes a little too helpful before you click on your answers, but that's what learning is about, right?

NEJM is famous for its long-established "Case Records of the Massacchuttes General Hospital" in which docs get to read a round-table discussion of a complicated case with a number of experts weighing in. Very valuable -- med students everywhere are told to read it -- but its dry and complicated as hell to follow. They literally transcribe the round-table discussion verbatim. I feel that this new interactive case format accomplishes the same goal but I actually learn becuase I'm participating and actually care (I admit it... I don't like to get questions wrong).

Overall, two thumbs up.

While I'm at it, I'm going to put in a one-line plug for the NEJM "Image Challenge" on the website. This shows pictures of pathology -- anything from photographs, radiology, microscopy, gel electrophoresis...etc. You pick the answer from the multiple choice on the side and get told right/wrong. Quick, visual recognition, great for keeping your brain plugged in on overnight where you have to stay awake but don't have the energy for more than a mouse-click.

Could Hawai'i be generalized?

2009-10-18T11:21:00.002-04:00

There is an article in this weekend’s NY Times that I found very interesting. It’s about the healthcare system in Hawaii – and how GOOD it is! The authors cite that Hawaiians live longer than any other state in the union and they they are generally healthier. The doubters among us say “no shit, Sherlock. It’s BEAUTIFUL all the time!!” However, there were some more intriguing tidbits in the article that made me wonder. Hawaii has the highest rate of breast cancer in the US, however, they have the fewest DEATHS from the disease of any state. Hawaii has the highest percentage of insured in the US and the lowest Medicare costs (possibly again contributable to that whole tropical paradise thing).

But really, the least number of uninsured? Massachuttess has the next lowest number of uninsured at 20%. Hawaii’s uninsured # is 10%. What’s going on? There is a law in Hawaii that every employee who works a minimum of 20 hours per week must have health insurance. Sure, there are people who try to circumvent the systems, employers making sure their employees only work 17 hours per week so that they don’t have to pay insurance, but generally the plans are cheap, no deductible, widely accepted and easily suffice for your average fairly healthy tropical paradise inhabitant.

I was puttering along this article until I hit the section where they start talking about the ERs in Hawaii. The author interviewed an ER doc who spends part of his year in LA and part in Hawaii. He described the Hawaii ER experience as “greased lightning.” Nationally, there are 400 ER visists/1,000 people annually. In Hawaii, that number is 200/1,000 people – half the national average. Again, you could make the tropical paradise argument, but Hawaii is not without its dangers. Anywhere there are highways, there are high-speed car wrecks. Just because the live in paradise doesn’t mean that Hawaiians don’t suffer from heart disease, asthma (highest rate in the US), COPD. Not to mention the kind of trouble the “touristas” can get themselves into with the vast number of adventurous activities available in Hawaii – there’s surfing, jellyfish, climbing, diving, parasailing, base jumping, heat stroke… all recipes for tourists ending up in the ER.

So why is this mystery ER doc saying that Hawaii’s ERs are “greased lightning”? The theory proposed by the article is that there is much better access to family care practitioners and general primary care docs, so patients go to their doctors for all the minor stuff rather than to the ER. i.e.—appropriate use of the primary care physician and the ER. This is something that I am continuously advocating as the root of our healthcare crisis—lack of access to primary care. I also always say that this is not going to be fixed without a massive expansion of our clinic system. The system as it is right now is at its breaking point on all fronts. This is the point at which Rob jumped into to play devil’s advocate.

What is the ratio of primary care physicians to population in Honolulu vs. NYC or Philadelphia? Barring that, what is the population difference? What kinds of numbers is each hospital on Hawaii serving in beds per population vs a NYC hospital? How many insured use the ER vs. primary care for minor complaints? How sick ARE these people in Hawaii (tropical paradise argument again)?

I’ll have to do more research and get back to those valid questions. For now, it appears that the spin on the NYTimes article agrees with my personal opinions – we need more primary care!

Hawaii’s system is not without problems. A number of the hospitals, especially on the outer islands, are failing. The rate of uninsured is increasing due to the current economy and the system is not built to handle the uninsured right now – it is a system built to handle almost 100% insured. It is interesting to wonder if the resources and the finances will be able to withstand what is to come. Also this whole “greased lightning” thing… I can’t see it. Maybe an entirely decompressed healthcare system works. I just don’t know.

Puppy Update!!

2009-09-20T11:41:00.007-04:00

My parents are still gladly suffering through "ridgeback puppyhood" with Deka, who is now 8 months old! Rob and I went over for some sukiyaki the other night (and some furrball time).

Sukiyaki = the best food EVER. Japanese mish-mosh of yumminess.

Back to the nonexistent point... I was really impreesed with how Dek is doing! She is obeying commands and actually didn't eat a single scrap off of hte knee-height coffee table! The whole point is to just share some pics to the pets! =).

Sashi looking regal as ever :) (and begging for food)

The not-so-small-anymore baby looking somwhat sad at having to be good.

Felix finally figured out a way to hide and still be pet --
the pup can't see him, but we can!

Oscar is more brave...venturing all the way out to the couch.

The Tale of A3

2009-08-26T15:16:00.002-04:00

I've been working night for almost a week now. I like working nights -- I prefer the patient population and the structure (starts out busy, tapers off) and by about 2am, whoever is coming in is genuinely sick. That being said, there can be nights like last night (I slept!) or there can be nights like what is now being called "A3 night" among the residents.

I walked into shift. The ER was packed, the rack had 3 or 4 charts in it, the signout was clean (fortunately!) and I picked up the first chart -- 50 year old guy with syncope. groan.
(translation of above for my non-medical friends: there were 3 or 4 patients to be seen, signout is patient handoff from one doc to another at the end of shift so that care continues and being "clean" means that there isn't much to do on the patients who are being transferred.)

Syncope (fainting) is the presenting complaint for 1-3% of annual ER visits nationwide. There are over 112 million ER visits per year according to the CDC, making syncope account for up to 3.3 million ER visist per year. As a comparison, "chest pain" accounts for approximately 6 million visits per year. So yeah, syncope is common. Of pateints complaining of syncope, only 34% get admitted to the hospital and, of those only about half actually get diagnosed with a cause for their syncope -- this doesn't take into account the patients who complain of syncope and then upon further questioning turn out to have had "near-syncope", aka- lightheadedness. I couldn't find a number for how many patients fall into that category, but I promise you it is a LOT.

Back to the "Tale of A3"... I'm looking at my guy, who is sitting up, awake, alert, telling me he feels kindof silly for being in the ER. I haven't laid hands on him yet-- we're still in the talking phase -- his monitor looks good, EKG normal, normal heart rate, normal blood pressure, normal oxygen content, but first thing I notice is, "wow, this guy's story sounds like he really did loose consciousness!" He doesn't have any medical problems, no medications, no allergies, no ciagaretts, no alcohol, no drugs, nada. I ask if he felt anything funny before passing out and he looks at me and says "You know doc, I'm kindof feeling it right now. A headrush thing..." aaaaand he's unconsicous. I look at the monitor and he is asystolic!!!! Heart NOT beating. Well fuck.

I call for help, sternal rub him to wake him up, I'm about to lay him out and start chest compressions when he wakes back up! He was out for about 5 seconds -- by the time the rest of the ER staff arrives they're looking at me like I'm crazy because his heart is beating and the patient is like, "I can't believe I passed out again!!" This episode made number 3 for the day.

He does it a fourth time about 20 minutes later, this time while the nurse is with me. Everyone sees that one. We need cardiology and we need them 5 minutes ago. I go directly to the top and page the SENIOR fellow (this is kindof ballsy for an intern) "ED STAT"... I didn't even leave a phone number. (later he told me he thought that the page was hillarious) But he appeared in about 2 minutes, so it had the desired effect.

Recap: I have a patient who is going periodically flatline on me, crash cart is OPEN at beside, code meds are already drawn up into syringes, the senior cards fellow has no clue what is causing this becuase the guy's EKG looks like it could be in a textbook under "normal," and the patient is looking at all of us like we're crazy 'cause he feels fine.

He can't be moved from the ER becuase what if he goes asystolic and this time doesn't spontaneously recover. It's too dangerous for him to be being wheeled down a hospital hallway when that happens. But he NEEDS to be in the cardiology intensive care unit.

The decision is made that we need to put in a pacemaker in the emergency room to take over triggering heartbeats when he heart pauses. It's simple -- we thread electrical wires through a vein in the patient's neck into their heart. However, before we can do that... the patient's heartrate starts to slow to the 20's. We're all thinking, "here he goes again!" Nope. This time, he has a seizure! (actually, "seizure-like activity"... medical technicality) and afterwards he is vomiting, confused and has zero short term memory. We went from conversing with and intelligent, cognizant guy to: "wha? who're you?" "I've been passing out? NO WAY! SERIOUSLY? duuuuude." "Why is my wife here?" "Wha? who're you?" ... repeat. He couldn't follow commands any more because he couldn't remember them and he was vomiting on top of that. The decision was made to intubate the patient to protect him from inhaling vomit in his confusion.

