The Mad Hatter

A Puzzler

2011-01-31T23:52:00.000-08:00

I must admit that US foreign policy is a puzzle to me.

The US invaded Iraq to spread freedom, liberty, and democracy, right? It had nothing to do with oil or the attempted assassination of Bush senior. I think I remember hearing things about Iraq becoming a beacon of freedom and democracy in the region that would invite all of its Arab neighbors to join it.

The closest US allies in the region are dictators such as the Saudia Arabian royal family, Mubarak in Egypt, the royal family in Jordan, and the now ousted dictator of Tunisia. Why is it that the US government fears democracy in those countries? Perhaps it is because democracy is a flawed system and they know the results such a system will produce. It may produce democratically elected Islamic governments as occurred in Palestine (Hamas), Hezbollah in Lebanon, or some of the Islamic parties seen in Turkey and Pakistan.

In the end, the word "democracy" is a piece of propaganda that our government uses when it wants to as an excuse to do something like invade Iraq. Ultimately, it is a philosophy they fear when it is applied to other places such as Egypt.

Glissading

2010-12-14T23:02:00.000-08:00

I went on an excursion with 6 other people from church to watch the meteor shower last night. It was originally going to be a cross country ski trip but for reasons I'm not entirely sure about, we decided instead to go hiking. We decided to go up Flattop mountain. The trailhead is an easy drive from Anchorage. Flattop is just over 1000 meters in height. The first 4/5 of the trail was nice. It was challenging enough to keep someone like my sister Bethanie entertained, but not treacherous. The last portion of the trail to the peak of Flattop is treacherous. Not only that, but the last 75 feet of trail before reaching the summit is this not quite vertical ice shelf. We decided that since we were so close to the summit, we might as well go all the way to the top. Afterwards we decided that it was a classic case of group think in which we made decisions as a group that we would never have made individually.

So going up that last 75 feet was treacherous, but doable. You just focused on the next toehold or fingerhold while trying to ignore the fact that you were at a kilometer of elevation in the middle of the winter. The view from the top was absolutely phenomenal. The half moon illuminated things tremendously, being reflected brilliantly by the snow. The meteors were brilliant. However, the wind absolutely howled up there and temps were around zero. We were all dressed for the weather, but it was definitely cold.

I was also beginning to feel like a cat who had climbed a tree only to realize that it couldn't get back down. The path back down looked so much more vertical from above than it did on the ascent from below. Furthermore, it was obvious that if you slipped, you were going to not stop sliding for quite a ways and would pick up a great rate of speed. 10 feet to the right of the trail was a precipice off which a fall really didn't look survivable. To the left of the trail it looked like the ice covered service extended down about 75 feet with occasional jagged boulders protruding through. I began to remember various trauma patients I had cared for and knew for a certainty that if a single misstep occurred while descending the ice field, I would be lucky to get away with just some chest trauma or an orthopedic injury. Did I mention that I really, really don't like heights?

Two of the guys who were along had a fair bit of mountain experience. It was obvious to me that they felt like we had made a poor decision in climbing to the summit with the inadequate mountaineering equipment we had with us. We really had no ice climbing equipment. We had lights, sleeping bags, and food but that was it. So they instructed us on how to basically crawl down the ice field with your back pressed against the ice. The technique basically involves lying flat your back. You attempt to maintain some sort of traction on the ice with three limbs while pounding a foothold into the ice with the heel of your foot. Once confident that the "ice step" you've created will hold your weight, you slide down the few inches until your heel is resting in it, and then begin the process all over again with the heel of your opposite foot. In this manner you descend a few inches at a time. Meanwhile, your hands being pressed against the ice sheet make you begin to wonder why you can't hardly feel them anymore. All this while the precipice is off to the immediate right and the boulders are immediately below.

Somehow we all managed to inch our way down the ice field safely with no major misadventures. As we got lower, the snow became deeper and covered the protruding death boulders. Then I learned how to glissade. If descending the almost vertical ice field was one of the most terrifying things I have ever done, glissading was one of the most exhilarating. To glissade is basically a fancy term meaning that you slide down the mountain in a seated position pretending that you are riding a sled when in fact you are sliding rapidly down the mountain in a seated position without a sled. In this manner we rapidly descended what had taken us a good 45 minutes of climbing.

It was a beautiful night. I was thankful to be alive and healthy and that all of the other climbers were OK. I even thought today about getting ice climbing gear and taking alpine mountaineering lessons. Then I thought about feeling like a cat all bushed out at the top of a tree and decided it was much more comfortable down here in the valley. However, when taking care of a busted up trauma patient in the future, I no longer have the right to ask myself "I wonder what in the world he was thinking." Instead, I’ll be thinking, “That could have very easily been me.”

Below is a picture from the internet of how Flattop looks during the day this time of year.

Cat Wars

2010-12-05T21:56:00.000-08:00

Here is a picture of my cat where I think that she belongs...

This is a picture of my cat where she thinks she belongs.

The cat wars commenced soon after I my sofa was delivered to my house. I'm all for having a cat snuggled up with you while your reading a book comfortably on the living room furniture. The great deal on the furniture at a super discount furniture store clouded my judgement and I failed to foresee that my cat's affinity for comfy furniture would result in clumps of hair that are annoyingly visible. I lost the battle the first week, and had almost decided that it was a lost cause. However, then I remembered that my house has an upstairs thermostat and a downstairs thermostat. I cranked the heat way down on the downstairs one. This resulted in a rather remarkable temperature differential between the two levels of the house, and the cat is now much happier sleeping on a pile of laundry upstairs than she is downstairs on the furniture.

Visions of Ham Catastrophes

2010-11-28T20:16:00.000-08:00

The week was crazy and quite frankly left me feeling a little bit like I might make a good Proverbs 31 woman. Besides having one of the busiest operative case loads of any week since I started working I also cooked enough ham to feed 40 people for Thanksgiving dinner, hosted a visiting missionary from Uganda and then had a bunch of people over for Sunday lunch. It feels a little bit like being a hamster running on one of those wheels except the wheel seems to be spinning just a little bit faster than you can run.

My church had a potluck Thanksgiving meal. After signing up to bring the ham, I then panicked and realized that I had no idea how to prepare it and maybe shouldn't be venturing into such an endeavor when 40 people would be able to witness the disastrous results. First of all, I had no idea how much ham I needed to feed that number of people. After 20 minutes of staring at the pile of ham at the grocery store, I finally decided to lose all pride and find some grandmotherly looking person and ask her how much to buy. Fortunately the random grandmotherly person I encountered was full of wise advise regarding how much to buy although I think she thought it a bit strange to be stopped by some desperate random stranger asking such things.

I then realized that I had no clue how to go about preparing it for consumption. After looking up several very conflicting internet recipes, I broke down and got more advice, this time from a grandmotherly appearing lady in the hospital where I was doing rounds. She was full of sage advice regarding ham preparation, and didn't stop talking about it until well after she had exceeded my attention span.

Fortunately, the ham turned out OK and there was exactly the right amount. So on this Thanksgiving weekend, I am thankful that I avoided a ham catastrophe. I am also thankful for my church and the opportunity to have people to share ham with. That being said, I may sign up to bring the rolls next year....

Remembrance Day

2010-11-14T19:32:00.000-08:00

This past week was Remembrance Day here in the US of A. It is not a holiday that I generally pay any attention to, other than being annoyed at the inconvenience of the post office being closed or the bank shuttered.

The church I attend now has much more preaching on the peace position and our role as peacemakers in the world than any church I have ever attended previously. It is a focus I enjoy and agree with. I also had to chuckle at a recent bumper sticker I saw that said something to the effect of... "Our country will have its priorities right when education is fully funded and the military has to hold a bake sale to buy a bomber."

However, despite my lack of support for the military as an entity, I was more aware this year of the sacrifices many have made while doing what our government told them to do. The first is a resident I trained with in general surgery. He and his wife live here in Anchorage with their two toddlers. He was deployed to Qatar for a six month tour of duty leaving his wife and children to do the single parent thing.

The other person who has made the military and its sacrifices more real to me is a man who works in my office. He was a marine and spent time in Iraq and Afghanistan. He was in Fallujah when they had to go house to house fighting the Al Qaida insurgents. He saw horrible things and had to do horrible tings. The war and the friends he lost in it seem to never be far from his mind. Remembrance Day was important to him because he was remembering friends.
He brought a book in to work, that was much like a high school yearbook. In the front it had several pages of pictures of those in his company who had died, followed by pages of pictures from their time overseas. It was moving to look through that book and feel the trauma of war.

On this Remembrance Day, I prayed that God would care for the families separated by war. I prayed that God would heal both the warriors who have fought, and the communities of people that have been destroyed by war. Most of all, I thank God for the privilege of living in a place blessed with peace.

The inanities of Daylight Savings Time

2010-11-07T22:07:00.000-08:00

Entering my first winter this far north, I have concluded that it is utterly inane for a state at this latitude to adopt Daylight Savings Time. The bureaucrats who signed this state up for this time saving mechanism must have either been crazed by sun deprivation or eternal day.

Today time changed and I turned my clock back an hour like most of you did. However, tomorrow when I go to work, the sun will not be up yet and when I get home it will most likely have set already just like it was before the time change!! That makes the whole exercise seem rather pointless and futile to me. Perhaps this the westernmost portion of the continent on which we reside should protest this insanity by joining the easternmost portion in having clocks set a half hour different year round.

Termination Dust

2010-10-14T20:59:00.000-07:00

Termination dust admittedly sounds like what some sci-fi novel might call your remains after your vaporization by a weird alien. I have discovered that is not in fact what the term describes. Living in a new land with its own set of seasonal rhythm and characteristics is interesting.

A few weeks back I experienced my first earthquake. I was getting ready to drain an abscess when my patient said, "Either there is an earthquake coming or else you gave me some really good medicine. You might want to hold off for a second doc." I then noticed that feeling you get when you feel a train coming before you actually hear it or see it. This was followed by a feeling kind of like being out on a boat when the water is rough. About the time I began to wonder if it was going to stop or get worse, it chose the former option.

I quickly learned that the first thing you do after an earthquake is run to the internet to check how strong it was. That way you can know exactly how close you were to an untimely demise. Unfortunately the sudden rush of people to computers causes the website that report such things to crash. I guess it is a ritual I need to become accustomed to living in the most seismologically active part of North America. All in all it was a bizarre experience. The idea that the ground doesn't move is one of those things that I had in my brain alongside of rules such as the constant effect of gravity, the inability of humans to walk through solid matter, or the concept that time moves forward and cannot be reversed.

In addition to earthquakes, the other weird thing here is the experience of watching the colder seasons march inexorably towards you before you see them. Termination dust is the first dusting of snow that appears on the lowest level of the mountains where it is cold enough for snow not to be liquid. The mountains beside my house were initially snow free. Every day I look at them and see that the termination dust is moving ever steadily my way. It feels as though winter is stalking you and that you are fighting a losing battle as it marches steadily towards you.

I haven't ever experienced a winter that gave you so much warning it was coming. It adds a sense of anticipation to the season. It is nice to live in a place where the rhythm of nature does not follow the pattern I am used to. It adds an element of newness and wonder that is difficult to capture in one's adult life where there is less and less in the world of nature that seems new and unpredictable.

Sinister Sheep

2010-09-08T16:20:00.000-07:00

"I'm not a conspiracy theorist, but..." is one of my least favorite lines to hear conversationally. However, it is an apt way to begin this post. I am certain that I am on to a rather sinister plot for world domination being implemented by the Dall sheep of Alaska.

It all started as a whale-watching excursion. Various random strangers in places like gas stations or the grocery store had felt compelled to tell me that the belugas were back in the Turnagain Arm and that they had seen them. Seeing a whale seems to give certain people a special kind of joy that they cannot keep to themselves and therefore feel compelled to share with complete strangers. Labour Day evening therefore found me driving home along the Turnagain Arm after a day spent watching a tidal bore (it was a bore), beluga whales, seals, and salmon when I came across the following scene.

This is the major highway connecting Anchorage to all points south, and I had never seen vehicles pulled off to the side of the road like this before. Being a herd animal, I decided to pull of myself and see what was going on.

Upon slowing down, I noticed these people with rather expensive looking machinery, and figured that the attraction must be in the direction indicated by the machinery.

Sure enough! Below are a few pictures of the Dall sheep grazing along the ridge overlooking the highway.

Why in the world would wild sheep want to eat grass along the highway when they can have nice clean grass way high up on the mountain or back along some deserted ridge? Why in the world would a herd of sheep want to be around noisy vehicles eating grass that surely must taste a little bit of gasoline or diesel? I think that I am on to them. If you look at the first few pictures, you will see that this highway is a two-lane highway. Posted speed limits are between 55-65 mph. Obviously all of these people walking along the highway with their vehicles parked illegaly were creating a hazard to both themselves and oncoming traffic. My theory is that all of the sheep at the annual Dall sheep convention decided that the human herd was growing too large. They therefore decided to create a traffic hazard by posing along major highways, thereby endangering the tourists (like myself) who would feel compelled to stop and take pictures. Fortunately, on this day, their dastardly plot failed as no humans were injured as a result of these photographs. However, be afraid. Be very, very afraid.

This is the Turnagain Arm. Sorry. No belugas. They're not very photogenic.

Summer vacation

2010-08-29T17:14:00.001-07:00

Supposedly I moved to Alaska to work. So far, I have behaved more like a tourist, spending most of my time hiking and fishing. It is a great time of year to play tourist in Alaska. These tourist type of activities have been punctuated by occasional reminders -- hospital orientation, credentialing committees, onerous paperwork -- that eventually I am going to have to start working again. This will become a reality on September 1.