After that, things went much more smoothly. He had another episode of asystole while I was placing the pacemaker (I got to put in a transvenous pacemaker!!!! SO COOL!), but otherwise, things were ok. He went up to the Cardiac Internsive Care Unit where he got a multi-million dollar workup, a permanent pacemaker was surgically placed and he was discharged after 4 days -- the cardiologists still had no clue why his heart was stopping.

That was the first 4 hours of my shift. Cleanup takes an hour (the room looks like a hurricaine hit it). Next up in A3 was a ruptured ectopic pregnancy who got rushed to the Operating Room in about 20 minutes flat. We were able to diagnose her rapidly with a life-threatening condition and get her to help. Later, the Ob/Gyn came down and told us that she had over 3 liters of blood in her belly and they were able to successfully stop the hemorrhage. Yowzer.

Clean the room again (antoher hour becuase it looks like another hurricaine hit it after the ecotpic -- running around to get IVs, blood, fluids, ultraosound, yada yada.) and a little old lady comes in. Another syncope. Moderate language barrier and no one around who speaks Mandarin, so the story is fuzzy, but it sounds like she's having seizures. However, she's sitting in bed looking all cute and normal. Ok, chill out, we'll get Neurology. Neuro's evaluation gets interrupted becuase a stroke rolls in, whatever, she's fine.

All the docs are chilling back in the doctor's room, we're tired, it's been crazy, things are finally settled, the stroke is in the MRI and it's 6am. The overhead comes, "doctor needed in A3." again!?!?! Yep, little old chinese lady is having a seizure. Well, at least that's confirmed. She's gonna be admitted to Neurology. However, her seizure isn't breaking despite medications. Takes about 20 minutes, but we finally get the seizure to break and once again, the room looks like a tornado hit it. The nurse is begging us not to put any more patients in her room and just let her finish the last hour of her shift in peace!

Fortunately, that is exactly what happened. =)

I leave in the morning, sun is up, it's a hot August day and I look around -- it's weird to be outside. Every once in a while we get a gift. A reminder of why we spend our days and nights inside with beeping machines, no windows, drunks, crazies, the smattering of rediculous complains, disgruntled people and admitting residents who resent that you are making more work for them. The story above is why. This is what I do. And this is why I do it. Damn straight.

Rachmoninov

2009-07-30T17:56:00.004-04:00

So, friends both new and old have begun calling, E-mailing and texting to find out if I am still alive! I am -- no fears. However, I am currently working in the Medical Intensive Care Unit, which is occupying more than a significant portion of my life.

I was originally going to talk about my experiences there over the past few weeks -- especially last night when I was on 24-hour call. I shocked my first cardiac arrest (and brought him back!), watched the 3rd year medicine resident perform a procedure that currently takes me about 20 minutes in about 30 seconds flat in a crash situation... and much more. Crazy, amazing 24 hours of my life.

However, sitting here in my living room listening to Rachmoninov's 2nd Piano Concerto on my formidable and kickass stereo system, I realized that I have talked about many things on this blog, but am yet to mention a final HUGE aspect of my life -- music.

I grew up in a home where we didn't leave the TV on -- we left the CDs playing. Continuously. Beethoven would be blasting on the first floor, Mahler on the second and some version of whatever was popular at the time on the third (my room). Every day when I came home from school I had to do my homework (like every kid), clean my room (never did that) and practice both Flute and Piano. At my peak in high school, I was playing the flute at least 6 hours a day between rehearsals and practicing. Without enough time to practice at home, I would practice at school during lunch and my other free periods. I was in literally every musical group in my high school (except for Jazz Band) -- and there were quite a few! I also spent a full 10 years from the age of 12 to 22 first in local youth orchestras and then in the non-music-major orchestra during college.

Music brought me to lifelong friends, took me all over Europe, brought me skill and accomplishment -- brought me solace.

Medical School threatened to kill all that.

During the first months of medical school I left music. I thought I needed to focus -- work harder than ever. After a few months of wondering why I hated my life so much I called my parents -- could we get my keyboard from Grandma's in Florida? Something in my voice must have told them I was in dire straights. Without hesitation or questionning I had the keyboard in my dorm room within a week. My mood improved immensely with playing. I had learned something valuable -- music wasn't something I did. It was my sanity.

I resumed flute lessons with my long-time teacher of now over a decade -- Mr. Jones. Maybe even more so than the playing, Mr. Jones became a rock for me during medical school and now during residency. Having no connections to the medical world, I could go to him every weekly and vent my frustrations (a lot of "look what medicine DID to me this week!") and he would be outraged, threated to lock me in my apartment when I needed to study more and generally kick my butt my drilling the music for a hour so I couldn't think of my frustrations.

Now I practice on my off days (which are rare), struggle to go to the Philharmonic as much as possible and usually listen to my iPod in the hospital in the morning while reviewing the computer for overnight events on my patients. It is not the satisfaction I used to get from playing an orchestra, but it is a compromise for now.

Enjoying NYC

2009-07-19T19:03:00.002-04:00

Announcement: I have *officially* completed my first month of residency!! (only 46 more to go, as my Residency Director likes to point out...).

Over the past month I have done some cool stuff (I pushed tPA on a patient!! my med peeps will know what that means. It was very anticlimactic, but cool nevertheless). I have had lots of lectures and educational time as the program eases us into reality. I have made mistakes but fortunately haven't harmed anyone. One huge thing is that I have been talked to a LOT about how HARD intern year is and how important it is that I make the most of my free time.

Being that I am more than a bit of a homebody, this could present a problem. When I am busy and working hard, I am much more inclined to just drop dead at home when I have a day off. My seniors and attendings, however, are telling me that such behavior will lead to a never-ending spiral that ends in hating life. Or something along those lines.

So, I decided to start out strong and have been really enjoying myself during my free days (of which I have had 4.) and Rob has been a tremendous help in working towards this goal.

First off, there 4th of July, when I showed for a shift I wasn't supposed to be working. My salvage: a day on a beach in the Hamptons with Ted (Rob's old roommate) and his family and, ofcourse, Rob. I even took the midnight train back to NYC and had that song "Just a small town girl, livin' in the lonely world... took the midnight train going aaaany-where..." stuck in my head for the two hour ride back. The day was, in a word, fabulous.

Then there was last Sunday, when I hung out with friends on Saturday night at a wine tasting, slept until 11:30, went to fancy-schmantzy brunch at Sarabeth's with friends, discovered that Rob and I in a Barnes and Noble is a recipie for spending WAY too much money and then ended up down at Battery Park looking out at NY Harbor and reading for the afternoon.

This weekend I actually had BOTH days off (amazing!) and I've met new people, gone to brunch x2, took Sashi and Deka to the park, spent the day at Coney Island and am now in the process of cooking some genuine russian dumplings from Brighton Beach. Again, so great!

I think I need to keep this up. (Here's hoping I can!)

Back into puppyness...

2009-07-09T19:51:00.005-04:00

It's been a while since I wrote about the antics of my parents' new puppy, Deka. She is now 5 months old and is just barely starting to show some signs of calming down... sometimes.

My mother recently convinced me to go with her to Deka's dog training class. The puppy decided to buck and whine every time another dog was getting attention that she wasn't. She sits like an angel (my mother had taught her that when she was 10 weeks old). The "no jumping" training was a complete and utter failure. The best, however, was the "come" training.

For this exercise, the trainer stands on one end of the room attempting to hold the dog (usually an easy job... until you separate Deka from my mother, and then you have a bucking, whining, crazed 60lbs of muscle) and the owner stands at the other. When the dog is released, the owner calls the dog and tries to get the dog to come to them. The other dogs looked like this...

Deka, however, looked like this...(That's Deka a few weeks ago at the doggy park.)

She went careening across the room at a FULL SPRINT, crashed into my mother at full tilt, bounced off, shook herself off, spun around a few times and promptly sat to receive her treats. Not only that, but she did it three times! The whole thing was hillarious, but I think the funniest part was the absolutley careening into my mother each time rather than stopping BEFORE knocking her owner over.

I'll leave you with a few more Deka at the doggy park shots.

Yeah, this last one is Deka sniffing the butt of a Great Dane. So funny.

What makes a Trauma Center?

2009-07-04T12:39:00.002-04:00

Numerous recent conversations with friends of mine have brought me to seek an answer to the question, "What makes a trauma center?" I run into this all the time because Columbia is a Level II Trauma center while Cornell is a Level I Trauma center. What do these different designations mean?

The concept of the "trauma center" began in the 1960's in either Baltimore, MD (Ever heard of the hospital called the Shock Trauma Center? yeah.) or Chicago, IL (Cook County, the hospital that the TV Show ER is about). These are facilities who are equipped to handle any form of trauma care or complication 24 hours a day without delay in care.

What do the levels mean?

Level I: 24-hour in-house trauma surgeons and anesthesiologists as well as rapidly available (at Cornell, that means <10 onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://www.myds.com.au/img/game/Trauma-Center--Under-the-Knife-1.jpg">es. In addition, Level I's must be conducting active scientific research into trauma care, be involved in trauma education (ie- have a trauma fellowship) and be able to and willing to act as a referral center for neighboring regions. You might be thinking this is extremely expensive. It's even more expensive than you are imagining, I promise you.