Up until this point, I have always worked under the supervision of someone else. The prospect of being out from under that supervision is both exciting and slightly daunting. I am eager for the ability to form relationships and treatment plans with my patients and then see those plans through to completion. As a resident, I was often only involved with a patient at one point along the journey of preoperative care, surgery, recovery, and postoperative care. I am eager for longer term patient relationships.

I am also eager to get back into the OR again and do cases. There is something about being in the OR that gets into a person's blood. Not having worked for a couple of months, I am definitely eager to get back to doing surgery again. It is very gratifying to work through a diagnostic challenge, successfully perform an operation, and then help the person through the postoperative recovery. Ideally it is a very rewarding journey that makes someone else's life better.

However, no matter how good you are as a surgeon, you will have complications. It is inevitable that there will be people who you operate on that are worse off after the operation than they were before. If someone has colon cancer, I can take their colon out, but I cannot tell them with 100% confidence that they won't have a heart attack, get a pneumonia, or have a leak where I reconnect their colon. Some of those patients even die as a direct result of the fact that you did surgery on them. I think that being out in practice on my own now, I will feel a higher level of personal ownership of these complications than I did as a resident.

In any case, it is good to be done with formal training. It was really good to have 2 months of vacation between residency and starting work. However, I am itching to get started and am really hoping that I don't have a perineal evisceration (no, you don't want to know) as my first case like one of my colleagues did who started a month before me.

A trip to Haiti

2010-08-22T22:06:00.000-07:00

Visiting Haiti this past month brought back a lot of memories. There is something about being in a place and experiencing its sounds and smells that jogs the memory like nothing else. When I was a teenager, my family lived in a small Haitian community for a year. I returned there for a visit 5 years following my family's departure, but did not return for the next 15 years.

It was somewhat surreal returning to a place after 15 years of being away. I didn't recognize some of the people, while others like Pastor Paul and his wife are timeless. It certainly was a small taste of heaven being able to visit people that my family knew 2o years ago.

I also very much enjoyed seeing where my sister Bethanie works. Despite the years that she has been down there, I never had the opportunity to see where she was working until now. Although she is a very descriptive writer, there is nothing like seeing the place for oneself. After seeing the work that she does, I came to the conclusion that she is the closest thing to a saint, in the Catholic sense of the word, that I know.

Here are a few pictures from the trip....

Here we are at the MAF airport, arranged by height. The MAF pilot was wonderful, and helped us escape what would have been hours of bouncing along awful roads while moving at a snails pace.

A vaccination post with Bethanie. Not shown is Claude, the main source of entertainment for the event.
Bethanie and I at the top of the mountain. The valley below is where she and many of her patients live. They could have climbed the mountain in a fraction of the time that we did.

Here we are climbing the mountain overlooking Bethanie's house. It was a pretty steep climb. The little guy leading the way for us obviously thought that we were pretty wimpy climbers.

Here Bethanie is treating a hand wound. The man is a mason and must continue to work despite a fairly serious wound.

This picture is of Bethanie in the clinic warehouse. The clinic distributes medications and has a number of patients with HIV or TB who are given food as part of their treatment.

How a Seemingly Innocuous Day Degenerated into a Flight to the Wrong Country as a Perpetrator of Domestic Violence

2010-08-03T13:20:00.000-07:00

The day came upon me harmless enough, introducing itself through the annoying yet innocuous means of my alarm clock. My sister, Bethanie, has lived in Haiti for several years, and i have yet to visit her there. That was all going to change today. I moseyed out of my friend's house where I had spent the night about 30 minutes later than originally planned, but early enough to still catch my flight to Port au Prince.

I returned the rental car without incident, and caught the shuttle to LaGuardia. I had just flown in there the day before. Oddly, the automatic check in kiosk wouldn't issue me a boarding pass and instructed me to speak to an agent. This entailed standing in a long line for 20 minutes, the only entertainment being the irate man berating a ticket agent for her insistence on charging him $200 for some service the airline was wishing to provide him.

I finally reached the ticket agent and stated that the machine had been unable to help me. She examined the gibberish that the machine had printed out for me, and explained that it seemed to think that there was a problem with my departure city.

The feeling of realization that came over me is akin only to that experienced by those who have a dream where they are in the middle of giving a public speech only to realize that they are half clothed. My worst dream of that nature was one in which I was doing a leg amputation and realized that I had amputated the left leg instead of the right leg. That kind of a dream is a terrible sinking feeling at its worst. Fortunately, the amputation dream resolved itself by the discovery that the patient was on his stomach rather than his back and the correct leg had been amputated after all, but I digress.

I suddenly realized that I was at the wrong airport. I was supposed to be at JFK, but was actually at LaGuardia. There was no way to get over there and checked in before the departure of my flight.

The ticket agent at JFK was helpful. In fact, she went way beyond helpful. She booked me standby on a flight to Miami and then on to Haiti the next morning. There was no fee for this even though it was obviously my fault. Furthermore, she refused to charge me a baggage fee even though one of my suitcases was overweight by 2 lbs. I like nice people, and am not accustomed to finding many of them working in airports.

I then made my way through the security process and to the departure gate. The flight to Miami looked very full, and the standby list had 13 names on it including my own. Things did not look good for me. They started boarding the plane, and it soon became apparent who my fellow standby participants were. One was an African gentleman who appeared to be Somali and didn't speak much English. He got in the boarding line repeatedly only to be told each time to wait for his name to be called by the boarding agents. Another man kept going to the counter every few minutes to see if he had a seat yet. A tired looking man was slumped in the corner not looking too hopeful. A young woman with a baseball cap, two black and blue eyes, and some other very impressive facial bruises kept anxiously looking at the standby list between applying makeup in a hopelessly inadequate attempt to conceal the evidence of whatever incident had occurred in her life.

Finally everyone was boarded, and the standby list was down to 9 people. I gave up hope of making it on that flight. About 10 minutes later they called my name and one other one saying that we had seats on the flight. I was overjoyed as I collected my ticket. The stewardess instructed me and the lady with the black and blue eyes to follow her to our seats as they were in a hurry and needed to depart quickly.

It turns out that our seats were at the very back of the plane. As I walked past all of the plane's passengers, following the stewardess and the lady with the bruises, I realized that lots of people were glaring at me! It dawned on me that since this lady and I were boarding the plane together 10 minutes after everyone else, people thought I must be the source of her black and blue eyes!

Even though I was flying to the wrong country and was viewed by many as the perpetrator of domestic violence, I was just very grateful to be on board and hope to make it to the correct airport at the correct time tomorrow.

Music of Authenticity

2010-07-25T14:35:00.000-07:00

I was recently thinking about some of the music I enjoy listening too. Some of it I enjoy listening to simply because of the sound itself, whether it is the vocals or the instrumentation. Other pieces of music are just very intellectually stimulating while also being aesthetically pleasing. Arvo Part, Philip Glass, Vivaldi, Bach all fall into this category for me. Another category of music contains a theme or a message that I listen to the music to receive. A lot of Christian music falls into this category.

My favorite music, though, is that which expresses the deepest emotions of the author. Several great examples of this that I deeply enjoy are Mozart's Requiem, Steven Curtiis Chapman's album Beauty Will Rise, and the song When The Tigers Broke Free by Pink Floyd.

Mozart started the composition of his requiem in the final months of his life as his health was failing. Though he was able to complete a rough draft, he did not survive to complete the piece. However, the result is a powerful piece of music. I think much of the power of the piece comes from the authenticity of the emotion about death the author was experiencing. I have only heard a live performance of this piece once. It was wonderful, and reduced me to tears at one point. However, the elderly lady a row in front of me provided a source of distraction for those of us within 10 feet of her as her hearing aid would screech rather loudly when the music rapidly changed from loud to quiet.

The album Beauty Will Rise was recorded by Steven Curtis Chapman a year after the sudden, accidental death of his 5 year old daughter. He calls the album his "personal psalms." Like the Biblical psalmists, he very authentically describes his emotions of loss and the subsequent questions about God, yet always manages to come back to a trust in God's control and ultimate goodness. What could be tacky and sappy if written by someone else is something very powerful and moving when written by someone who experienced a pain so deep that he nearly retired from his career as a musician.

My final favorite example of authentic music is When The Tigers Broke Free by Pink Floyd. In it, Roger Waters describes the pointless death of his father in WW II when he himself was only 5 months old. When he talks of the pointlessness of the death, the lack of regard the military command had for the life of ordinary men, and the callous impersonal nature of a condolence letter signed by the king with a stamp rather than an actual signature, it transports you to the place of emotion that he experienced. The result is a poignant piece of music expressing the pain of loss and pointlessness of war that is only so within the context of the life experience of the author.

Wouldn't it have been easier for Mozart to just go ahead and die and forget about writing his Requiem? Wouldn't it have been easier for Chapman to mourn the loss of his daughter in private and retire after having already been one of the most successful Christian musical artists? Wouldn't it have been easier for Waters to keep his personal losses out of his music? Yet I suspect that each of these artists experienced healing at some level by turning their emotions into music. I for one am thankful they shared those emotions with us.

What are your areas of emotionally deep and sometimes painful life experiences? How might God plan to redeem them in a similar way? Though you may not be a musician and have the ability to express those things musically, let God use those things redemptively to bless others. Sometimes something of beauty results just as it did in the case of these musical pieces.

Oh Canada

2010-07-18T13:45:00.000-07:00

Having completed my training in at the end of June, I found myself with 2 months of free time before beginning my first job where I will be working on my own. After 1 year of kindergarten, 8 years of grade school, 4 years of high school, about a year of Bible school, a 4 year bachelors degree crammed into 3 years, 4 years of medical school, 6 years of a surgery residency, and a year of fellowship training I was ready for a break.

I am spending a couple of weeks with my parents in Northwestern Ontario near to where I grew up and then am going to Haiti for a couple of weeks to visit Bethanie and some family friends. It is good to spend time with family again.

As someone who grew up in Canada but now resides in the US of A, I cannot help but compare the two places. Canadians clearly have two things in which they are vastly superior to their American neighbors.

The first of these is the design of their money. Rather than having drab green bills, the paper currency is bright and attractive appearing. Apparently international currency traders think so too as demonstrated by their overwhelming urge to exchange drab US currency for bright, appealing Canadian currency thereby propelling the Canadian dollar to ever higher highs in comparison to the US dollar. Furthermore, those annoying $1 bills that you get in the States don't exist here. One and two dollar coins truly make your change worth something.

The other area Canadians clearly have attained superiority in is their ability to creatively flavor potato products. As a child, I remember visiting the States and having one flavor, regular, of potato chips to choose from. At that time Canadians already had numerous potato chip flavors to choose from. Eventually the slower Americans south of the border caught on to the idea.

However, Americans clearly lag behind Canadians when it comes to knowing what to do with French Fries. The most creative thing Americans could think of doing with French Fries in the last decade was to rename them "Freedom Fries" when the French wouldn't buy in to the concept of the Iraq War being a smart thing to do, but I digress. Here in Canada, you are not limited to putting Ketchup on your fries. All restaurants offer vinegar packets which turn French Fries into something heavenly when combined with salt. If you are at a restaurant in any way more sophisticated than McDonalds, chances are that you can get things like gravy and maybe even some cheese, sour cream, or bacon bits added on to your fries.

Clearly, short trips to Canada are probably better for the waistline and cholesterol count than long ones for this Canadian returning from exile.

Moving

2010-07-08T19:59:00.000-07:00

I remember my Dad helping me with one of my moves over the years and saying that 3 moves equals one housefire. I've thought of that every time I have moved since then. Getting ready to move again, I've come across countless boxes of stuff that I thought I'd use at some point again in life when I packed them. Now I look at them and realize that they've collected dust for a year and will probably never serve any function in my life. For example, I discarded boxes of notes from medical school that I thought maybe someday I would want to look at again. I'm not sure what I was thinking when I kept those.

I'm glad that when we finally get to our eternal home, there won't be anymore moves. There won't be boxes of stuff to pack and unpack. I doubt we'll even have to do any housecleaning. Sounds heavenly to me!

Illegal Immigration

2010-05-02T16:51:00.000-07:00

I don't know many of the details regarding the Arizona immigration law. I do know that it seems to have prompted a bit of an uproar politically in this country. Living in Texas, I agree that this issue is one that the country does not do a great job with.

Isn't it kind of ironic that the people most worried about illegal immigration are mostly descendants of people who moved to this country despite the opinion of the existing occupants that their doing so was illegal? If Americans truly believe in democracy, don't some of those God-given inalienable rights apply to people who aren't Americans? Most of the opposition to immigration stems from people's selfish desires not to see their standard of living decline. Many people also feel threatened by the prospect of becoming a racial or linguistic minority in their own country. If God created all humans equal and did not draw borders on the world he created, does it not make sense for those of us who are Christians to welcome immigrants even if it might mean that our standard of living suffers or we are not part of the dominant culture?

Scripture consistently sides with the "have nots" rather than the "haves." In Leviticus the Isrealites were instructed that "The alien living with you must be treated as one of your native-born. Love him as yourself, for you were aliens in Egypt. I am the LORD your God." I think the issue is relatively clear for believers. If you are an evolutionist who believes in the survival of the fittest, I suspect that a different approach to this issue is what you have in mind.

How a hurricane changed my life

2010-04-03T15:06:00.000-07:00

I think I was a third year general surgery resident when Hurricane Katrina hit the southern US coast. I lived fairly far away and didn't think much of it though I did feel badly for the people affected by it.

Two of the storm refugees blown up to Chattanooga were Bruce Lynch and Norris Jackson, both residents at a military hospital in Missisippi. Their program was destroyed by the storm. Norris was a couple of years ahead of me, but Bruce was at my level of training. Over the remaining three years, I came to know and respect Bruce greatly. He and his wife were active in their local church. His father was a pastor, as is mine.

When graduation came, he and his family moved to Anchorage, Alaska having been assigned to a military hospital there. He told me there was a group of colorectal surgeons in Anchorage looking for a partner. After looking into it, and discovering that there was a Mennonite church in the area I could attend, I was even more intrigued.

After visiting, I signed a contract with the group there as a part-time surgeon working 4 out of 6 weeks. I am looking forward to having a real job as well as the opportunity to have a significant amount of time off.

I owe a thank you to Hurricane Katrina for sending Bruce Lynch and his family my way. I wouldn't have heard about the job otherwise.

In praise of simplicity

2010-03-22T19:52:00.000-07:00

I just finished reading the sentinel paper published by Dr Norman Nigro in 1973 on the use of combination radiation and chemotherapy for the treatment of anal cancer. In it, he proposed using these modalities as an adjunct to surgery. Eventually he discovered that these patients did not need surgery at all. In his brilliant first paper on this topic, he cited a total of 5 references. Most academic papers have way more than that. I have read that Einstein's paper on relativity cited no references. I guess when you have something truly original, you can just simply state what you think.

You might be insane if...

2010-03-15T20:15:00.000-07:00

The program director for the fellowship was kind enough to give the fellows tickets to attend the annual Houston rodeo. I must say that cowboys are absolutely insane. I can't imagine deciding that it would be a good idea to jump on the back of a bull and then see how long it took to buck me off. My personal belief is that they all ought to be declared insane.

That's News??

2009-12-27T15:57:00.001-08:00

I've previously posted about my surprise at the repeated news coverage regarding the death of the oldest person alive. Amazingly, it is a story that repeats itself quite regularly, being eclipsed in shock value only by the repeated appearance on the global scene of the youngest person alive.

I was reading the news coverage of the attempted airline bombing in Detroit. Amazingly, the Nigerian government condemned the attempted attack. Also amazing was the recent US condemnation of Iran's use of force against government protestors.

Maybe there should be a rule that such government condemnations are only given media coverage if they represent a complete break from what the expected official government response would be. Examples of stories that would merit coverage would be a US statement condemning Israeli "security measures," Ahmadinejad condemning Hugo Chavez's next weird rant, or Russia condemning NATO's decision not to build a missile defense shield. Somehow most of the "news" doesn't seem newsworthy.

The Great Job Hunt

2009-12-21T19:06:00.000-08:00

It is a privilege to have multiple job offers in an economy in which unemployment is 10%. It is also nice to be very near the light at the end of what has been a very long tunnel. While it has been fun to interview for a job, it has also been difficult to sort out exactly what it is I want in a job. Hopefully I will come to some sort of decision by the end of January.

What I have enjoyed the most about the job interviews has been the real estate tours. It is the point of the interview experience where the discrepancy between what I want and what they think I should want is the most glaring.

I wear the same suit to the interviews that I wore for medical school interviews, residency interviews, and fellowship interviews. Despite having gained a few pounds (me - not the suit), it still fits. Most people do not associate the plain suit with a religious statement. For example, the realtor taking me on my last real estate tour asked me what kind of place I would be looking for. I proceeded to tell her that I was very happy with my two bedroom-one and a half bath condo that I had in Chattanooga. She then stated that as soon as she saw the suit I was wearing, she was sure I would just love some of the trendy, preppie sorts of places downtown.

The realtors never quite seem to get the fact that I indeed aspire to nothing more than the 1000 square foot condo I owned in Chattanooga for which I paid $25,000. Instead I get shown 5 bedroom mansions that have way too much lawn to take care of. After making subtle hints about these places such as, "I bet that place is no fun to clean," I generally give up trying to be shown places that I might actually be interested in living in someday. It seems to me that such houses not only represent luxurious status symbols, but a ball and chain which I for one don't wish to wear.

Bizarre thoughts on the macroscopic

2009-11-27T20:24:00.000-08:00

While reading the December National Geographic issue, I came across the map of our own Milky Way galaxy. Our solar system is this little miniscule dot in it all. As if that sort of scale isn't enough to make you feel insignificant, it turns out that there are probably 100,000,000,000 galaxies in the "observable" universe. That immediately made me wonder how you determine what an "observable" universe is, and how many more billions of galaxies there are in the unobservable universe if such a thing exists.

Unfortunately, my thinking has progressed little since childhood when I made myself dizzy to nearly the point of nausea trying to fathom the fact that on the one hand the universe must have an edge, while on the other hand it would be impossible for it to. This makes me no less dizzy now when I read that the diameter of the universe is 156 billion light years. It instantly begs the question, "what lies just at the edge of our universe that is 156 billion light years in diameter?"

So anyway, in thinking about this all, I realized that on the microscopic level, we have seen life forms at ever diminishing scales. We discovered mulitcellular microscopic organisms, eventually discovered unicellular bacteria, and then discovered non-cellular semi life forms like viruses and prions. What if there are whole sets of life forms on ever increasing macroscopic scales that are too big for us to discern, just as if we were a bacteria living in the GI tract of some creature huge beyond our imagination.

I suppose I ought to shut this ramble down and go to bed before the thought police analyze this and send me to the loony bin all sugared up with lithium.

I'm freezing

2009-11-22T18:33:00.000-08:00

Today when I walked outside, I knew immediately that it was the end of November. It is cold. In fact, it was very cold. It brought back memories of my childhood in Northern Ontario when there were several feet of snow on the ground. The van that took us to school every morning had these horrible vinyls seats that were hard and freezing when cold. You knew not to sit in a spot where you would have to scoot over when the next kid was picked up and freeze your poor backside all over again. Yes, this morning it was cold, and I wished that I had worn a long sleeve shirt instead of a short sleeve one as I braved the frigid 50 F weather. I might have to actually turn the heat on in my apartment!!

The Great American Ponzi Scheme

2009-11-15T18:51:00.000-08:00

Every month I send a cheque to a bank in my hometown of Dryden, ON. It is in US funds. They convert it into Canadian funds, deposit it into my account there, and then automatically withdraw most of it to make a payment on my Canadian student loans. This is a ritual that has been occurring for the past 5 years.

When this ritual began in July of 2004, I was able to get $1.32 Canadian for every $1.00 US that I deposited. Last year the curriencies traded at parity briefly. Currently I can get about $1.05 for every US dollar I send north. By the time this ritual ends in a few years, I would not be shocked to be getting even less. What is going on?

I think it is something I call "The Great American Ponzi Scheme." This is rather like the internet bubble at the turn of the millenium or the real estate and banking crisis of the last few years, except it is on a much larger scale. I am not an economist. I am a surgeon, and surgeons like to keep things simple, so forgive me if I do not grasp the complexities of the global economy.

The way that I understand how things work is this. We are a consumer society. As a whole, Americans consume more than they produce and definitely consume a disporportionate share of global resources on a per capita basis. Currently, the Asians (mainly Chinese) ship us manufactured goods. The Saudis and emirate states ship us oil. In return, we send those countries US dollars. Because these countries do not buy products from us of equal value, there is a trade imbalance, meaning that they have all these pieces of paper we've sent them that they have to do something with. They therefore send the money back to us by buying US government treasuries, US corporate debt, and shares in US companies. This capitalization injects money back into our economy. This is spent by us to buy more Asian manufactured goods and more oil from our Arab buddies.

This all works well as long as people like our Arab buddies feel like they are making money on the investments they have made. However, when treasuries pay interest rates that even a man with most of his digits amputated could count on his remaining fingers, there is not much reward for buying them. This reward vanishes and even turns into a punishment when the US currency depreciates as it has against most other currencies. Many foreign investors who bought treasuries with one year maturations would have been better served to keep their money in their native currency, stuff it in a sock under the mattress, and pull it out in a year.

Unless the government is able to quickly reduce the annual national deficit well below the trillion dollar mark, the Great American Ponzi Scheme will be revealed for the economic deception that it is. Given that a democracy with 2 and 4 year election cycles promotes short term fixes rather than long term more effective solutions, I think the possibility of that happening is remote.

Thou shalt hear a voice saying "this is the way, walk in it."

2009-08-23T20:02:00.001-07:00

That's the Scripture passage I think about periodically when my my very bored, monotone sounding GPS system talks to me.

Her favorite phrases seem to be "recalculating" or "turn left" or "turn right" or "arriving at destination." I have often wondered what sort of adventure it would take to make her seem less bored. However, no matter how many wrong turns I make and regardless of the rate of speed I make them at, she always sounds very bored.

I felt a little foolish plunking down the money for the system several months ago. I feared that it would be some electronic gadget that would lie around collecting dust after minimal use. However, two months into my time in Houston, it has proven to be a lifesaver and has probably payed itself off in gas saved by not wandering aimlessly around this sprawling metropolis. It is quite phenomenal really. I can type in "post office," and it almost immediately lists the five nearest post offices.

Recently someone asked me how to get to one of the hospitals I have been to a number of times. I gave them a blank look and replied that I really had no idea... I just followed my GPS.

My only complaint is that it sometimes makes me do things that I think are downright cheating. For instance, I was in a traffic jam the other day, and it told me to get off at the next exit. I did so, thinking it had calculated some wonderful backroad plan for getting me to my destination. A la contre, it immediately got me back on the same highway at the next entrance, probably having gained me two car lengths by getting off and on the highway. However, she sounds bored even when executing such devious plots.

Can't we just call a duck a duck?

2009-08-15T17:35:00.001-07:00

Have you ever wished that politicians could just honestly present realities? Two recent examples come to mind in which politicians say that our society can achieve mutually exclusive goals.

The first is the attempt to become more environmentally responsible while trying to stimulate the economy. Basically, consumerism involves the consumption of natural resources. The extraction and sale of these natural resources creates jobs which is great for the economy, however it is really lousy for the environment. So while "cash for clunkers" is great for the economy, it really is bad for the environment. The reality behind this debate is that people in the USA consume too much. As a country, we need to lower our standard of living to something that is sustainable.

The next example is the health care debate. Obama is promising to socialize health care while not decreasing people's current access to care and also not increasing the deficit or taxes as a result of doing it. That is sheer lunacy. The president also struggles with the facts of the debate. In a recent speech, he stated that we need to spend more money preventing and managing diabetes rather than paying a surgeon $50,000 to do a leg amputation for it. I agree about the prevention part, but disagree about the surgeon part. Surgeon's do not get paid even $1000 for an amputation. Furthermore, the fee they do receive for the amputation includes all of the care they provide to that patient for the 6 week postop period, they also have to pay office costs and malpractice costs out of that fee.

President Obama also said that we can save costs by using cheaper equally effective treatments. He gave this example. "If there is a blue pill that works just as good as the red pill, but costs half as much, we should use the blue pill." I agree. However, the problem is that often times the red pill works 20% better than the blue pill, but costs 3 times as much. Patients who are not paying for the pill themselves think they deserve the red pill.

Our healthcare system spends horrible sums of money on treatments that only very marginally improve outcomes. We also spend tonnes of money on people who are going to die in a matter of weeks no matter what you do. For example, Avastin is a drug used for chemotherapy in colon and rectal cancer. It was found to increase survival from 8 months on average to 10 months on average. Basically if you took the drug, you were on average going to live 2 months longer than someone who did not take the drug. That's great right? The problem is, that a course of chemotherapy with this drug costs $30,000. Another example is the terminally ill patient whose family has not accepted the fact that they are going to die imminently. The patient gets lots of blood transfusions, radiographic studies, blood cultures, antibiotics, and other meds all to very marginally delay what all of the healthcare providers know is an imminent death. However, Americans believe that they have a right to receive any medical test or intervention that might possibly be of any benefit no matter how miniscule regardless of their ability to pay. We already have socialized medicine. This is all just an argument about who is going to pay for it.

What currently happens in the healthcare system is that when you show up in an emergency room, that hospital is obligated to take care of you regardless of your ability to pay for it. It is like showing up in your local grocery store, declaring that you have no food whatsoever at home, and expecting them to load up your grocery cart with free groceries since no one can live without food.

What needs to happen in our healthcare system is an honest discussion. We all die. We need to be more comfortable with our individual mortality. We also need to decide at what level a treatment becomes prohibitively expensive. In other words, at what level does a treatment become so expensive that it is too expensive to be the standard of care?

I think the Democrats have been brave to tackle this minefield of an issue. The status quo cannot continue. However, I would really like to hear the president say that part of the answer to the healthcare issue is an acceptance that death eventually finds us all and that we cannot afford every invention that medical technology brings us. The benefits of a treatment need to be weighed against its cost.

Endings

2009-05-27T17:42:00.001-07:00

The residency thing has gotten down to the last few weeks. Its sort of hard to imagine life in another place doing something else. I've been at my current address longer than anywhere I've lived in the last 16 years -- and I've liked it here. Chattanooga has been my favorite place to live since leaving northwestern Ontario. It has a sense of history, scenic beauty, and just plain old livability that I haven't found in the other places I've been.