Level II: must have 24-hour availability of all the required specialties, but they do NOT have to have training programs in all the specialties. In addition, they are not required to be conducting ongoing research into trauma care.

Level III: does not have 24-hour access to all the required specialties. However, they DO have the facilities required for emergency management, critical care and general surgery for simple trauma patients. These are generally smaller community hospitals without all the specialties that may be required, such as neurosurgery or hand surgery.

Level IV: Their job is to asses, stabilize, and transfer to a higher level center. So, Columbia is a huge hospital with residencies in everything under the sun, so why is it level II? There are a number of resons. First, no super passionate trauma surgeon. Second, the ER is literally in a DIFFERENT BUILDING from the rest of the hospital. Little bit of logistical stupidity. It is just too far from the ER to transfer an unstable, hemmorrhaging trauma patient to the operating room. (lots of famous trauma centers, like Shock Trauma, have a Trauma operating room literally adjacent to the Emergency Room. The patient is moved about 20 feet to get into the OR). Third, lack of trauma research. Fourth, lack of a full cohort of trauma-specialized staff.

That is all going to change. Dr. Maruzio Miglietta is a recent addition to the Columbia Presbyterian surgical staff. He is a trauma surgeon who has trained at every big name in Trauma that exists. The guy's resume is mind-blowing. He is dedicated to increasing the level to Trauma care at Columbia by first building staff and then getting the funds to remedy the physical and logistical issues that prevent Columbia from becoming Level I. His vision for Columbia will require increased staff, development of a Trauma fellowship, resesarch (which he is already conducting) and construction to change the layout of the ER to make it more trauma-friendly. The construction is already planned -- the Columbia ER is embarking on a renovation project that will renew the facilities from top to bottom.

I, for one, am very excited about this prospect. Columbia is in a high-trauma neighborhood of New York City and yet, we don't see many traumas due to our Level II status. A recent fire on the Columbia hospital campus sent three injured trauma patients to Harlem Hospital!! How embarassing. Hopefully, under Dr. Miglietta's direction, all that will change.

Tale of the missing patient...

2009-07-04T10:31:00.004-04:00

Rob is encouraging me to collect "Tales from the ER"... and felt that this one deserved to be told.

Recently, I had a lost patient. Columbia's ER, while one of the largest in NYC (second or third) is really not that big when it comes down to it. Four rectangular patient areas connected in a line with short hallways in-between.

I sent the patient to ER x-ray expecting him to be back in about 15 minutes. His admitting doctors show up and, no patient! I direct them to x-ray. No patient. Radiology claimed they had sent him back. His wife was standing at my area's nurses' station without her husband.

Radiology didn't have him (the patient was stretcher-bound). In fact, his stretcher was still in x-ray with no patient on it. Multiple loops through every area of the ER did not reveal my missing patient. Overhead announcing his name and asking him to return yielded nothing. The surgery residents admitting him were extremely kind in trying to help my search, however they had no idea what the patient looked like! It is triply hard to find a patient in an ER if you don't know what they look like without walking patient to patient and taking names. As a result I was running around the ER with a team of surgeons trailing after me for an hour.

It should be pointed out here that (said in a snooty voice), "doctors don't run." However, we do walk damn fast.

The search expanded into the main hospital hallways around the ER. Maybe my stretcher-bound patient had wandered out... somehow. Security was notified and everyone was radioed the patients description (he looked like 90% of the patients at Columbia).

Finally, when me and my entourage made our fifth run through the ER, the patient is miraculously sitting in his assigned slot, in a wheelchair, looking definitely worse for the wear. Where had he been? CT on the 6th floor of the main hospital! Someone had taken the wrong patient from x-ray OUT of the ER and across the street and up to the 6th floor. Who takes an emergency room patient out of the emergency room!?!?! (point #2: the ER has it's own CT scanner INSIDE the ER. There is no need to patients to go to main CT in the hospital.)

The lesson for budding young doctors out there? Tell your patient the plan! I had told my patient, in detail: "You're going to x-ray. When you come back, you are going to drink contrast liquid. 2 hours after that, you are going to get at CT scan." If I hadn't, he wouldn't have put up such a fight in the main hospital CT (apparently, he caused a bit of a scene). The patient himself knew that he was lost and got himself returned to the ER. I just ran (read: walked briskly) around like a chicken without a head trailing a team of Transplant surgeons.

Intubation workshop

2009-07-02T09:56:00.010-04:00

I knew there was a reason I wanted to come to this program. They held an intubation workshop for the interns (formal advanced airway training is during second year, but they want us to at least have a clue). We walked into the room and rather than intubation supplies, the first thing we saw were splinting supplies.

(To catch my non-medical colleagues up, to intubate someone is to put a tube down their throat so that you can hook them up to a breathing machine. It is a definitive airway for patients who can't breathe on their own. No breathing = no life, so, it's important. Splinting is applying a strip of plaster cast to stabilize a part of the body and then wrapping in an ACE bandage.)

What the hell does applying a cast have to do with intubating a patient?
The pictures below illustrate what happens if you move your wrist to rock the blade back and forth... you knock out your patient's front teeth. Yet that doesn't stop most young doctors because the more natural thing to do when you can't see is to rock your wrist. BAD. You're supposed to pull UP towards the far corner of the ceiling as in the second picture.

So, how did we look while trying to do this?

Yeah EM interns!... No opportunity for wrist movement this way. (I am totally the shortest person in my class by far... Joyce, Edozie, Debbie, me, Rishi).

The thing is, this is BRILLIANT! I have been to many intubation workshops before. During Anesthesia as a third year medical student, Emergency Medicine three times (one on each rotation) as a fourth year medical student, ACLS this year, and yet I NEVER GOT IT RIGHT. This time it was easy as pie. Two seconds and I had a perfect view (you have to view the vocal cords and watch the tube pass between them, otherwise you're just going to end up ventilating the patient's esophagus, which lies right behind the airway) and in another 2 seconds, I had an airway. 5 previous intubation classes and all anyone had to do was put a cast on my wrist. So impressive.

First Shift

2009-06-26T13:38:00.002-04:00

So, I had my first shift as an "offical" ER doctor last night. Let's just say, if I wasn't used to people calling me "Dr. Hamburg" before, I am now! However, I still feel like a total fraud. Walking into the busy ER at noon to start my 12 hours, I made the conscious decision to go slow, be thorough and not make mistakes. It didn't matter how full the rack of patients to be seen got, I wasn't going to let it pressure me.

Fortunately for me, it was a relatively calm day for Columbia Presbyterian (meaning that, instead of patients lining every inch of space inside the curtains and stretchers end to end along every single wall and solid structure, there were two patients to a curtain and stretchers occupying every other hallway space).

My "welcome to a new world" wake-up call came about 5 minutes into my shift after I had seen my first patient. I wanted to order Morphine to help her with her pain, but I know that I'm not allowed to prescribe medications... or so I thought. I asked my attending to sign off on my Morphine order and he said, "You're a doctor now. This is the LAST order I will ever sign for you." whoa. (Turns out that in the ER, I am writing med orders under the auspices of the hospital and therefore am allowed to prescribe medications.)

I made it through the shift without too much stress, managed to see 4 patients (I was reassured that this was normal for a first shift), got mistaken for a nurse about a hundred times (the ER was literally 79 degrees and therefore the white coat got ditched in about 30 seconds), learned the names of 4 nurses and one unit clerk (I feel that is an accomplishment), managed one barely stable patient who continuously threatened to tank on me (just to keep the adrenaline level up), signed about 100 orders "Dr. Hamburg" and prescribed narcotics to my pain patient like nobody's business all the while desperately trying to not chew my nails with nervousness that I would overdose her.

Damn I love my job.

Chicago Urban Health Initiative

2009-06-21T11:50:00.021-04:00

Do you know what has been happening at the University of Chicago ER? No? Time you found out about the University of Chicago Urban Health Initiative (UHI).

Originally designed in 2005 as a community outreach program created to educate the South Side community about what healthcare options were available to them and how to decide when/when not to go to the Emergency Department. By the end of 2008, U of C still had the longest wait times in the country and the highest percentage of patients who left without being seen (something considered very bad in the emergency med world).

Surveys conducted at the U of C estimated that 40% of its 80,000 annual ER visits were non-emergent and did not require the services of the emergency department. When the economy really decided to tank, U of C decided to “up the ante,” so to speak. They announced that they were changing their method of triage by putting MDs in the triage area to asses need for emergency room resources. Those patients deemed non-emergent would be sent to a network of “20 community health centers and more than 60 UCMC doctors” as well as 2 participating local community hospitals for care. (hmmm… 30,000 patients… 60 physicians. That math does NOT work). The medical community swallowed this lump with difficulty and something doctors love to do called “watchful waiting.”

In February of 2009, on the heels of the above announcement, the University of Chicago hospital announced it was going to be firing 5% of its staff AND cutting down Emergency Room resources, mostly in terms of decreased numbers of inpatient beds available to the Emergency department. This coming from the hospital with one of the highest frequencies of ER boarding times up to 72 hours! Both the Chairman of Medicine and the Chairman of Emergency Medicine resigned to protest this announcement, causing BIG headlines. This was when I first learned about what was going on in Chicago. The protests worked. The hospital still fired staff, but they did not cut emergency room resources. As a result of the media attention, the UHI has come under severe scrutiny.