I'll especially miss my coffee shop haunt -- Stone Cup. The people there are usually some sort of weird combination of anarchists/communists plotting the transformation of civilization by overthrowing it, church youth groups doing Bible studies and prayer meetings for all in the vicinity to hear, hippies just wanting a warm place in the sun, anemic looking academic types who are looking for a place to study, the gen-Xers looking for a cheap internet connection, and then all of the normal people like me. The anarchist/communist group is my favorite because they gave me a free bagel one night. I think the older members of the group are communists while the younger ones are anarchists. In addition to all of the folks that show up there, I like Stone Cup because it has a gorgeous view of the city -- the Tennessee river, the lighted walking bridge across the river, Coolidge Park and its carousel, the Hunter Museum, the Tennessee aquarium, and of course the Smoky Mountains.

Yep, Chattanooga has been a nice spot to park for a few years.

Islands colliding in the mist

2009-03-29T13:17:00.000-07:00

I have spent the last three months on the "orange service." It is the service where we as residents are given the most autonomy in patient care. It has at times been a stretching experience and has at times been quite rewarding. There isn't anyone much more grateful than the patient who has had a colostomy reversed, a cancer removed, etc.

The tough part of the job is being the one to have "the talk" with the person you've just discovered has a cancer. Its especially difficult when the prognosis is clearly not amenable to intervention for cure. I've often thought that at some level that moment isn't fair to either doctor or patient. The people I deliver this sort of news to are people whom I have often not spent more than an hour with, at least where they were conscious. I have no idea who they are, what sort of life they have constructed, what their belief system is like, and cannot anticipate how they will handle the news. By the same token, the patient has no idea who I am, what my belief system is, and whether I feel comfortable with their displays of emotion. The terminal cancer talk, which can be one of the most devastating things anyone ever tells you, takes place between two utter strangers.

Some folks and their families degenerate into rather noisy, dramatic displays of emotion. Others are very matter of fact about the whole thing. Interestingly, people of faith are usually the most unreasonable about accepting a diagnosis of a terminal illness. We in communities of faith like to talk about how we have a reason beyond this life for living, how we are not afraid of death like nonbelievers, etc. However, I have seen these families torture their loved one with weeks or months of futile, agonizing care because "God is gonna heal momma." I remain baffled as to why many non-believers are more accepting of death than believers are. Is it that at some level they recognize it as a normal part of the life cycle? Is it that Christians somehow view God's purpose being one of protecting them from bad things, rather than their purpose being one of eternally worshipping God?

Send more catnip

2009-03-14T11:47:00.000-07:00

I'm usually of the opinion that there is a reason why the ancient Egyptians worshipped cats, not dogs. I mean who would ever mistake a dog for a deity? They are known to eat their own feces after all!! To make matters worse, after eating something nasty, they want to lick your face. Definitely not a candidate for the false god list.

My cat is usually a well-mannered, well-behaved critter. However, this winter she has developed a bad habit that recently left me with a rather stiff neck. Cats have this passion for finding the warmest place on the premises and then parking themselves there.

I had been working on some documents on my computer for awhile, and decided to take the trash out. When I came back, my cat was sprawled comfortably across the computer keyboard, presumably for the heat generated by it.

Once I had kicked her off of my computer, I discovered that the screen now was presenting things upside down. I would have had to turn the screen 180 degrees to have the display back in the usual anatomic position. I figured fixing it wouldn't take very much time... I mean if a cat could figure out how to adjust the display so that she could read it while her head was upside down, it shouldn't be that hard. About an hour later, after trying every computer control screen on the system, I had a very stiff neck and still had an inverted image on my screen.

Fortunately, Al Gore invented the internet for us years ago, and I eventually googled fixing the upside down screen. It turns out toddlers have been pulling this trick for decades, and after reading the upside down advice on google, my screen was righted.

Now if I could only figure out how to keep the cat away from the computer. Yesterday she locked the keyboard. However, she was kind enough to leave the instruction panel displayed on how to unlock it. So if you get an email from my address asking for catnip, please disregard it.

Long time no post

2009-03-08T16:49:00.000-07:00

Yeah, I've kind of been busy.

My life in Chattanooga is sort of on a downward slope now. I'm trying to get some of those remodelling projects done that I've been procrastinating about so that my house will sell. I've even started packing some stuff. The fact that I won't need that stuff for several months is a sign that it might be better served by being taken to the dumpster. Maybe my little sister was right though, stuff has feelings too.

Fortunately the real estate market in Chattanooga really hasn't declined at all. Property prices are pretty stable from where they were at a year ago. Hopefully that will hold until my place is sold.

I've found the economic politics of the last year to be very interesting. Both parties have missed the key point about the housing collapse... the problem was due to people consuming more than they were able to afford. People took on more debt than they were able to handle. The solution to this is to give banks gazillions of dollars, and then chastise them when they don't lend the same way to the same people who got us into this mess to start with. On a federal level, the consensus seems to be that the problem can be solved by the government spending massive amounts of money and thereby taking on massive amounts of debt. Wasn't it debt that created this problem in the first place? What ever happened to people trying to live within their means?

Recently someone commented to me that at least things can't get any worse. I was rather baffled that someone could say something like that, and asked them if they had ever been to Haiti. People feel entitled to our current way of life, and have no concept of what most of the people in the rest of the world live like. I'm sure that Obama will soon wave the magic wand that he promised to wield, and no one will ever have to work again, health care will be free for everyone, food will magically appear in the kitchens of all, and all of our cars will always be brand new.

How is that for a rant?

Hello 2009!!

2009-01-01T14:41:00.000-08:00

I did something really exciting for New Year's Eve. I slept all night!

I know that such things as the New Year are arbitrary marks on the calendar, but they're good times for thinking about what has been and will be nonetheless. I've really enjoyed living in Chattanooga for the last 5 1/2 years. I'm also looking forward to moving on to what comes next in life. Hopefully nothing like Ike comes after us in Houston while I'm there.

The first 6 months of my chief resident year have flown by. I'll spend the next 3 months on the resident run service. It is the service on which residents have the most autonomy during residency. I feel ready for it. It is generally a fairly busy service, so I'm sure that I'll be ready for something different by the end of March. Tuesday's clinic apparently has 60 patients scheduled. It will be busy even if we have the normal number of cancellations/no-shows.

Hope that you have a blessed New Year.

Oh no, it happened again!!

2008-12-29T07:47:00.001-08:00

Its unbelievable, it happened again!!

http://news.yahoo.com/s/ap/20081229/ap_on_re_us/obit_oldest_american_man;_ylt=AhckdBn_m.H.t4ReZvwWeHIDW7oF

Bail anyone?

2008-12-29T07:41:00.001-08:00

After about 6 years or so of having an expired passport, I've decided to spend my afternoon tomorrow getting a new one. Now that the Bush presidency is coming to a close, I might just get by without too much hassle. My last passport is full of stamps to evil places such as Pakistan and Afghanistan. Hopefully no super-vigilant Bush minion will decide that I look like the terrorist sort. If they do, please come down to Guantanomo, or however you spell it, and bail me out.

P.S. Yes, I do start working in Houston in 2009, not 2008 as previously posted.

Staplers and such

2008-11-30T13:10:00.000-08:00

This past Wednesday found me behind a desk with one of my fellow chief residents interviewing 20 applicants for our residency positions. It was a fun day. Having just completed a whole raft of interviews myself as a candidate, it was interesting to be the one doing the interviewing.

Wednesday was also an interesting day because it was the day that my own match for a fellowship position in colorectal surgery occurred. It was the most competitive match year for that sub-specialty in years, with 1/3 of people applying not obtaining a position. I was one of the fortunate 2/3's of applicants to obtain a spot, and was even more fortunate in that I obtained my first choice. So beginning in July of 2008, I will be a Houston resident. Whatever happens, at least I won't be cold.

Its sad to think of leaving Chattanooga. I've enjoyed living here and will miss the other residents and faculty whom I've come to know so well over the last 5 years.

The next 6 months will be busy ones with clinical work. I've also broken my pledge not to do more research and have embarked on one research project and one clinical case report, both of which will probably turn into journal articles somehow or another in the next 6 months. At least I won't be bored!!

Miracles

2008-11-11T16:43:00.000-08:00

My oldest smallest sister is coming to visit my humble abode tomorrow. She will be stopping by as she passes through to Louisville, and will then stop by again and stay for a day or two on her way back to climes more temperate.

It is a very auspicious event, its not every day that I have the prilivege of hosting a visiting missionary. I expect to be regaled with stories of hungry cannibals, transformed savages, and miracles too amazing to describe.

Unfortunately, I've been working on a little miracle making of my own. You see, it has been nearly two years since I last hosted anyway in the aforementioned humble abode. Me not being here for much more time than it takes to boil some spaggetti, gobble it down, and then trundle off to bed makes for a rather untidy place. Not having had the motivation of facing social rejection due to the state of my humble abode, things have sort of accumulated.

Last night found me scraping away at the buildup of stuff inside the microwave. Tonight found me tidying up the guest room. Tomorrow will consist of throwing all of the remaining junk into the other room. I wouldn't want the visiting missionary to catch some awful malady after surviving for years as a poor, starving missionary.

Presidential Race

2008-11-08T12:27:00.000-08:00

I'm glad for a lot of things, but mostly right now I'm just glad that the presidential race is over. I'm sick of it all after two years of coverage. Why can't we just do it like Canada and have a snap election that is over in a month or two?

I'm also glad that Obama won. I'm not sure that he'll make a better president than Bush, or that he will be better than McCain would have been. I don't think that all of the troops will be out of Iraq by the time he leaves office, and I don't think that he will magically solve economic problems brought on by people whose desires were bigger than their pocketbooks. No, I'm glad for one simple reason. I think that his win has meant a lot to many non-white Americans, and I'm glad for that.

His election has also raised some really interesting issues about race and our conceptions of it that prove that our society has done anything but move beyond racism, despite what the pundits would have you think. Both of my points on this are probably not politically correct, and have not been stated by the media that I have heard.

First of all, why is someone who is half white and half black called black? Especially when that person was not raised in a black community or black culture, if there is such a thing? The reason our society calls someone like that black, is because we have an almost Nazi conception of race when it comes to defining who is white. It is a pure-blood philosophy. If you are 3/4 white, and 1/4 black, you're still not white.

My second point is that racism works both ways. I have been to predominantly black neighborhoods where black cashiers have served black people behind me in line. That is racism. The same holds with elections. The media focused on whether there would be a "Bradley effect" in which non-black voters would not vote for Obama despite telling pollsters otherwise. Is it not just as racist for black voters to vote against McCain because he is white, as it is for white voters to vote against Obama because they says he's not?

The End of the Garden

2008-10-14T16:49:00.000-07:00

The last couple of years I've had a wonderful time gardening during the summer. This summer I canned all sorts of tomato products and even canned some dill pickles. This year's garden if dying off, not due to weather yet, but rather due to the neglect of the gardener gone on various trips interviewing for fellowship spots around the country. Turns out that plants love water, and don't seem to do so well without it. Ahh well. It was fun while it lasted. Too bad that the academic year ends at the end of June. I'll be moving right in the middle of gardening season next year and won't be able to much horticulture I'm afraid.

Will work for gas.

2008-10-01T17:03:00.000-07:00

On Monday I was in Atlanta for a fellowship interview. While I was there, I decided to check in on a good med school friend, Tejas Desai. It was really good to see him and his wife again. It had been about a year since I last saw them. He is finishing up a nephrology fellowship. They have a chosen a rather bad period of time to live in Atlanta. Last summer everyone in Atlanta was hoarding water because the reservoirs were almost empty. This summer everyone is hoarding gasoline if they can find any. The city looked like a scene from the 70's and the Iran oil crisis, except they forgot to use old cars. Any gas station with gasoline had a line of 10-20 cars waiting to fuel up. The situation is getting worse in Chattanooga as well. The last time I posted, half of the gas stations had fuel. Now only about one in 7 or 8 do, and they sell out quickly. Today I had to wait in line for the first time to buy gas. Its all just really bizarre.

Got Gas?

2008-09-28T14:50:00.000-07:00

These be bizarre times. The banks are going bankrupt. The gas stations are all running on empty. Ever since Hurricane Ike, half of the local gas stations have no gasoline. The other half of stations that do have fuel have only one grade available. Its not just Chattanooga, either. Gas stations in Nashville and Atlanta are also apparently running on empty. Makes you wonder if them Old Order folks don't have it right after all. Makes you wonder where its all heading...

Chaos and Mayhem

2008-09-14T17:53:00.001-07:00

I'm sure that all of you all are much better behaved than me, and never ever have evil impulses. Sometimes you wonder where in the world some ideas come from.

For instance, I was walking through the hospital the other day. My route took me through the pediatric hospital. There is a little library/play room for the kids there. There was a big sign on the door saying "Radio-a-thon" on the door, and a very prim, proper looking lady was talking into a microphone. I desperately wanted to pound on the windows, make faces through the glass, or even burst into the room screeching like a banshee. The very thought of it all gave me the sniggers for the rest of the day.

Then the other day, I was taking my garbage to the dumpster. My thoughts were on making enough noise when I got there so as not to startle the raccoon that normally is feasting in the dumpster that time of night. The aforementioned beast and I both had a very startling experience one dark night when we met. I had tossed my bag of garbage into the dumpster when I flying ball of fur came whizzing back at me. Anyway, I digress. As I said earlier, I was walking towards the dumpster thinking about the raccoon. I came up on a big fire engine parked in the street with its engine running. There were no firemen in the vehicle as they were all off somewhere in the vicinity doing firemen sorts of things. From deep in my childhood fascination with big red fire engines came this urge to climb into the drivers seat, flip on the sirens and lights, and go hurtling around town at 90 mph running all the lights.

Maybe I need some of that "xnax" that some of my patients talk about. (Known as xanax in dialects other than hill-billy.) Hill-billies also have high-needle or hyenal hernias instead of hiatal hernias. But that is unrelated to the general theme of sowing chaos and mayhem.

Blue Vicryl

2008-08-24T11:03:00.001-07:00

In June of 2009, I will have completed a 6 year residency. It is hard to believe that those years are almost at a close now. However, they are, and it is time to start planning for what comes next.

One of the men I have been the closest to during my residency has been Dr Moore. He is a colorectal surgeon who moved here shortly before I did. He and his family had moved to Chattanooga from Pennsylvania where he been in practice for a while. There are many things I respect about how he treats his patients, lives his faith, runs his practice, and relates to his family. When I think of how I would like to be as a man in 20 years, there are many things about him that I would like to emulate.

It is hard to know how much a mentoring relationship like that influences decisions we make, but I suspect it has played a very large role in my decision to pursue a colorectal fellowship after residency is complete. I am currently in the middle of that application process. I plan to do 10 interviews, most of which occur in late September and October. In November the Match occurs and I will find out where I get to spend a year doing a colorectal fellowship should I match. I am looking forward to the opportunity to meet people at the various fellowship programs as I interview.

The Great Kidnapping

2008-08-10T19:52:00.000-07:00

Today I was fixing a hernia in the OR.

The room circulator and the CRNA got into a discussion about the Rapture that I thought was hilarious.

CRNA: I just don't believe in the Rapture. I've never known anyone to just up and disappear.

Circulator: That's not how the Rapture works. Everyone disappears all at once, not one by one. I know it hasn't happened yet because I'm still here.

CRNA: I don't want no part of that. Ain't no one gonna be kidnapping me.

Lawyers

2008-08-02T17:53:00.001-07:00

When I started medical school, I felt fairly ambivalent about lawyers. Then I got served papers in a lawsuit my intern year in which some lawyer made me sound like a truly evil sort seeking to inflict pain and misery on the world. I no longer felt ambivalent about lawyers. The lawsuit was dropped pretty quickly, but the feelings were still there.

Sometimes I think that God arranges things just to show us some of the rough edges we have in our attitudes. A month or so ago, I was on call. I got a call from the ER doctor asking me to come down and evaluate a patient. Apparently my intern who usually fielded such calls first was no longer responding to pages. I trudged down to the ER and looked at the labs and radiographic images. All of these studies looked fairly grim, and I guessed that the patient probably had a year to live at most.

I went to retrieve the chart from the ER doctor. "Oh, by the way," he said, "you ought to know that this guy is a prominent medical malpractice attorney." Something in my heart remembered all of the false things that someone like this man had written about me, and it rebelled at the thought of dealing with this patient.

However, I went and talked to him and examined him. By the end of it all, I just wanted to cry. Here was a man in his prime to whom I had just given the worst news of his life.

Friday there was a very nice card from him in my mailbox thanking me for my empathy and work on his case. I feel better about lawyers now. I suspect the Lord probably arranged his visit to the ER and my intern's lack of response to his pages just so that I could get loosen up on a little bit of unresolved feelings in my heart.

Last Night of Trauma Call

2008-06-14T14:38:00.000-07:00

I recently completed my last night of trauma call . . . ever. The night had the usual assortment -- drunk, high, doped up, the not so brilliant decision makers, and the just plain unlucky. It brought back a lot of memories, and made me a little bit nostalgic.

There is something about being the trauma chief resident that changes you, and makes you different from most other doctors. When someone is deteriorating or even about to die, you have to make decisions very quickly. You learn that sometimes you do everything you can, and the person still dies -- its not your fault. You learn to break very bad news to families, and inevitably make the mistakes of painting a picture that is too optimistic or grim. You learn that you can't always be nice -- sometimes when the system isn't working smoothly for a patient who is in trouble, you have to find the source of the problem and perhaps rub someone's fur the wrong way.

The other thing you learn how to do is to perform the emergency procedures in surgery. That last night of trauma call, I thought back over some of the things that I had learned in the trauma bay. It was where I put my first chest tubes in. It was where I placed my first large bore central venous lines. It was where I learned how to quickly stop or control bleeding from major wounds, and also how to sew wounds up. It was where I had learned how to intubate patients. I had done several Emergency room thoracotomies there, in which you cut someone's chest open to diagnose and treat injuries to the heart, lung, etc.

However, in all of my 5 years of doing trauma, there was one procedure I hadn't ever done or even seen. On several occasions, I had a knife in my hand ready to do it, but at the last minute didn't need to. A cricothroidotomy (cric for short) is the way to obtain emergency surgical access to the airway. If a patient cannot deliver oxygen to his lungs, he will die. Establishing an airway is therefore one of our first priorities when evaluating a patient. This is preferably done by inserting a tube through either the nose or mouth into the trachea.

I had pretty much resolved myself to the fact that I might not do a cric during my residency. I felt confident that I could do one if needed. I had read the books, and could recite the technique. I had even taught courses to other people, and showed them how to do it on pigs. However, nothing is ever the same as being in a situation where it is you, a knife, a person who will die in a minute or so if untreated, and often a chaotic room full of people running around in circles.

My last night of trauma call was a busy one. There was a car wreck with several badly injured folks. There were the usual ATV/motorcycle accidents. In the midst of all of this, a patient was rolled back to the trauma bay with no advance notice to us. While I won't go into the details of his mechanism and injuries due to privacy laws, it very quickly became apparent that he wasn't going to be able to survive breathing on his own. The initial attempt at intubation failed miserably, and it was obvious that we would not be able to secure an airway this way. My attending and I decided it was time to cric him.

It went beautifully. We very quickly established an airway via a cric. The patient stopped acting like he was going to meet his Maker that day.

Although the entire night was busy, I left the next day feeling a sense of closure to my trauma experiences. There were no emergent procedures that I hadn't done at some point. I was ready to move on.

Great Idea

2008-05-20T16:49:00.000-07:00

I'm not sure if this is legal, and haven't tried it. It is an escalation of the strategy I've described in a previous post regarding how to deal with bulk mail. I think its pretty funny.

Enjoy.... http://officeofstrategicinfluence.com/bulkmailer/

Murdercycles

2008-04-09T17:47:00.000-07:00

I'm back in the trauma world for another final go round this month. Next year I'll be in my final year of residency, a so-called chief resident, and won't have to do trauma.

I have mixed feelings about all of that. I have generally enjoyed being on the trauma service. The cases are intriguing and stimulating. However, they are really not scheduled, and therefore occur whenever some poor soul decides to fall victim to trauma.

The four calls I've had this month have been the usual mix of folks, though we've had a lot more motorcycle accidents lately. I guess the arrival of spring has given people the urge to strap their rather fragile bodies until two wheels and an engine. Numerous such experiments have proven that people who leave the murder-cycles (as we call them) mid-trip don't tend to fare too well. Leave such antics to the people in the movies who are actually indestructible.

The most difficult thing about being on the trauma rotation is operating on someone for hours and then losing them. It really leaves you wiped out physically and emotionally. However, the payback comes when you watch someone walk out of the hospital who you know would have died were it not for what you did for them. So I'll enjoy my last month of trauma, and hope that the weather gets cold and keeps all of the would be murdercycles inside.

New Shoes!!!

2008-02-17T13:57:00.000-08:00

I've been the proud owner of the same pair of shoes for over 4 years now. Some folks have hinted that they needed to be retired. I returned to the call room one day to find my shoes wearing this sign. That was about a year ago. However, I got another year of life out of them.

However, I finally decided that they had given up the ghost, and needed to go to the place where shoes find their eternal rest. The shoe salesman at the shoe store even offered to throw them away for me. She acted somewhat horrified that a person would wear such ratty things. However, I think it was all a facade, and she was trying to take possession of them. I was frankly rather afraid that if I'd be held responsible if someone caught a disease from them. They've been drenched in human blood on several occassions when the wearer was working on some poor trauma patient. They've had their fair amount of exposure to the normal hospital pathogens. After 4 years, they are probably so toxic that they'll never decompose. Some archealogist will discover them and probably display them as a shoe mummy.

The Holiday Spirit

2007-12-30T20:17:00.000-08:00

Traumatic injuries are generally divided into two groups: blunt and penetrating. Blunt trauma is caused by falls, blows, and motorized vehicle accidents. Penetrating trauma is caused by guns and knives. Penetrating trauma is much more likely than blunt trauma to require operative management.

Here in Chattanooga, we do not see as much penetrating trauma as residency programs in bigger cities do. I suppose this is good in that you're not as likely to be shot while performing normal civilian activities, however, from the perspective of a surgery resident, it is not viewed in quite that light.

I had off for five days around Christmas, but have been on call after Christmas. Something about the holiday time must put people into an absolutely ornery mood. I have seen more penetrating traumatic injuries in the last two nights of call than I have seen in the entire past year. The same thing happened to the people on call over Christmas. I guess bringing all these families and "friends" together over Christmas and New Years might not be such a good idea.

I have one more night of trauma call on New Years Eve before switching services. I've spent the last two nights of call up all night operating on gun shot wounds and stabbings. We'll see if that trend continues.

Moving again...

2007-12-25T19:45:00.000-08:00

Life in December is good.

I like the way that all of society paints itself with a veneer of Christianity, albeit a thin one. Its nice to turn your radio on and hear Carols. In a society that no longer treats Sunday much differently than a Saturday, its nice to drive around and see almost all businesses closed.

I've now lived in Tennessee longer than any other place since leaving Ontario almost half a lifetime ago. Its nice to have been in a place long enough to put a few roots down again.

However, I have accumulated a fair amount of junk during this time here. My dad is fond of saying that three moves equal one house fire. Not having moved in about 4 years, I'm in bad need of either another move or else a house fire. Since neither seemed to be in the cards anytime soon, I did the true American thing, and rented a storage unit.

Yes, this Christmas break found me moving boxes of unused items, gardening supplies, a bicycle, etc all over to the storage unit I'm renting. I suppose I must just have missed moving too much.

December has also been a good month since I've been on trauma. I enjoy being on the trauma service. Most of the time you're dealing with beligerent drunks who really don't have much of anything wrong with them besides scrapes and bruises. However, every now and then someone rolls in the door who is actively dying on you. I love the diagnostic challenge of those situations. You have to make diagnostic and treatment decisions quickly, and often times with very little information. Watching one or two patients eventually leave the hospital who came in near dead is what makes this rotations worth it. After December, I have one more month on trauma, and that will be it.

Or this one

2007-11-25T19:45:00.000-08:00

A few months back I found myself in a mall doing some clothing shopping. I don't like shopping in general, and in particular don't like clothing shopping. The clothing I do buy, I keep forever. I still have stuff from high school in my closet, though those items have tended to shrink with age.

Back when I was a kid, clothing was easy. I got to wear whatever had managed to survive the abuses of 3 Esh boys, the youngest of which was just older than me. School clothing was easy as well, since we had to wear uniforms. We wore navy blue pants, a light blue or white shirt, and a blue vest.

While browsing the clothing racks in the mall, I came to a realization. I do not presently own any navy blue pants, light blue shirts, or dark blue vests. Furthermore, the thought of wearing anything of that nature is very unappealing. Probably the next time I wear anything of that colour, I'll be old, senile, and unable to have the sense to protest. I've performed my lifetime's quota with those colours.

Neither does this one

2007-10-21T20:31:00.001-07:00

It all came about due to a conversation with a friend of mine who is also a surgery resident here with me.

Somehow I mentioned that I had been to Bangladesh back in my younger days. It turns out that he had been there back in his younger days too. Talk eventually turned to Bangladeshi cuisine. It turns out that he wasn't such a big fan of it. In fact, he said that he had subsisted on peanut butter for days to a week at a time. Peanut butter!!

Now I like me a nice gooey peanut butter sandwich every now and again. However, the craving for it doesn't hit that often, and I could most certainly not eat it every day in a row. The more I thought about it, the more I decided that peanut butter probably should not be included on any list of edible substances.

Here is my rational. I have a 40 oz bottle of the stuff in my cupboard. Being a single guy who spends most of my time at the hospital, I eat most of my meals somewhere other than my house. Even when I do eat at home, I rarely eat peanut butter. I just don't get a hankering for it that often. However, the stuff doesn't spoil. It just sits there in my cupboard and patiently awaits my next craving for it. It never has a bit of fungus or bacteria growing on it even though I've probably had this current bottle of the stuff for a year or two.

Doesn't that strike you as odd? Every other thing that is edible in my kitchen is either in the refrigerator, freezer, or in sealed metal cans. The exceptions to that would be the bottles of vinegar and cooking oil as well as the spices, but one could certainly debate whether or not those substances are edible as well.

Bacteria will eat almost anything, including stuff we would never consider edible. For example, I had some newspaper in the garbage can. Somehow it got wet and then sat there for several weeks as several more layers of stuff got put over top of it. One day I caught a waft of a foul odor and discovered that it emanated from the garbage can. Lo and behold, bacteria had begun fermenting the newspaper. Yet these same bugs leave my peanut butter alone as it sits in my cabinet for months to years.

The stuff seems suspect to me.

The Post Has No Title

2007-08-30T18:41:00.000-07:00

I've been admittedly absent from the web for quite some time. My email account has way too many emails in it, and the whole blog thing has been sadly neglected. Quite frankly, things have just been really busy what with gardening, playing vascular surgery resident, and more recently having been elected by the residents to a one year term as co-president of the Erlanger Housestaff Association.