Has anyone died from these changes in routing strategies? No. Are the clinics complaining or the other hospitals involved protesting? No. The media drudged up one story of a 12-year-old boy who was bitten on the face by a pit bull and was sent to Cook County for surgery from the U of C ER… Of course, if you look at the date of the incident, it occurred before UHI became more strict and before the Feb ’09 announcement. In many ways, that makes the story of the boy worse (he’s fine, by the way), but not the fault of UHI.

The American College of Emergency Physicians (ACEP) rapidly came up with a statement condemning UHI’s policy of turning away non-emergency patients, stating that it was “dangerously close” to violating the Emergency Medical Labor and Treatment Act (EMTALA) of 1986 which states that all hospitals receiving government assistance (everyone) are required to provide treatment for all individuals seeing emergency medical care, regardless of insurance or immigration status. HOWEVER, it IS legal to transfer a patient from one emergency room to a clinic, another hospital or a government-run system. This clause was originally intended for transfer to better care (eg- a hospital without a cath lab can transfer a patient having a heart attack to a hospital with the ability to perform cardiac catheterization and open the blocked vessel). U of C is using a broader definition. This month, Representative Bobby Rush is calling upon congress to conduct an investigation into the UHI, specifically to determine if the Emergency Department is “patient dumping” under the auspices of the UHI – a practice specifically forbidden by EMTALA.

Emergency physicians I have talked to fall mostly on the side of disagreeing with UHI, but not for the reason you might expect. There is a fabulous editorial on the ACEP website by Dr. David F. Baehren (takes a while to load) that really illustrates the difficult position emergency physicians are currently in. On the one hand, our specialty was developed to treat the critically ill or injured. To provide life-saving treatment immediately without consideration to cost, insurance status, nationality, social status or anything else. What we have become is the one and only safety net for a broken medical system – a net that is stretched to breaking point. The actions at the University of Chicago may be the first rope in the safety net breaking. We, the emergency physicians, need help. Time for the other medical professions to step up and save us.

I essentially see the U of C’s UHI and an attempt to build a primary care network in South Side Chicago. I believe that such a network – a cooperative relationship where primary care physicians and clinics support our nation’s emergency rooms by increasing in number, making their presence known and encouraging appropriate utilization of medical resources can make a huge difference in our nation's healthcare. A strong network, where the Emergency Room physician can say “this stubbed toe can be treated by your clinic, I’ve called them and they will see you at 2pm.” And the clinic can say “Your shortness of breath is very concerning, We’ve called the Emergency Room and they have a bed for you and are sending an ambulance to get you.” Is what we NEED! Emergency physicians I have talked to about UHI are concerned about it because they worry that the network is too weak (only 38% of patients referred out end up going to 2 or more clinic visits). They worry about patients slipping through the cracks and about someone making a mistake.

As much as we suffer being the nation’s medical “safety net,” emergency physicians also take a certain amount of pride in our role as the dutch boy with his finger in the dam. There is fear that the changes taking place at the University of Chicago could become widespread in the wrong ways and thus leave the poor and uninsured without anywhere to receive treatment. This is a bastardization of the goals of UHI. Nevertheless, it is a valid concern that needs to be closely monitored.

Back in chi-town!

2009-06-13T18:10:00.003-04:00

So, this week has been.... eventful. And I have to compliment myself for actually doing something genuinely spontaneous (more so than one of my favorite activities -- setting out for an area of the city for dinner without plans and randomly picking a place by walking around... doesn't really count as spontaneous, I guess).

First off, I officially started pre-residency orientation. I got to meet all of my new co-interns, experience my first team ass-whooping in the code simulator, experience my first team rebound so that the second mock code didn't whoop our asses, got bored out of my skull in hospital orientation (because I already know the function of the hospital pharmacy), received a prescription pad that I can't use legally for another year but I'm sure will be used up in about 3 months anyway (senior residents have to sign off on our prescriptions), discovered that orientation was planned in such a way that I now have 5 days off in the middle (wtf?) and somehow ended up in Chicago on 12 hours notice.

Yep, you read that right. It ended up as 17 because of the airplane needing to be fixed (for my experience, par for the course when O'Hare gets involved in my life... whether I'm in NYC or Chicago when it happens). The point is, I am in Chicago and 24 hours ago, I had no idea that I would be sitting in my friend Ashley's apartment looking out at Michigan Avenue!

Now, off to call people, tell them I'm here, find someone to have dinner with (Ash was unavailable)... I kindof can't believe I'm back after 4 years away!

Grad Pictures!!

2009-06-05T11:36:00.003-04:00

Graduation was a success!! Millions of thank-yous need to go out to tons of people, but I would like to especially thank Rob and Bernie for documenting the entire day with TONS of photographs!

Check out the photos at:
http://picasaweb.google.com/leah.hamburg

Graduation

2009-06-02T07:00:00.000-04:00

I am standing at the end, at the beginning.

I never thought of my life beyond medical school. Sure, the "someday I'll have kids" stuff, but I never really gave true consideration to my life after today.

I have jumped off of some life-cliffs in my time. Times where I felt fear at taking that step, fear and exhilaration as if I was standing on the edge of a cliff. I always took that next step -- I always felt the free-fall before I landed into my new position/routine/school. Voluntarily. Because I had to. Jump off of the cliff to get to the goal: become a doctor. Everything was a step towards my goal. Every fall only temporary.

Weird how goals sometimes get reached.

Today I feel the breeze. My metaphorical hair is blowing but I don't feel the cliff. For the first time, I see before me a road and I am standing in the grass. All I have to do is step on.

The Night Angel Trilogy by Brent Weeks

2009-05-27T16:00:00.000-04:00

I just finished reading a series of books called the Night Angel Trilogy. This trilogy, consisting of The Way of Shadows, Shadow's Edge and Beyond the Shadows is written by Brent Weeks and was one of the most interesting series I have read in a while.

Basically, this group of books is about a rogue assassin named Kylar (a pun in "killer"). Yep, I said rogue assassin... you know it has to be cool once those two words are put together. The series starts with Kylar as a young boy growing up on the streets, follows him through his training as an assasin and his breif stint as a killer-for-hire before his monumental decision to go rogue... and that's just the first book! The second book follows Kylar's struggle to leave the world of killing behind and (as we can tell because there is a third book) his failure to do so. Finally, Kylar and the characters who have surrounded him since his childhood grow up to be powerful people who change the world in which they live significantly.

Brent Weeks creates an entire world in these books -- we're talking multiple different countries each with their own culture, quirks and skills. There is the country full of evil magicians, one full of people who deny magic even exists, a south pacific island paradise country and many more in-between. We've got two different types of magic weilded by three different types of people, kings, 700-year-old immortals on both sides of the fence, zombie-thingies, a bunch of different religions, love and betrayal and un-betrayal... everything you could want. By the middle of the second book you are following at least 4 different plot lines (don't worry, they re-converge by the end of the third book) taking place at the far corners of Brent Weeks' world. Despite this, I didn't have trouble following what was going on! A truly remarkable feat.

When asked to compare this series to another, I can't think of one. It's not quite "epic" in the way that Lord of the Rings is epic. There's no innocence and it's too gritty to be "harry potter-esque." Really, the thing that comes most to mind when I read these books is the last book I reviewed here, The Name of the Wine, by Patrick Rothfuss. Both are dark fantasy imbued with magic, but not consumed by it. I highly recommend this series of books. I devoured them in less than a week -- Rob just devoured the entire second book in a single day!

Paperbackswap.com

2009-05-27T15:38:00.003-04:00

This past weekend, my college roommate, Genevieve, told me about this great new website that she has been using called paperbackswap.com. I have been using this website for 2 days and I already think it is fantastic!!

Basically, you do what the website says. You post paperback books (and hardcovers) that you want to get rid of. These enter the website's database and people can search for books just like on Amazon. If someone finds a book that they like, click on the "get it" link and an E-mail is sent to the person who owns that book. If the owner is able/willing to mail it to the person asking for it, the owner prints out a shipping label with the recipient's name and address. Did you know that a paperback book can be wrapped into an 8 1/2 x 11 piece of paper? You use shipping label is your wrapping paper! How cool? The owner pays postage to sends the book to the recipient (usually $2-3).

On the other end... the recipient goes on the website and confirms that they got the book. When they do that, the owner gets 1 credit. 1 credit is good for requesting 1 new book. Now the owner gets to turn around and be the recipient of a book from someone else!

Basically, you pay $2-3 for a book instead of $7.99 AAAAAND you get rid of the books you have already read! There are TONS of books on this website, and joining is completely free. You just need to have a printer and some packing tape =). Thanks, G!!

Swine Flu Part 3B- Why is it so scary?

2009-05-25T15:27:00.010-04:00

We have finally come to the reason why I started writing this series of posts. I mentioned this in my last post, but the swine flu is actually less deadly than the annual influenza outbreak with an estimated mortality of 0.2% as opposed to the combined influenza and pneumonia mortality which ranges from 7-9%/year. However, swine flu is highly infectious, infecting a mind-blowing 60% of the mexican village in which it originated. I found an excellent answer to my question in the editor's comment on a CDC Morbidity and Mortality Weekly Report article published on May 7, 2009.

The scare-factor of swine flu is four-fold.

This virus has gone pandemic in a very short amount of time.
Higher percentage of patients with H1N1 are requiring hospitalization than with the normal flu.
The sickest patients are working-aged people.
Influenza season is about to start in the southern hemisphere.

I will explain each in more detail:
1. H1N1 has gone pandemic in a very short amount of time.
The seasonal influenza outbreaks tend to hover around the epidemic threshold. Each country/region has its own influenza virus subtype causing its localized, contained epidemic. Remember my analogy about flu from different regions of the world have different RNAs and therefore "look" different? This also helps to prevent one particular influenza virus from going global and causing a pandemic. H1N1 threw all of that out the window. It is so contagious that it has created a pandemic almost overnight.

2. Higher percentage of patients with H1N1 are requiring hospitalization.
But remember, they aren’t dying at the same rate. This increase in required hospitalization represents a huge change in morbidity (sickness) that our global healthcare system is completely unprepared to accommodate. We literally physically do not have enough beds to put people on. Not to mention lack of enough staff or medical supplies to treat the projected numbers of people who may need hospitalization. The CDC and public health officials are going to great lengths to change this potential outcome and I will discuss what they are doing below.

3. The sickest patients are working-aged people.
The highest rates of hospitalization are among 30-44 year olds. The seasonal flu tends to hospitalize children <2,>65 and patients with defective immune systems. The change in who is very sick can have a global economic impact as the workforce is affected. I don't think I need to go on about bad economic stuff.

4. Influenza season is about to start in the southern hemisphere.
This is bad news for them – there will be a whole jumble of influenza viruses going around. Differentiating who has H1N1 from others is going to be extremely difficult. Added to that is the issue of increased succeptibility to H1N1 transmission because the other viruses going around will weaken patient's immune systems and vice versa. It is unclear how H1N1 will interact with the seasonal flu but there is a huge amount of potential for reassortment and recombination as people become infected with more than one type of influenza virus at a time. The CDC is anticipating tremendous outbreaks of H1N1 in the southern hemisphere from June – October.

There are some things listed above that we can try to wrestle some control over. The fact that H1N1 is pandemic is over. The cat is out of the bag and there's nothing to be done about it. The fact that influenza season is about to start in the southern hemisphere is unstoppable. Sun rises every morning, sets every night, influenza season happens, fact of life. #2 and #3, however, are things that the healthcare community can try to effect change over.

One more science lesson for you, this time on epidemiology.

Outbreaks of an illness follow a bell-curve. First one person gets infected, they infect 5 more. Those 5 go on to infect 5 more each, etc. You get an exponential rise in the number of sick people in a given community/area/globe/whatnot. The bell-curve peaks and the height of the peak is determined by how infectious a disease is and how long it lasts. The peak represents the highest number of infected people in a population at one moment in time. You may be wondering, why does the curve come back down? For the same reason why you can't catch the chicken pox twice. After a person has been infected with the disease in question and has either a) recovered or b) died, they cannot get the diesease again. There are literally fewer people to are suceptible to the infection and therefore the number of people who get sick falls off until everyone has gotten it or there are too few people still succeptible to allow the disease to continue to propogate.

Important facts about the epidemic curve: 1) the line/bar represents number of active cases at that point in time. 2) area under the curve = total # of cases for the entire outbreak.

It is often difficult ot affect provision #2-- the total number of cases for the entire outbreak. However, we have a number of methods for adjusting the number of cases at any given time and lowering the peak of the curve. These things consist primarily of community mitigation (school closures, quarantine), vaccination and prevention with antiviral drugs. The ultimate goal is to get a picture like what we see on the right. This figure is EXTREMELY idealized but it makes the point well. Control measures will make the pandemic last longer and probably will NOT reduce the total # of people infected (area under the curve) but they will hopefully reduce the upslope and peak to allow for a manageable outbreak that our global healthcare system can absorb. The three goals listed on the figure are 1) delay outbreak peak (allows for vaccine and prophylactic strategies to be put into effect) 2) Decompress peak burden on hospitals/healthcare and 3) diminish overall # of cases.

What do school closures do? They are simply a delaying tactic. By reducing these reservoirs of transmission, public health officials hope that the peak of the pandemic can be delayed until a vaccine is developed and administration strategy is worked out. Slowing virus transmission will also reduce hospital burden and help our healthcare system to absorb H1N1 patients. It is an attempt to reduce volume of patients at any given time along the pandemic curve.

Where is the vaccine? Being worked on. Laboratories are working as fast as they can to develop and test a swine flu vaccine. If one is distributed (we were burned in the 1976 epidemic) it will be two separate shots that cannot be given in conjunction with the seasonal flu shot. Why two? Because good vaccines make your arm hurt. Patients would rather get sick than have their arm hurt -- it's a medical fact of life -- so by diluting the vaccine and spreading it out over two shots, it becomes publically acceptible. Patient's arms won't hurt.

There is a second problem with vaccination. Vaccination decreases numbers of people infected when initally given, but there will be a resurgence of disease later down the line due to the impossibility of vaccinating an entire population. You will get a bell curve that abruptly drops during the upslope only to peak later on. In some mathematical models, if vaccination is done incorrectly, this second peak can be even larger than what the original was projected to be! However, a correctly timed vaccination strategy targeting the correct population and lasting for the correct duration (4 weeks is better than 2 days) will significantly decrease the second peak. Even if a vaccine to H1N1 is developed and approved tomorrow, public health officials may correctly hold it until the appropriate moment in the pandemic.

The figure on the left shows how the number of hospital admissions would be projected to decrease using different durations of vaccination campaign from 2 days to 10 days. This particular graphic is for a theoretical smallpox outbreak, but the curve holds for all epidemics for which a vaccine is available. The timing and duration of any vaccination campaign is critical to its success in both protecting the public and reducing hospital burden.

That's all, folks! Write a comment if you have more questions!!

Bibliography:
Brownstein JS, Influenza A (H1N1) Virus, 2009 – online monitoring. NEJM. 2009 May 7 [epub ahead of print]

http://cdc.gov/flu/weekly/weeklyarchives2007-2008/07-08summary.htm

Update: Novel influenza A (H1N1) Virus Infections – Worldwide, May 6 2009. MMWR May 8, 2009 / 58(17);453-458 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5817a1.htm

Hupert N, Wattson D et al. Anticipating demand for emergency health services due to medication-related adverse events after rapid mass prophylaxis campaigns. Acad Emerg Med March 2007, 14(3), 268-274.

For informaiton on mathematical modeling for epidemiology, any articles by Nathaniel Hupert.
New England Journal of Medicine H1N1 center
CDC H1N1 center

I'm a goof :-P

2009-05-21T21:35:00.003-04:00

Sometimes I even amaze myself (and wonder how I have survived my life so far)...

My college roommate got married one year ago (congrats on your anniversary, Gen and Bren!!) and she asked me to act as photographer for her wedding -- a huge honor! I have about 2G of photos for her from her wedding, burned onto a CD complete with a slideshow of the best ones... and I have yet to send it to her.

Fast forward to this weekend. I am all packed and ready to go and visit the happy couple down in DC for the holiday weekend. Rob and I are leaving at 5:30am tomorrow morning. But I forgot the picture CD up at 83rd street! I go hauling ass up there late at night from 74th... stop by the pharmacy, straighten my room, open some mail... another friend of mine from college, Cara, calls. I haven't talked to Cara in a long time and we start catching up. I lock the door, walk all the way back down to Rob's apartment only to discover (after I am all warm and comfy in the 74th street apartment) that I forgot the photo CD!!

Yep. I just walked a mile for a CD that I forgot to get. Fabulous. I apologize in advance, Genevieve!

Swine Flu Part 3A- Why is it so SCARY?

2009-05-21T17:31:00.011-04:00

This question is actually why I began writing this series of posts in the first place. I knew that lots of people were getting infected, yada yada... but I also knew that it was not as deadly as your average seasonal flu, so I wanted to know why everyone cared so much! I just didn't get it. The truth is, it's not so much that the Swine Flu is scary now, but it has the potential to become scary, and that's what is scaring everyone.

In previous posts, I have gone over viral genetics and practical diagnostic information on Swine Flu. Bits from there will tie into today's post.

Let's start with some history. This is not the first time that we have seen Swine Flu (aka- H1N1, aka- Swine-Origin Influenza A Virus (S-OIV)). There was a small outbreak of H1N1 in the United States in 1976. During that outbreak, 200 people were infected. Companies scrambled to make a vaccine against H1N1 and were successful, but somehow something got botched. The vaccine was administered broadly in the area of the outbreak with the following results: 1 person died of the swine flu. 25 died of the vaccine. Oops. (it is important to note here that vaccine technology has improved TREMENDOUSLY since 1976 and the safety regulations in place by the FDA will prevent anything like this from happening again.)