I've spent the last month on vascular surgery, and will be there until the end of September. Unlike the trauma patients who tend to be young and reckless, the vascular patients tend to be old and worn out and have had the good fortune to somehow manage to outlive their circulation.

In other ways, trauma patients and vascular patients are very similar. Both sets of patients often get into the hospital due to lifestyle decisions they've made. Many of our trauma patients have altered mental status due to alcohol/drugs and then wind up doing something stupid. Vascular patients almost all smoke, or else did for a long period of their lives. Many of them also have high cholesterol and diabetes, both of which can be related to diet. Its somewhat disheartening to spend hours trying to open up someone's clogged arteries in an effort to save their leg from the pathologists specimen bin, only to visit the patient postoperatively to find that he has left the room to go outside and smoke. The empty McDonalds bag beside the bedside is no more encouraging. However, the bypasses and endarterectomies are technically challenging procedures, and are therefore very enjoyable to do. So its been a good month.

My favorite vascular procedure by far is a carotid endarterectomy. You have one carotid artery on each side of your neck, just beneath the jugular vein. Most of your brain's blood supply comes from these vessels. When they get clogged up from the toxins of living, blood supply can get comprised to the point where you have a stroke. In 1954, some brave soul figured out that if you took the crud out of the artery, strokes were less likely. We therefore perform endarterectomies in people with advanced carotid disease. There is something uniquely exhilarating about slicing someone's neck open, pushing the jugular vein out of the way, occluding the outflow and inflow of the carotid artery, cutting it open, grunging out the gunk, and then sewing the artery back together again. Its not a procedure I will ever do as a general surgeon when I'm finished with residency, so I'll live it up while I can I guess.

Why coffee is yummy

2007-08-01T18:39:00.000-07:00

Have you ever thought about how ludicrous it is that we enjoy music? For instance, I'm currently listening to Tchaicovsky's Swan Lake. I love that piece of music in particular, and his stuff in general. Isn't it just bizarre that our brains detect a combination of sounds and derive such a sense of pleasure from them?

I've also wondered who first came up with the idea of notes, a scale, and basically all the concepts you need to record on paper how to make a certain combination of sounds in a certain rhythm, pace, and volume. They must have been considered a lunatic.

For instance, let's say that I told you I was busy writing a concert based not on sound but smells. First you'd smell cut grass for 10 seconds, then maybe a faint whiff of tomato plants for 5 seconds, followed by an overwhelming odor of horse sweat for a minute. Then maybe you'd transition into a mediumly powerful smell of marigolds for 45 seconds. You get the idea?

If I offered to perform such a smell concert for you, you'd probably smile and politely oblige me. However, would you shell out your hard earned cash to attend a smell concert hall? Would you buy a smell album that you'd carry around with and attach to nosephones?

Enough of that. I'd better get busy perfecting a scale/note system for recording and replaying smells. After I patent my nosephones, I'll be rich.

Why do I have to have a title?

2007-07-10T20:26:00.000-07:00

Ok, so I feel like I should post again, but I don't feel like there's anything to talk about. My life has been comprised of a pretty much steady stream of car wrecks, knife stab wounds, and gun shots the last month and a half. The fact that I don't do drugs or alcohol makes me feel much safer. The fact that other folks do makes me feel much less safe.

One of the outgoing chiefs gave me the job of being the resident responsible for the medical students who do their surgery rotations here. I enjoy interacting with the medical students. The third year students haven't been jaded by the realities of medicine and therefore bring a fresh new perspective along with them. Its also really interesting to see how they each are different in their approach to the rotation.

For me personally, my surgery rotation as a medical student was a process of falling in love, but fighting it tooth and nail. Of the 165 medical students in my class, only 3 of us did surgery. At most medical schools, the number going into surgery is much higher. Our surgery program had the reputation of being "malignant." This basically meant that the attending surgeons were miserable and took it out on the residents. The residents in turn took it out on each other and the medical students. Hence, anyone who expressed an interest in doing surgery was thought to be slightly not right in the head. After briefly toying with the idea of doing pediatrics or ENT, I finally settled with what my heart was telling me to do. Every now and then you see a medical student come through and catch the surgery bug, so to speak. Fortunately, we are not a "malignant" surgery program, and a higher percentage of our students decide to do surgery.

I've found the best way to teach is through stories. There is nothing that will put students to sleep faster than asking them to recite lists or criteria. However, there is nothing like a story to perk them up. So therefore, instead of asking them to list Becks Triad (Jugular vein distension, Muffled heart sounds, and hypotension), you start with a story.

It might start out with a scenario such as Mr Jones presents to the ER following a knife stab wound to the left thorax after his girlfriend assaulted him. (As a side note, women tend to jab up with the knife, and therefore inflict worse injuries whereas men tend to jab down with the knife and don't cause injuries that are quite as bad.) Anyway, you let the medical student manage the theoretical patient. Inevitably the theoretical patient dies. You then backtrack to the critical decision and start over again from that point. Eventually they figure out how to save the patient. I've found they enjoy that method of teaching. I also find it moderately entertaining. So anyway, I'm looking forward to being the resident coordinator person for the medical students. Maybe I can even save some of them from monotonous careers in pediatrics (Just kidding Elam and Olivia. Really I am).

Chest tubes

2007-06-14T12:37:00.000-07:00

One of my favorite emergency room procedures is placement of a chest tube. The past week I've placed a number of them for developing tension pneumothoraces. Though I enjoy doing them now, I was petrified of learning the procedure as an intern.

Its a pretty straight-forward procedure that interupts a process that would result in the patient's death. The typical scenario is a patient who has been in a car wreck and has had significant force applied to their chest. Usually they have a number of broken ribs on that side in addition to the collapsed lung (pneumothorax).

A pneumothorax kills you fairly quickly if left untreated. You're lung is basically a big balloon comprised of a number of smaller balloons (alveoli). With blunt chest trauma, the lung is either punctured by broken ribs, or simply has a section that pops due to the rapid application of force after hitting the steering wheel or something. With each breath, air escapes out of the lung into the space between the lung and the thoracic wall. Each breath therefore collapses the lung just a little bit more. Eventually, so much air has escaped into the thorax that the lung is entirely collapsed.

What is lethal about a pneumothorax, though, isn't the collapsed lung. I have had several patients in whom we removed an entire lung for cancer, and they did just fine with one lung. Patients with a pneumothorax die because eventually the amount of air that has escaped into the pleural space is so great that it actually pushes the heart and veins that drain into it (superior and inferior vena cava) way over to the other side of the chest. Eventually things are pushed over so far that the veins are kinked to the degree that blood cannot return to the heart from the rest of the body. Your heart then has no blood to pump anywhere, and you die.

All this is stopped by making a several centimeter incision on the skin, dividing the underlying intercostal muscles between the ribs, and then putting a tube into the space between the lung and the chest wall. The air all comes rushing out, no veins get kinked, and another trauma patient is saved to eventually be released back into the wild.

Its a procedure short on technical skills (though you can actually kill someone during chest tube placement by doing something stupid like putting the tube into the heart) and high on immediate gratification.

Changing of the guard

2007-06-11T16:39:00.000-07:00

This is always a melancholy time of year. As I mentioned in a recent post, it marks the changing of the guard. A graduating chief class is replaced by a group of newly minted doctors stepping into their roles as interns.

At the end of every year, we have a few parties to honor them. The best is the one at Dr Barker's house. He sets up a few tents. Dr Maxwell roasts the meat... usually an all night ordeal. Sometimes its a whole hog. This year it was a bunch of ribs. They were splendid. At some point the chiefs are presented with a bunch of gag gifts. All in all, its a relaxing celebration of the accomplishments of the graduating class.

Every year, it gets a little bit harder to see them leave. I've spent four years with these guys, and have come to really enjoy them. Aderhold has been the source of numerous "ader'isms" that have made it to this blog. He's the guy who explained that hill-billies are poikilotherms, hence the rise in summer time traumas. He's also the guy who explained why pens in the south are called "ink pens." (Done to distinguish them from hat pins, bobby pins, pig pens, etc). Its also impossible for the guy to talk without gesticulating. Hence, engaging him in conversation during an operation is not wise. He will be heading back to his home town in south Georgia.

Mauldin decided that surgery wasn't for him after all, and decided to do an anesthesia residency. I've admired his attitude this past year. His decision to not practice surgery did not turn him into a jaded, negative personality. He was still a good leader and example to the rest of us. He will be doing an anesthesia residency in Atlanta.

Koontz was the ultimate example of taking responsibility for your patients and making sure that they got the best. He is also a publishing machine, who has probably had more publications than any resident to complete this surgery program. He is heading to Emory in Atlanta for a pediatric surgery fellowship.

Green is from Louisiana. He was one of those rare people who derive a true, infectious, joy from doing surgery. He's the kind of guy whom you'd call in the middle of the night to tell him about some disaster of a patient needing surgery. His enthusiasm never waned. He was just a real pleasurable person to be around. He'll be moving to Kansas City, Missouri to practice trauma surgery.

If you want to see pictures of any of these guys, or any of the other people whom I work with, go to... http://www.utcomchatt.org/Dept/Surgery/surgery.asp?dpage=residents

Our Lady of Uncanny Skills of Observation

2007-05-27T13:05:00.000-07:00

It was recently my birthday. I'm now at an age where I no longer proudly proclaim how many times I've ridden this ride around the local star, so the number of those trips will remain undisclosed.

On the day of my birthday, I received an email from Bethanie, my sister in Haiti. She stated that my birthday gift was stashed in my apartment. She had visited me several months back and had hidden it at that time. I was a little miffed that something could have been sequestered away in my space that long without my knowledge of its presence.

She was tipped off as to the optimal hiding place by one of/or two events. The first possibility would have been her observation of the state of my wardrobe. Perhaps she thought things looked slightly un-ironed. Or perhaps it was the fact that a request to use my iron and ironing-board prompted a ten minute search for the iron. In any case my birthday gift sitting right beside my ironing board in the closet remained undetected.

Compliments to her for her skills of observation. She's lucky though, a week prior I had briefly contemplated house cleaning that closet. However, the thought soon passed since I'm moving in two years and will inevitably have to do it then anyway.

On being a green-horn (green-thumb post having been taken already)

2007-05-27T12:20:00.000-07:00

My dad unknowingly stole my idea for my next post over on his blog. I was going to spend my time on this post reflecting on how a once loathed activity like gardening can turn into the highlight of one's day. However, he has much more eloquently described those sentiments.

The last three months have been wonderful. Spring time in Chattanooga is without parallel. I've been on research the last three months, which means reduced call responsibilities and a much less rigid schedule. However, my days of mid-afternoon naps, lots of extra-curricular reading, and just plain old free time are fast coming to an end.

Beginning in June, I'll be back as trauma chief again. My last stint was during the cold months of January and February. Summer months tend to be crazy busy with people out and about doing redneck/hillbilly sorts of things or just plumb driving too fast. Though the schedule for the coming academic year (starting in July) has not yet been released, I'm guessing that I'll be on trauma again in July.

July is always an interesting time of year. The surgery program here is 6 years long. About the middle of June every year, the 6'th year residents disappear. People who have become comfortable in their roles as interns, junior residents, or senior residents are suddenly bumped up one notch into positions of more responsibility. The feeling is one of mixed trepidation and exhiliration. Exhilirating because you've successfully traversed another year, but full of trepidation because you're trading a role that has become comfortable for one that stretches you to the edge of your skills once again.

Though I'm not really experiencing any change in my role here this coming year since the responsibilities of 4'th and 5'th year residents are virtually identical, there is an added element for me this year when the changeover occurs in July. It is then that a new batch of freshly minted doctors arrives fresh out of medical school. Medical school tends to be a very affirming, supportive sort of place. Though competition to get in is stiff, once there they do everything they can to retain you. A surgery residency is not that sort of environment.

July 1, they show up and are expected to morph into doctors after years of being a book-worm. Somehow most people make the transition, and actually make it quite well. However, along the way, some are so afraid of their own shadow that they are incapacitated by the fear of messing something up while others believe that they are the greatest gift ever bestowed upon surgery and fearlessly blaze trails better left unknown.

So far, I have been far away from the main campus every year when the newest batch of recruits arrived. During my second and third years I was stationed at outlying hospitals away from the mayhem of July at Erlanger. Last year I was on Cardio-thoracic surgery for three months and also escaped the transition time. This year there will be no escape. I'm on track to probably have trauma chief duties during July.

Trauma is a very difficult rotation for a green intern to start with in July. At that point you don't know how the system works, you're unsure of exactly what your job is, and even if you do eventually figure out what your job is, you're unsure how to execute the steps of doing it. Furthermore, you're on the busiest service at the busiest time of year for that service. Nothing can be handled over the phone. You haven't gained a sense of which details are important or superfluous. They therefore all become important, which is a rather stressful way to live. It all works out though. All of the patients get taken care of, and don't suffer any ill-effects from the transition going on. One of my former chiefs actually speculated that more mistakes occur at the end of the year when people are more confident and not quite as likely to regard every detail as being of the utmost importance.

As trauma chief, you have the pleasure of trying to provide some oversight to this whole process. You spend a lot more time awake at night, and more time overseeing minor details that interns eventually learn to handle without your help. You also get to listen to the attending surgeons, who usually are of the rather vocal persuasion that the newest intern class is exceptionally idiotic. According to them, every year's class is of unparalled stupidity and laziness, and as chief, you're admonished to whip things into shape.