Now we have what science is calling a "novel H1N1"... novel being the scientific word for "new." This figure shows us what happened. The colored bars represent viral RNA. On the left is the swine flu virus from 1976. On the right is the current pandemic virus. By picking up RNA from eurasian swine viruses made H1N1 newly infectious. Just as a person of Chinese ancestry is easily distinguished from a person of swedish ancestry, viruses with ancestry in different regions of the world "look" different to our immune systems.

Let's look at this outbreak. The first US case was a 10-year-old boy in california. He got sick on March 28th, 2009 and, by luck, was enrolled in a clinical trial for a new viral laboratory test at the hospital which treated him for his illness. His virus was analyzed and typed as "unspecified Influenza A subtype" (see Swine Flu part 2) and therefore sent to the CDC for analysis. It arrived at the CDC on April 15th, was discovered to be a novel H1N1 and the CDC notified the California department of health on the same day to institute epidemic investigation protocols. Around the same time, reports from Mexico were arriving at the CDC of an unidentified, severe influenza outbreak. The global health community is commending Mexico's health community and the CDC for their rapid and appropriate response. After extensive epidemiologic investigation, it is now thought that the first cases of swine flu may have hit the US as early as January of 2009 (public health lecture, Cornell U. Med Coll, May 20, 2009).

The initial reports of H1N1 in Mexico were in a town with a population of 3000. Mexican health officials reported to the CDC that 60% of the population was infected, but only 2 people died. The majority of the people infected were young adults with an average age of 27.1 yrs. Continued surveillance of global H1N1 infections has shown that the illness is most severe in patients aged 30-44 yrs old. Globally, these are the patients with the greatest rate of hospitalization. The CDC now estimates that mortality from H1N1 is 0.2% but warns that it is still too early in the pandemic to tell.

0.2%. I'm sure a lot of people have no idea if that is good or bad. The CDC tracks annual mortality (deaths) from influenza and pneumonia. aapproximately 7-9% of people infected with one of these two conditions will die annually. Comparatively, swine flu looks safe! However, an infection rate of 60% is staggeringly high. I was unable to find an estimate of how much of the population gets the seasonal flu each year, but take my word that 60% of the population infected is mind boggling.

I know I haven't answered the question, but I'm tired. I'm getting to it. The history is fascinating.

More to come....
--------
Bibliography:

http://cdc.gov/flu/weekly/weeklyarchives2007-2008/07-08summary.htm

Brownstein JS. Influenza A (H1N1) Virus , 2009 -- Online Monitoring. NEJM 2009 May 7 [epub ahead of print].

Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a Novel Swine-Origin Influenza A (H1N1) Virus in Humans. NEJM 2009 May 7 [epub ahead of print].

http://h1n1.nejm.org/

Moving... almost back!

2009-05-19T17:59:00.002-04:00

So sorry I have been AWOL! Mike and I have been moving into a HUGE new two-bedroom about 10 block up from where we used to live. It's exhausting, the place is a mess and I just found my computer! I'll be back once the new place is all set up =). E-mail me for the new addy... don't want to post it on the public feed (paranoid new yorker, remember?)

--L

Swine Flu Part 2- Do You Have Swine Flu?

2009-05-11T13:47:00.010-04:00

As promised, everyone wants one SINGLE question answered -- do I have Swine Flu??? You can go on the CDC website, like I did, and get confused. Then you can go to the WHO website and get confused. There is a whole lot of hand waving and paraphrasing for a number of reasons. First, the "flu" seems so commonly defined, no one bothers to define it anymore! Yet, there is confusion as to what exactly is the "flu." Second, illnesses are variable. If the CDC were to say "If you have swine flu, you will have these 5 symptoms..." and some guy presented with only 2 of the 5, the CDC would be in deep shit. Hooray for the American climate of litigation. Finally, the only definitive diagnosis for swine flu would be to isolate the virus from the patient, sequence the RNA and have the fancy lab machine spit out a yes/no answer. Of note, the lab machine is in Atlanta at the CDC.

Below: Influenza A
So, the answer to the simple question is simple (yes/no) but getting there is quite complicated.

The Flu vs. A Cold:
The primary scientific distinction between these two is that they are caused by different viruses. The flu is caused specifically by the influenza virus. (see previous post) The Common Cold is caused predominantly by Rhinoviruses (fall/winter) and Coronaviruses (young children, SARS). Viruses, however, are not like bacteria. We can just grow bacteria on a dish, throw a series of fancy dyes and chemicals at the sample and come out with a bug. Viruses require cells for replication, so we can't grow them in a petri dish. Doctors walk around the hospital saying "This patient has c. diff and this guy here has MRSA." (Both bacterial infections) However, we don't walk around saying "This patient has aborovirus and the guy in bed B has an arenavirus infection." Why? Because we don't know!

Below: Rhinovirus

Alright, so for the lab guys out there, sorry, your viral identification process takes too long to be practical. Now we have to rely on symptoms to distinguish a flu from a cold.

A cold is generally associated with cough, runny nose, sneezing, sore throat, headache. Symptoms last about 1 week. Occasionally a low-grade fever is noted.

The Flu has FEVER, muscle aches, weakness, headache, sore throat, cough, runny nose, sneezing. Symptoms last about a week. The influenza virus also has the ability to cause pneumonia and your regular flu season(winter) flu can be lethal in certain populations, hence, the flu vaccine.

The difference is subtle, but there. Illnesses that seem "virus-y" (think: head cold) but that also have a fever can be classified as the flu.

Variable symptoms:
Just because the textbooks say that patients sick with the influenza virus have a fever does not make it absolute. There is a very common saying in the medical world to remind physicians of this fact: "The patient hasn't read the textbook." In other words, no one is going to present as a textbook case. Beyond this, physicians are so skeptical that if a patient presents as a perfect textbook example of a particular disease, doctors start wondering if they are faking it.

Bearing this in mind, it's a good idea to stay home if you have cold OR flu symptoms, especially coughing or sneezing because the swine flu virus (as well as all the viruses discussed in this post) is transmitted through the air.

Diagnosis:
Right now, we are NOT in flu season. Our normal, annual flu epidemic (and it IS an epidemic, I promise) is in the winter months. November - March in the northern hemisphere, June - September in the southern. Fortunately for the medical community, this makes the diagnosis of Swine Flu right now much easier. If we see a patient with the classic "flu" but it's the summer, it's Swine Flu until proven otherwise. Then we take samples and send them to the hospital lab. The hospital lab machine only has the capability to diagnose one type of influenza virus -- the annual one, H1N3 (usually). If a patient has swine flu, the lab machine will spit back "unidentified influenza virus." Then the sample will get sent to the CDC in Atlanta for full genetic sequencing and definitive yes/no answer to the question "is this swine flu?"

Phew! complicated, I know.

Lange Review of Medical Microbiology and Immunology.
New York City Health Department Press Release

Next time: Why is Swine Flu so scary?

Swine Flu Part 1- Viruses and Genetics

2009-05-08T12:42:00.014-04:00

Recently, I have been fielding a whole slew of questions about the Swine Flu. To really explain this, I have to start from the beginning.

1) The flu = an illness caused specifically by an influenza virus. This is a type of virus like a whale is a type of sea mammal. If you catch the HIV virus, you have HIV, not the flu. Get it?
2) The genetic code of the influenza virus is RNA. It does the same job for the virus as our DNA does for us: it is the code of the genes (for the purposes of our discussion).

The news media has been explaining that the swine flu came about by evolving. This is very true, but it is confusing since we are taught that evolution takes millions upon millions of years and yet, here swine flu suddenly is. Let's start with human reproduction. One copy of every gene from the mother is carried in the egg, one copy from the father in the sperm. This allows for recombination of our genes with each offspring. Every child has half of its genes from each parent.

Viruses do not do this -- they self-replicate by infecting a cell, making millions of copies of itself and then breaking free of the cell to go infect more. This means one "parent" makes millions of "offspring" which are identical to the parent. Not only that, but when the replicate themselves, they hijack the cell's machinery for building RNA and proteins. Like an assembly line, all the different parts of the virus get made separately and then at the very end, everything gets packaged together into a new virus. (see below. Yellow = virus, red squiggles = RNA... remember that for later.)

How do humans evolve?
1) Mutation
2) Mixing genes which is called "Genetic recombination" (remember, 1/2 of each parents genes --> one offspring)

How can viruses evolve?
1) Mutation! however, mutation is a slow, slow process. In humans, it can take hundreds of generations for a mutation to spread throughout the population. It takes only a few generations in a virus (remember-- ONE parent --> TONS of offspring, no genetic mixing) AND those generations happen on the order of hours to days, not centuries or millenia. Still, too slow for the sudden emergence of the swine flu.
2) Viruses have figured out a way to have genetic recombination despite having a single parent per offspring. This is where subtypes come into play. Let me explain...

Earlier I said that the influenza virus is a type of virus like a whale is a type of sea mammal. But if you follow that out again, there are lots of types of whales -- humback, blue, killer... etc. Similarly, there are lots of subtypes of influenza viruses and these are classified by H and N. The swine flu is in the H1N1 subtype. The bird flu is H5N1. Different kinds of whales, but still whales. (Interesting side note, it was an H1N1 virus, the Spanish Flu, that caused the pandemic of 1918.)

Let's go back to looking at our simple virus diagram on the left. Remember that the red squiggles are RNA? They look like they are free-floating in the cell. They basically ARE! Now, imagine that the same cell got infected with two different influenza viruses at the same time. Those viruses would just have their RNA floating around free in the cell! When the virus puts itself back togehter, it grabs whatever RNA is sees... leading to a mixutre and a NEW type of influenza virus.

This is how swine flu came about so suddenly. A host, be it animal or human, was infected with multiple kinds of influenza virus at the same time. The viruses got scrambled inside the cell and out came a new kind of virus or, more accurately, LOTS of new kinds of viruses because each individual virus is going to have a random assortment of RNA from the two parent viruses (much like humans). Most of the new viruses formed from this method (called reassortment and recombination) will not live. However, with so many combinations, nature is bound to hit a jackpot at least once. Voila swine flu.

In fact, the swine flu virus has genes from so many different types of influenza virus that science is baffled as to how it got so many! Researchers are counting RNA from 3 different swine viruses, bird and human in the swine flu. As a result, this virus is something very novel that our bodies are not used to defending against. It doesn't look like other influenza viruses to our immune system, so it takes longer for our bodies to fight it off. This is accounting in part for why swine flu is so contagious.

The bad news: the flu vaccine will not protect you.
The good news: antiviral drugs (Tamiflu and Relenza) will work.
The bad news: antiviral drugs are not very effective after symptoms start, which is why they are not commonly used in medical practice.

I mainly used my memory to write this one, but here is an early and easy to understand editorial about swine flu.
Butler D. Swine Flu Goes Global. Nature 2009 Apr 30;458(7242):1082-3.

Next time: Do you have Swine Flu?

D'oh!

2009-05-05T12:54:00.005-04:00

Ahh, the antics of a 4 month old Ridgeback puppy. I must say, Deka is the most rambunctious Ridgeback puppy my family has had to date. She hasn't chewed any furniture, hasn't peed on the carpet, hasn't broken any lamps, but she's got a LOT of energy.

Deka's newest thing is that she likes to jump up and put her front paws on Sashi's back so that she can see over tables and counters. My father was chopping vegetables with the back of the knife overhanging the edge of the kitchen counter and the pup cut her forehead on the knife. Quick trip to the emergency vet resulted in 3 stitches and one of those space-dog cone collars. I don't have a picture of that cuteness because...

When they got back home, Deka went running into the house, tried to round a corner and caught the edge of the cone collar on the wall. This sent the pup flying and, ofcourse, broke the cone collar in two!!! Apparently she just stood up, shook it off, sniffed the collar (now on the floor) and ran away again!

The collar lasted a grand total of 30 seconds. I'm STILL laughing just thinking about it.

TasteCamp East!

2009-05-03T19:28:00.010-04:00

I spent this past weekend doing something I had not previously devoted much time to -- tasting wines. My family really aren't "wine-os," but since starting to date Rob, I have learnt a lot about paying attention to what I am drinking above answering the ultimate yes/no question: "do I like it?" He invited me with him to a weekend wine tour of Long Island Wineries organized for wine bloggers by a wine blogger at lenndevours. I have to say, up until the drive out (when I discovered that this was for bloggers and their significant others), I was very nervous about being among people so passionate about something I know very little. Put me in a room with a bunch of docs, I'm cool. Put me in a room with a bunch of classical musicians and I can hold my geek-ed out own (barely), but wine??

I must say, I had a great weekend! It was overcast and rainy, but that did not stop us. Lenn planned a whilrwind tour of the east end of Long Island which started with a fabulous gourmet dinner at Raphael winery Friday night. Saturday consisted of 5 actual winery visits with tasting wine from about 15 wineries thanks to a sponsored lunch. Saturday night was a "BYOB of your favorite" BBQ -- 'nuff said. Sunday topped the weekend off with a ferry ride across to the south fork to visit the last two wineries and, finally, beer at a pub. Overall, we drank wine from 20-25 Long Island Wineries. Nice sampling.

Of all of these wineries, three places stuck out to my inexperienced palate -- Shin Estates Winery, Lenz Winery and Channing Daughters Winery. The wines from these very different wineries were all great!

Shin Estate Vinyards is on the North Fork and is part of a select few growers on LI trying to go organic. They spent a very long time explaining the difficulties of being organic on LI. These are not hippies waving their hands around doing a rain dance (joke intended). They are concerned farmers using science and collaborations with Cornell University to decrease their impact on nature. Plus, they are making damn good wines while doing it! Two of my favories of the weekend were the Shin Estate Cabernet Sauvignon 2007 (barrel sample) and their Shin Estate Sauvignon Blanc 2008.

The Lenz Winery was one of the highlighs of the weekend for me. The winemaker, Eric Fry, met us and took us on a two hour tasting through almost exclusively tank and barrel samples of his upcoming vintages. It was fascinating to listen to him talk about his wines -- he believes very strongly in aging wines and therefore doesn't release wines until he deems them ready to drink. Their current Merlot release is 2001. Plus, there was the hilarity of walking all over the building -- start inside, the out to the right, then back in, out ot the left, back in, around back... you get the picture. Rob and I ended up taking home the Old Vine Cabernet Sauvignon 2002.

Finally, our last stop of the weekend found us at Channing Daughters Wineries on the South Fork of LI. Unlike most of the wineries we visitied, Channing Daughters focuses on white wines -- a refreshing change from a weekend of mostly underwhelming reds (except for those noted, ofcourse). Here we met James Christopher Tracy, another incredibly knowledgeable and engaging winemaker who was unafraid to experiment with his vineyard. Rob and I bought 5 (count 'em, FIVE) different wines here: Channing Daughters Sauvignon Blanc 2008, Vino Blanco 2007, Rosato Cabernet Franc 2008, Blaufrankisch 2007 and a 95% merlot blend, Sculpture Garden 2006.

To learn what qualified people think about all the wineries we visited this weekend, check out Rob's blog, WinePost and from there link on to others who were there this weekend. Enjoy!

Pictures from the weekend at: http://picasaweb.google.com/leah.hamburg

The Name of the Wind by Patrick Rothfuss

2009-04-27T20:13:00.000-04:00

I just finished a book titled "the Name of the Wind" but Patrick Rothfuss. It is this author's debut novel and I have to say that I really loved it! The book is a little daunting when you pick it up -- a 750-page paperback doesn't fit easily between your fingers -- but it kept me thoroughly engaged.

A number of things were interesting to me about this book that actually didn't have anything to do with the actual plot. First, we are introduced to our characters at what seems to be the end of a story, not the begnning. The main character, Kvothe (pron. quothe) seems to be a great man who is "retired" and is living his life as a humble -- undercover -- innkeeper.

Second, there are two stories and two very different characters in the person who is Kvothe -- the boy and the innkeeper. The bulk of the book is Kvothe telling his life story to a scribe. Kvothe went to "magic" school as a young boy -- this gave me a little bit of a dark "Harry Potter" feeling. The author frequently jumps back to present-day innkeeper-Kvothe as the narrative gets interrupted by the daily activities of running an inn. While reading the chapters about the young Kvothe, I would completely forget that I was supposed to be reading a narration and would often get a little jarred when the author swapped back to innkeeper-Kvothe.

Finally, the plot itself. This book, while huge, really is simply setting the stage for the later books of the trilogy. The entire book encompases a little over 24 hours of innkeeper-Kvothe's life -- the first of three days he has agree to spend recounting his life story. The majority of the book is the narration of Kvothe's boyhood and adolescence. However, enough strange stuff is happening in innkeeper-Kvothe's life during the opening and closing of the novel -- the two evenings on either side of the day of storytelling -- for the reader to want to learn the backstory so that we can get to the current-day stuff! In terms of young Kvothe's plot, there is love, tradgedy, mishaps typical of magic school, adventure and, of course, a dragon. What more could an adventure/fantasy reader want?

Overall, five stars for this book -- I devoured it in two days of good reading (thank you to summer coming early to NYC!).

All Parents are Crazy

2009-04-20T10:25:00.000-04:00

My parents are crazy. Always with the best intentions, but still... nuts. Usually in a lovable, easy-to-shrug-off way, but still... crazy. Despite this, I make the argument that ALL parents are crazy. It's the prerogative of being of parent.

I spent the weekend visiting my parents in Florida with my boyfriend, Rob. First thing, our flight was a half an hour early. Rob sensibly suggested, "Shouldn't you call you dad and tell him we ran early?" "Nope. He already knows" was my completely confident reply. And he did. My father has flight-tracker send updates to his iPhone. He knew we were landing early before we did and was already at the airport. Kindof eccentric, but in a lovable way.

Rob works in the wine industry. Therefore, part of the weekend was spent running Rob around to my parents favorite wine shops. The two of us were sent on an "errand" to Total Wine (actually, that worked out well -- Rob bought my parents a case of different wines to taste), tasted wines at Crown Wine and Spirits and finally, the local gourmet shop. I think Rob talked more wine this weekend than he usually does during the week! My dad took notes... literally.