I was recently talking with one of the nurses who has been here for decades. We were discussing the upcoming influx of greenhorns and the derogatory opinion the attendings usually have of the new arrivals. She remembered when many of the current attendings were new interns, and started telling stories. One of the smartest attendings we have, who is usually also of the persuasion that the field of surgery is going to the dogs, was an intern when she was a nurse there. One day she called him up for because a patient had a low grade fever, and she wanted to give him tylenol (a rather low-risk, standard intervention). He was rather flustered about what to do, and told her that he really wasn't sure that he could do that and needed to ask more experienced people what to do. How soon we forget how helpless we once were, and how much more we have to learn ourselves.

Even though I am sad to see this year's 6'th year residents leave, much the way staff and friends at NYP did when I was growing up, I am eager to help a new batch of interns take those first few baby-steps towards becoming a surgeon. Its a path I'm not at the end of yet myself, but one that I'm just far enough along to know how to help them navigate the start of.

The touring life

2007-05-14T17:35:00.000-07:00

Having completed my tour of North America, with stops to visit the parents in Ontario and my pediatrician cousin in Ohio, I arrived back home safe and sound.

I enjoyed the drive. I got to Ontario fairly late, and wound up doing the several hour drive from the border after dark. I saw 5 moose and 8 deer in that 200 kilometer stretch of highway, or 1 approximately every 10 miles. I had forgotten how brilliant the stars were up there, and how much darker the sky was at night. I also watched the Northern Lights dance across the highway as if celebrating my return to the North. It was all just perfect, besides needing to keep an eye peeled for wildlife.

The forests were bone dry there. Driving home, I smelled smoke through much of Ontario, Minnesota, and northern Wisconsin. Interestingly enough, after crossing from Virginina into Tennessee, I smelled smoke again. I guess those fires down in Georgia must have been polluting our clean Tennessee air.

In any case, it was really good to see my folks again, as well as Matt, Olivia, and Lyric.

Border Fences

2007-04-29T15:01:00.000-07:00

I'll admit that I was proud.

Everyone else's garden plot at the Nature Center was overgrown with a thick mat of weeds left over from last Fall's neglect. I attacked my new plot and won a glorious victory against the weeds, beating them back to the edge of my borders.

Temperatures were in the 70's and planting things seemed like the logical thing to do. A brief visit to the local nursery resulted in numerous eggplant, tomato, and pepper plants occupying the space left by the weeds. In true Mennonite fashion, my garden plot was much better tended than any other plot. I could almost taste fresh tomatos and hot peppers.

Than the Canadians sent a blast of their air down this way (We really need a border fence to prevent that sort of thing). Suddenly tempartures were in the 20's. It took me about a week to muster up the courage to look at my garden plot again. Sure enough, everything I had planted was about as brown as the dirt it was planted in.

I guess I need to remember that this isn't gardening the way it was in northern Ontario, where you put stuff in the ground and keep your fingers crossed that it will mature prior to the first Fall frost.

Feeling Green

2007-03-28T18:41:00.000-07:00

You know those beautiful nature pictures in which everything looks so vibrant at first glance? Then you get to looking at things closer and you realize that not only are the trees green, but so is the sky and the water and anything else that might be present in the picture. I first learned about such filters when my dad helped me with my photography endeavors for the regional ACE convention.

Currently everything in the Chattanooga area is covered with a similar green haze, just as if you had green contact lenses or a green camera filter. You wake up in the morning, and your car is covered with a green layer of tree pollen. So is the road around my apartment. The pollen is so thick in the air that you can almost chew on it. Fortunately I don't suffer from allergies.

Yes, spring has arrived here and it is wonderful. I recently put flower pots back outside. This weekend I'll be putting the garden in. I probably should have done it last week with as warm as its been this week.

I don't recall pollen like this when I was a kid in Ontario. I guess the birch and poplar trees were too intent on getting on with energy storage before the next deep freeze that they invested their energy in leaves more than in flowers and pollen. Instead of the pollen turning everything green, we had the wonderful army worm. Millions of those little buggers would appear, munching their way through everything green in sight. They created a dilemma for people like my youngest sister who were too squeamish to walk on a living critter. You could actually hear the sound of them popping as you drove down the road.

I guess given the choice between pollen and worms, I'd take pollen.

Right vs Left

2007-03-13T18:30:00.000-07:00

After posting the last post, I realized that my time spent reading X-rays may have created some confusion in the last post. When reading an X-ray, you describe findings based on the side of the findings in the patient. Therefore, a right pneumothorax is on the patient's right side, even though it is on the left side of the image displayed in front of you.

When I mentioned that Dr Cofer was on the right side of the picture, I meant that he was actually on the right side of the stage. He is actually on the left side of the picture. One of the invaders is on the left side of the stage, but on the right side of the picture. I didn't figure that you all would have difficulties differentiating the two, but just wanted to make sure that you knew that I didn't.

Actually, the more that I think about, the more I think that I am incorrect in describing Dr Cofer as being on the left side of the picture. If you are ascribing sidedness to a picture, you are giving it a human attribute. If you are therefore talking about a picture as though it possessed sidedness just as a person does, then Dr Cofer is on the picture's right side while the visiting invader is on the left side of the picture.

To make things clearer, perhaps I should say that Dr Cofer is on your left side as you look at the picture. However, that might lead you to believe that he wasn't in the picture, but actually stood by your side. It would also be incorrect if you happen to be reading this blog while standing on your head or while reading the reflection of your computer screen off of a mirror.

Ahhh the joy of making complexity out of what appears simple.

An Invasion

2007-03-13T17:58:00.000-07:00

The other day our hospital was taken over by a large number of armed men. Elevators that normally take you to any floor in the hospital suddenly refused to stop on certain floors. The roof that is immediately above our lounge and call rooms, and is a favorite place for the smokers to do their thing, was taken over by snipers. We were given stern instructions not to go there. When men in dark suits with big guns tell you that, you tend to believe that obedience is in your best interest.

Here are a few pictures documenting the beginning of the invasion after the men with guns had cleared the path.

The leader of the free world, whose very presence resulted in a severe decrease in freedom for all in the same building, met with the leading hospital people. Dr Cofer, a liver transplant surgeon who is the surgery program director, is on the right side of the picture below. Although I knew he played a key role in whether or not I advance to the next level of my training, I think I'll try even harder to behave knowing that he has the ear of the man leading the men with guns.

Fortunately, plenty of cameramen were there to record the invasion. The presidenct remains popular in Tennessee. It is the only state to have elected a freshman Republican senator who just happened to have been the mayor of Chattanooga at one point. Local newspapers reported that the visit was a reward to the area for having elected a Republican.

For a full record of this occupation of Erlanger hospital by men with guns, visit either of these links from which the above pictures were borrowed. . .

http://www.erlanger.org/bushvisit/Bush001_199.pdf
http://www.erlanger.org/bushvisit/Bush200_319.pdf

Home Again!!!

2007-02-13T16:53:00.000-08:00

There just ain't no place like home.

I arrived back from the Southeastern Surgical Congress in Savannah, GA this evening, I thank God that the presentation went well, and that our paper was well received. I was quite nervous, but apparently it didn't show too badly. I had rehearsed the talk so many times prior to giving it, that I kind of went into autopilot mode. There were some amazing people at the meeting who have written or edited major textbooks on surgery. Presenting a topic in front of such an audience is a daunting undertaking, and I'm thankful to have done well. However, I suspect they all at some point or other in their lives have had a "first paper" to present and felt just as nervous.

Perhaps the most stimulating talk of the meeting was one given by Dr Ponsky on the future of surgery. He is famous for inventing the Percutaneous Endoscopic Gastrostomy Tube, otherwise known as a PEG. He is working on techniques of doing surgery without external incisions. He showed a video put out by a group of Indian surgeons (India Indians as opposed to Canada Indians) in which they performed a human appendectomy by advancing a gastroscope into the stomach, creating a hole in the stomach, and then introducing the gastroscope into the abdomen through this gastric hole. They were then able to do an appendectomy, close the gastric hole, and deliver the appendix through the patient's mouth.

No one in the US has tried this technique on humans due to fears of the gastric hole reopening and then leaking into the abdomen. That would have the same consequences as a perforated gastric ulcer. However, I bet that down the road in my career we'll be doing a lot elective surgery such as appendectomies and cholecystectomies using such approaches. Eventually we'll either get it to be as safe as traditional methods, or else the public will demand it despite the slightly decreased safety.

So the meeting was a great experience and I learned a lot. However, I'm very thankful to have it all behind me now.

Science, Quackery, and Faith

2007-02-04T15:39:00.000-08:00

The last month, and especially the last two weeks have been none stop insanity. On trauma, there are two chiefs, and we split the call time. Therefore I am on call for twelve hours, switch out with the other trauma chief for twelve hours, dash home and try to catch some sleep and perform the necessary tasks of being a human. Inevitably, though, some major disaster of a trauma patient rolls in about 30 minutes before change-over time. Your twelve hours off turns into ten as you sew up seemingly endless lacerations or trundle someone off to the OR for a splenectomy or something.

In about a week, I have a scientific paper to present at the Southeastern Surgical Congress in Savannah, Georgia. The time off to attend the meeting will be a welcome break. However, I continue to cram to prepare for my presentation. I think that it will go Ok, but I have to be prepared for it.

Scientific knowledge is an interesting thing. It is like a giant pyramid. What one person discovers is entirely dependent on what so many other people have discovered before you. In turn, what you discover lays the groundwork for the discoveries of other people. Eventually your work becomes obsolete as the people who follow you build on what you have done. The fund of knowledge that we have built up as a society is a tremendous legacy for the future. However, what we know is so miniscule in comparison to what remains to be discovered that it makes the collective knowledge accumlated by science look like idiocy. In the end, God's ways are and always will be so much higher than anything we can ever hope to know or achieve.

Therein lies the error of modern science. It assumes that we can know and explain everything. Christians know otherwise. However, the arrogance of secular science is not as disturbing to me as the attitude of many Christians towards science. Based on the conflict between modern science and the Bible about origins, many Christians condemn science in its entirety. Any scientific finding that is in conflict with their world view is dismissed based solely on the faith that their world view cannot be wrong. While the strength of such faith is to be admired, it remains irrational. It has at its heart the existential "leap of faith" championed by one of my favorite authors, Kierkegaard.

What is missing in most cases, is the rational basis for the leap of faith that has been taken. Not being able to explain why their worldview is correct other than the fact that they believe it makes them no different than fervent believers in other faiths such as secularism, Islam, Hinduism, etc. While they are lucky enough to have been born into and to have inherited what I believe to be the only correct worldview (ie Christianity), they would probably have blindly embraced whatever philosophy had been spoonfed to them at whatever impressionable moment of our life beliefs are formed.

This irrationalism leads to a rejection of science as a whole. In my opinion, this is why many Mennonites and Amish people are so susceptible to medical quackery. Truth is established by testimony, not by science. Therefore when James Miller (I do not know anyone named James Miller, although I apologize in advance to any James Miller's that I should know whom I'm forgetting now that I do know) tells Ida Yoder (Also don't know anyone by this name) that his mother's, uncle's, nephew was cured of cancer by a snake oil peddling quack, it is accepted as truth. That is how people of faith establish truth--by testimony.

Being a doctor means that friends and acquintances feel obligated to tell you about their medical woes and experiences with the health care system. When I was a medical student, I was never quite sure how to react to people who wanted (?) my opinion about whatever alternative medical therapy they were pursuing. Intially I smiled, nodded, and politely avoided conflict when John or Jane Miller (the Menno version of Doe) asked what I thought of chiropractors, not getting children vaccinated, chelation therapy, etc. However, I eventually decided that my politely smiling, nodding avoidance of conflict could be interepreted as tacit approval and belief in whatever form of medical quackery was being described. I therefore changed my approach to being more honest in my lack of confidence in those therapies being much more than placebo.

Since then, I think that I have lost a friendship or two over the matter. When you don't believe that the modern medical system is a giant conspiracy designed to take over the world, you become a part of the conspiracy and are therefore evil. However, I would rather be seen in that light than feel at all responsible for the health consequences someone suffers for not accepting the appropriate role of science in our lives.

I suppose that I ought to make a little disclaimer at this point, as I've said enough inflammatory type things here to be hung and quartered by both the Christian and non-Christian readers of my blog. To my non-Christian friends, you already know my worldview. I already know that we don't share that. I still like you and can disagree with you while accepting you as a person.
To those who can't miss their chiropractor appointment... I don't entirely reject the utility of chiropractors. However, their role should be limited to treating the spine. When they venture into attempts at treating cancer or other things by one of their kooky methods, that is when they turn into quacks.

A traumatic death

2007-01-15T18:51:00.000-08:00

Dr Aderhold has a famous speech entitled "Hill-Billys are Poikilothermic." The speech was first given some warm night when he was trauma chief, and the blood in the local hill-billy population was coursing with energy. Dr Aderhold is a very entertaining, animated speaker, and even more so when he is frustrated. The night of the inaugural poikilotherm speech, it had been very warm, and the local hill billy population was out in full force, with a small percentage (meaning a large real number) winding up in the ER under his care. I will not even attempt to recount the substance of the poikilotherm speech, since the effect is lost when it is not given by a bug-eyed, wildly gesticulating, eloquent trauma chief with hair and glasses somewhat askew. In any case, the tale will outlive Dr Aderhold's time with us which is set to expire in 5 months.

A week ago I was in the "how-much-longer-'til-winter-is-over-mood," otherwise known as the belief that global warming is mere wishful thinking. Then Saturday things got down-right balmy. I was told, though I never got out of the hospital to witness it, that temperatures were in the 70's. Unfortunately, the hill billys groggily emerged from hibernation, saw the beauty of the January day, sunned themselves on the rocks, and then began zipping around doing hill billy things.