Then there were the various assorted activities with the dogs. The trip to the beach worked out well-ish. My mother tried to panic every time a dog came over to say "hi" to the puppy. The weekend was rounded out with an insane and exhausting trip to an art fair... The puppy kept on whimpering while walking around. Werealized that the pavement was too hot for her baby paws... oops. We had to carry her. Then the big girl, Sashi, decided to protect our lunch table from every passing dog... of which there were millions. Then the fair turned out to be crafts not art... I'm unclear as to the distinction, but my parents complained. Oh yes, and apparently my parents weren't expecting a huge crowd... on a fabulous sunday... in april...??

Despite the crazyness, there was the entirety of Saturday, which Rob and I spent lounging by the pool, swimming, reading in the hot tub and generally getting very sunburnt. Fabulous. The food and wine were universally excellent all weekend.

Rob and I walked into the airport after the disastrous art fair experience on Sunday and sighed a huge, exhausted sigh of relief. He turned to me and said, "Baby, your parents are kindof crazy." I smiled back and said, "So's your mother, but I love her anyway." And that is exactly my point. So they're nuts and sometimes things (like the art fair) turn out to be a disaster. They're parents! Parents are all crazy -- mine included.

Mom with Deka, 14 weeks old.

On Birthdays...

2009-04-14T14:05:00.000-04:00

So, today is my Birthday. yay!

Every birthday I tend to compare it to previous ones. Kindof a "how am I doing this year?" thing -- but only in the sense of the actual, physical, day-of-birth way -- not in a general "life" kind of way. A lot of the birthday-days that I have had I have forgotten. They were normal days. The worst ones have stayed with me, so have the best.

Worst birthday-day ever -- I think that here there is a tie, colored by the age at which these birthdays happened.

1) When I was in Jr. High, all your friends would get you a balloon on your birthday and the trick was to walk around the school with this HUGE bunch of shiny "Happy Birthday" balloons tied to your backpack. On my 13th Birthday, a catty girl I didn't even like decided to be mean and told all of my friends that I didn't want any balloons that year. My gullible friends believed her (figures) and no one brought me balloons! As a 13-year-old, this was devastating. I went to the bathroom and cried. My friends felt awful, so the next day each brought me TWO balloons -- completely making up for the horror of the day before. So, sucky birthday-day, but I got over it 24 hours later when I definately had the biggest bunch of balloons in the school.

2) My 22nd birthday. I had just broken up with a long-time boyfriend, was taking time off before starting medical school and was unexpectedly now sleeping on a pull-out couch in my parent's new apartment. My parents had made plans long in advance and so they were out of town for the weekend (I was supposed to be living with my boyfriend, remember?). All my friends were still in college -- I had graduated early -- and the few in NYC were unavailiable. I sat in an apartment that didn't feel like home, broken-hearted and alone. I baked myself an entire cake, frosted it and proceeded to try to eat it. VERY bad idea. Once the clock turned to the 15th, I got over it. The blessings of age and maturity.

Best birthday-day ever:
My friends at college threw me a surprise party for my 21st birthday at my favorite restaurant. Not only that, it was fantastically perfect spring day in Chicago. It was the middle of midterms week-- none of them really had the time to celebrate and yet here they all were! Complete with balloons (I guess it's a theme), flowers, gifts and, ofcourse, alcohol.

How is today comparing? Pretty good. Didn't get out of bed until noon, reading a fabulous book, birthday wishes rolling in on Facebook. It's junky outside -- grey and overcast. My roommate reports that it's "meh", which in sane-person terms probably means "cold." My boyfriend tells me I have a cupcake from Crumbs coming my way (whee!!) and dinner. Plus, I have yet to change out of my pyjamas. I think all things are looking good for a nice day. Happy Birthday to me!

Rhodesian Ridgebacks

2009-04-12T15:20:00.001-04:00

My family is in love with a breed of dog called the Rhodesian Ridgeback. My parents currently have their second, Sashi, and third, Deka. Longtime dog owners, my parents constantly rave about how Ridgebacks are the smartest and best dogs they have ever owned. As for me, we had a poodle when I was a kid and got our first Ridgeback when I was 7. Prior to the infamous poodle (kindof a blip in the "Hamburg dog history"), my parents owned all cold-weather dogs... Samoyeds, Huskies and Alaskan Malamutes. Ridgebacks are quite a different direction from the breeds my parents used to favor.

The Rhodesian Ridgeback takes it's name from both it's country of origin and most distinctive feature. The breed was originally developed in the south african county of Rhodesia (now Zimbabwe) in the late 1800's by mixing a local african dog with european immigrants. The african breed contributed a ridge of hair that runs the wrong way up the Ridgeback's spine. The hairs point towards the dog's head, not tail. During the original breeding of the dog, it was noticed that the dogs with ridges were better hunters and protectors, their main purpose in Africa. They were first accepted to the AKC under the "hound" group in 1955.

The rumours you have heard about this dog are not completely true. This dog was bred to hunt lions in africa and to protect the homsteads and children from predators. They don't kill lions. The Ridgebacks were used in packs of about 20 dogs each to corner and harass a lion until the hunters could then approach and kill the lion. Due to the ferocity of lions, this was an effective but not very efficient way of hunting -- quite a number of dogs from the pack would be killed on every hunt. They were also often put out with the children to protect them from cheetahs while playing.

Ridgebacks are extremely devoted to their "pack" of people and extremely intelligent. However, they tend to be a little aloof towards strangers. This is not one of those super waggy dogs that jumps all over everyone on the streets of NYC. More often than not, the little children complain "Why doesn't the doggy look at me?" Sashi has learnt to tolerate the audacity of New Yorkers to pet anything that walks by without asking permission. Deka is yet to experience New York City... we'll see how she does.

This breed also known for adjusting itself well to the lifestyle of the family. If every member of your family runs marathons, you will have ridgebacks that run marathons. The dogs can do it, come home and look at you as if to say, "When do we go again?" Alternatively, if you have a "lazy" family such as mine, you get lazy Ridgebacks who sleep on the bed all day. I took my lazy Sashi for a run once... I don't think her nose even broke a sweat after 4 miles.

Overall, I am as in love with this breed as my parents. I chase down Ridgebacks when I see them in New York City -- within a block. Similarly, I have had people chase me for much more than a single block just to meet mine! Huge stamp of approval.

Sashi, Deka (April 2009)

Me, Sashi, Kala (Sept, 2002)

Intro

2009-04-12T14:35:00.000-04:00

I thought that I would start out by introducing myself and explaining a little about why I suddenly decided to start a blog.

I don't have a theme for this -- it really is simply that I recently have discovered a number of my friends have blogs and reading theirs has made me think, "Hey, I could write a post about this... or that..." at increasingly frequent intervals.

Now, the title. First, "pets." Pets because I really can't live without those furballs. I don't have any of my own right now, but my parents have 4 -- 2 dogs and 2 cats -- including one 12-week-old puppy. Most of my funny stories from my childhood involve my pet-siblings (only child). My parents tend to guilt-trip me into visiting them by pleading "but your cats miss you sooooo much...." or "the dogs really need someone to take them to the park..." You get the picture.

Second, "posts." Eh, this is there for the purposes of alliteration and the fact that this is a blog of random things.

Finally, "medical mysteries." I am soon to embark upon my residency in Emergency Medicine at the New York Presbyterian Hospital Cornell/Columbia. There are plenty of medical mysteries in Emergency Med... and tons of crazy stories (really, why does anyone go into EM if not for the stories?). It worked in the title, pulled in that whole "soon to be doctor" thing. I'm not so good at the catchy/creative thing, so hats off to Rob for coming up with the title after only about 30 seconds of thought!

On to the second aspect of this post... about me. I am a born 'n bred New Yorker -- I love this city. I "techically" grew up on Long Island. Minor technicality. I was actually born in the same hospital that I will be doing my residency. By the time I was 18, I was sick of high school students getting plastic surgery and driving BMWs, so I escaped to Chicago for four years. That taught me two things. 1) Midwesterners are the nicest people in the world. I had culture shock because they were so much nicer than New Yorkers. 2) Chicago is COLD. Not just "brrrr," but "holy-shit-my-hair-has-become-icicles-and-I-have-tears-streaming-down-my-face-'cause-my-eyes-are-involuntarily-tearing" cold... Chicago and I didn't agree. I came running back to NYC and medical school at Cornell. Also jokingly referred to as "citibank medical college" because the chief donor to the college is Sanford Weill of Citibank fame.

The arduous process of choosing to go into Emergency Medicine involved numerous side trips into music, relationships, sailboat racing and a summer in Tanzania. Primarily. Plus a pure hatred of insurance companies, outpatient medicine and being woken up at all hours of the night. I want to treat whoever comes through my doors. I want to take my salary and at the end of the day go home without worrying. When I eventually have kids I want to know their names. Yeah, that would be a good start. Names at least. During my first year of medical school we had a lecturer who was a surgeon. His wife had just delivered their sixth child. The surgeon was ecstatically happy becuase this was the first delivery he had actually made it to. I know that I don't have a choice but to be at the birth of my children, but that comment put a lot into perspective about medicine for me. Not only that, but I vowed never to marry a surgeon.

I think that's all for now. As promised by the title, I will leave you with a picture of the newest baby, Deka. She is a 12-week old Rhodesian Ridgeback (post on ridgebacks to come) but in this photo, she is 8 weeks old. Also, she has fallen into that pool... twice.