Its still balmy and warm, but I'm not on call. Therefore I'm sunning myself on the rocks while my fellow trauma chief deals with newly energized poikilotherms.

On leaving my apartment to write this to you all, I witnessed a traumatic death right outside of my apartment. There was a brief struggle as the soon dead one was ensnared by numerous roaps. He struggled valiantly, beating frantically against both the roaps and the attacker. However, the winged dead one was soon subdued by the eight-legged arachnoid. I left with a few tears in my eye as the engorged spider feasted on dead moth.

What a world it is. So beautiful, yet so permeated by death.

New Beginnings

2007-01-04T17:35:00.000-08:00

With the new year came a new clinical rotation. It is one that has of yet been untested waters for me, so that is always fun. For the months of January and February, I'll be trauma chief for the first time.

Trauma surgery is one of those experiences that is both quite envigorating and very, very melancholy. There is very little as stimulating as having a patient roll in the door, usually by some over-excited EMT's, with no labs done, no physical exam, and no radiographic studies. You never know if you'll be cutting them open in a minute or two to do an open heart massage, or if you'll be sending them home from the ER. Its also very sad too. What is a stimulating diagnostic pursuit to me, or a very cool surgical case is someone's life that will often be forever changed, or perhaps even ended, because of the injuries they've suffered.

It does make you put your seat belt on and slow down a little bit whenever you hop in your car. It also makes me watch any motorcycle that I see like a hawk. They have a way of getting into somebody's blind spot and then paying us a visit. In medical school, a forensic pathologist once told us that he was, "So afraid of motorbikes I won't even get on a parked one." Its a sentiment I've come to share.

We really are fragile creatures who feign indestructibility.

A Yew Norker goes South

2006-12-31T12:14:00.000-08:00

Sign language for "no more pictures"

I wish Hans would have Kleenexes.

Way too much coffee.

Not enough coffee.

Immersed in bleeding heart liberal propaganda

So many books and nothing to read.

Scenery without the nose pickers.

Scenery with the nose picker.

So Darren, why did 'Jenny' just buy chandelier crystals on EBay?

"This kitchen is filthy!!"

Phew! Glasses are for the birds!

Must not show teeth when smiling.

And then, like, we went hiking, and like some birds that were like singing and like flying around in the trees and stuff. And it was like really, really cold.

News that shouldn't be

2006-12-12T18:59:00.000-08:00

So I'm supposed to be finishing a presentation on Cecal Volvulus for grand rounds tomorrow. Last year when I was supposed to present at Grand Rounds, I woke up 15 minutes before I was supposed to be presenting. That is about how long it normally takes to drive to work. Fortunately I arrived just as they were getting ready for me to start, and the presentation went well other than the fact that my mouth felt like chalk the whole time. It did leave me feeling frazzled the rest of the day too. I guess that's all a result of the sympathetic system on overdrive.

Anyway, I'm hoping to avoid a repeat of that tomorrow. I have some great intraoperative pictures showing a huge cecum and a necrotic transverse colon. Pictures enable the audience to feel like they were right there, thereby making the presentation more interesting. In case it wasn't already one of your life goals, I would recommend putting not ever being an "interesting case" right up there with some of your top priorities.

So I was reading over some news stories as a way of procrastinating my work on this project. I ran across the headline "World's Oldest Woman Dies." Somethings just shouldn't be news. I think I've seen that headline every week or two the past year. The world's oldest person is supposed to die. Its what the oldest person does, usually fairly imminently. Its kind of like running the headline, "Worlds Youngest Person Born." You could run that story every day and talk about what genetic/environmental factors caused them to be youngest person alive. You could throw in some cute baby pictures (you could even use the same picture every day since babies generally look the same), and your newspaper would sell like hotcakes. I will give it to you that a life lived 116 years should be celebrated, but still, a 116 year old person dying should not be news. So anyway, the next time that you see a headline proclaiming that the world's oldest person has died, write a letter to the editor asking when the story about the world's youngest person being born is going to run.

M & M (not the candy)

2006-12-07T08:06:00.000-08:00

Surgery residency programs across the country have a weekly Morbidity and Mortality (M & M) conference at which any deaths or complications are discussed. It is basically a discussion of what happened and whether or not the complication could have been prevented. Presenting a case as an intern is a daunting task, as the faculty may ask any question they want. It tends to be the conference at which the well-prepared residents shine, and the poorly prepared ones crash and burn. It is my favorite weekly educational conference unless I am the one presenting a case gone wrong.

I always get nervous prior to any presentation there just because you cannot always predict which way a discussion will go, and therefore what questions you will be asked. Any medication used or not used, any procedure done or that could have been done, and diagnosis and its differential are relevant topics for discussion.

Today I presented a case. It involved a topic that we don't deal with much in modern day surgery since the advent of H-2 blockers and proton pump inhibitors, but which the older surgeons who practiced prior to the advent of those medications dealt with very commonly. It is therefore a diagnosis that people in my generation are not as well-versed in and therefore not as comfortable discussing.

I therefore spent the entire evening yesterday frantically reading every text book and operative atlas I own that had any discussion of ulcer surgery. I discovered various new operative techniques I hadn't even known existed. Every text supported our management as appropriate despite the complication, and that was reassurring. The conference went well and I survived unscathed. No unexpected topics were raised by anyone. The conference did fulfill its purpose though, as I definitely learned more about gastric surgery through the process of reading for it.

This month I will be on research after spending a busy month last month basically operating non-stop. With two papers due to two journals in the first half of December, I will be busy. However they both will be published, and one will be presented by me at a major conference in February. It is nice to see some of the work from previous research months finally paying off although I am getting more and more nervous about presenting in February. I will be presenting a paper on breast cancer treatment. We have very solid data, but it is intimidating to know that surgeons who have been in practice for decades, some of whom have specialized in breast cancer surgery, will be listening and then will be free to ask any questions they want to. In the next two months, you can guess what I'll be studying. A favorite quote of my med school friend, Tejas, is "the dictionary is the only place where 'success' comes before 'work'."

Lawyers

2006-11-11T17:36:00.000-08:00

All of the older docs that I work with have a story of being named in a lawsuit. Most of them told to prove an educational point and are usually about documentation.

One of the doctors I know who is the most meticulous about documenting his conversation with patients and their family members regarding the risks of surgery was once sued by a family. The basis of the lawsuit was that they hadn't been told that the patient could die as a result of the surgery. He unfortunately did die. The lawyer who filed the lawsuit apparently didn't do a good job reading the medical chart, because right there in the preoperative note was a list of potential complications explained to the patient and his family that included death. The lawsuit was dropped.

One of the funnier stories, but with very unfortunate consequences for the resident involved, was a lawsuit over a foreign body left in a patient's abdomen. The patient came to the ER with cholecystitis, and had a laparoscopic cholecystectomy done without incident. He came back to the emergency room about 6 months later with abdominal free air and required emergency surgery. On the abdominal X-ray, there was a metallic object that the radiologist said might be intra-abdominal. Those who examined the patient knew that it was a ring associated with a skin piercing. However, the patient got a lawyer and a lawsuit was filed alleging that the skin ring was something left inside his abdomen at the time of the first operation. The lawsuit was eventually dropped when the lawyer realized that he didn't have a case. However, the resident involved in the first surgery had just matched to do his fellowship in heart surgery. He had been approved for a mortgage to buy a house in the city he was moving to. When he went to close on the house, they found out that he had a lawsuit pending against him, and denied him the mortgage. He was unable to get another bank to give him a mortgage at that time and lost the house that he had been attempting to buy.

Another surgeon I know had a bogus lawsuit filed against him. A month before the case, the lawyer called and offered to settle for a million dollars. He refused. A week later the lawyer called again and offered to settle for $500,000. He again refused. A week before the trial the lawyer called and offered to settle for a five figure sum which he said were his costs to date for filing the case. The surgeon again refused and at this point told the lawyer that he would not settle for $5 if that was offered as he was not guilty of malpractice in the case. The case was dropped by the lawyer prior to going to trial.

Another resident was sued by the family of a patient who claimed that the patient died after a gunshot wound because the resident didn't plug the skin holes through which the patient was exsanguinating. In reality, plugging the holes would have meant that the blood would have exsanguinated anyway, but just would have been inside of him rather than on the floor. The end result would be the same either way. That case was also dismissed

A couple of years ago I had a case filed against me and a number of other doctors and nurses who had taken care of a certain patient. It was eventually dropped, in my opinion because the allegations were ridiculous and false, but I of course am biased when it comes to evaluating a case filed against me. What amazed me about the whole process was reading the deposition. It basically made it sound like all of the medical people involved in the care of the patient spent their time figuring out how creative ways to harm him and make sure that he never recovered. I was hurt that someone whom I, among others, had tried so hard to help was bitter enough toward me to make those allegations. The case has been closed for quite some time now. I recently came across some of the associated legal documents when I was cleaning. I'm getting ready to send out Christmas cards, and have felt compelled to send them one. If I have a current address for them, I probably will send them one and not say anything about their lawsuit but just wish them a good Christmas season.

The legal system in the US is out of control. A recent study published the worst five states for medical malpractice insurance for surgeons. They were Florida, Pennsylvania, Ohio, Michigan, and Illinois with annual malpractice insurance rates of $150-200,000 per year. That means that a surgeon wishing to practice there has to shell out a six figure sum each year just to have insurance. That doesn't include office costs, salaries and benefits for office staff, etc.

Then people wonder why medical care is so expensive.

Its like Dr. Barker, our senior trauma surgeon, says. "All you are is a walking lottery ticket to these folks."

A Taste of Double Exposure Style Humor

2006-11-02T19:48:00.000-08:00

I don't really care much who wins the various Senate and House races across the country. I do enjoy following politics for the entertainment value. This photo responding to Senator Kerry's comments about kids who are too dumb to go to college getting stuck in the military and being shipped off to Iraq ranks as one of the funnier things I've seen for a while.

Junk Mail

2006-10-30T16:09:00.000-08:00

Every day, I make the trek to the mail box. After arriving, I dig around in my car for the key, climb out into the now rather bracing fall air, look for the mailbox with a wad of now black bubble gum stuck to it. Mine is the mailbox right below the one with the wad of nasty black goo. Then I open it, eagerly anticipating something wonderful. I don't know why I look forward to checking the mail so much. All that is ever there are bills, medical journals that get placed on the already high mountain of unread medical journals, and of course junk mail.

The junk mail promises all kinds of wonderful things. Some lead me to believe that I've just won millions. All I need to do is mail this little form in, and oh, by the way, returning the form automatically signs you up for delivery of their wonderful overpriced product.

Then there are the student loan people who promise you thousands of dollars just for switching your loans over to them. All these are disguised to appear as though they're official mailings from the US government.

Then there are the credit card applications. The key to happiness involves simply filling out the application, and unlimited spending power will be yours.

I could go on. However, I have now come to anticipate the junk mail the most eagerly out of all the things that I receive in the mail. A few months back, I had the startling realization that most of these irresistible offers came with a postage-paid envelope to make your reply more convenient.

Now I send them all kinds of wonderful things to thank them for sending me their kind offers. I've sent a bunch of tracts from church, other times I've just stuffed their propaganda back in the envelope and sent it back to them. Even my cat has made a few contributions with some of her hair. Once she was even kind enough to send them the label from her cat food bag. I'm so proud of her for being so selfless

I really love checking the mail.

The Meaning of Life

2006-10-25T09:28:00.000-07:00

It had been a very relaxing, enjoyable week of vacation. Crashing at Jennifer and Darren's place was alternated with visiting friends in New Jersey, Pennsylvania, and New York City. As the airplane touched down in Nashville, I breathed a sigh of relief glad to back on terra firma following several hours contemplating the absurd insanity of being in a tin can thousands of feet above the planet's surface. It also felt good to back in Tennessee again.

In a moment of minor anxiety, I realized I couldn't remember what section of the parking lot my car was in. I remembered it ended with a "9", but couldn't remember what letter preceded the "9". Fortunately, I discovered that all of the sections started with an "S", meaning that I had to be in "S9". We could discuss the lack of rational efficiency behind the redundant use of "S" before all of the numerals when assigning appelations to parking lot sections. However, that has nothing to do with the meaning of life. Just let it be known that if I'm ever elected president in chief of the Nashville airport, I promise to remove the "S" from all of the numbers.

Relief at finding my car where I had left it and remembering where I had left it was short lived. A quick search revealed that my car keys were not in my pockets. That was not all that worrisome given that I hadn't needed them for the past week, and they were probably therefore in my luggage somewhere.

A quick search through my luggage demonstrated no car keys. A very thorough search resulting in luggage contents being spread across the pavement also demonstrated no car keys. Another very meticulous search through every pocket, every nook and cranny of every bag also demonstrated no car keys. This was definitely not good.

Making matters worse, it was 11:00 PM, the temperature felt like I was on the tundra, and my cell phone was not working. I repacked my scattered possessions, and thought about my options. The ticket booth where you pay your fee for parking was a five minute walk away, so I decided to see if they had a phone. However, I had no desire to make the trek with all of my luggage in tow. Leaving it all there by my car seemed like an option likely to generate interest by the local bomb squad. Fortunately the dilemma was solved by stuffing it all underneath my car. Fortunately the area was deserted and no one reported my strange behaviour to the local authorities.

Honda Care, the Honda roadside assistance plan, was very helpful. They promised to have a locksmith there in 30 minutes. All I needed to do was sit by my car and wait for them to show up. I therefore sat by my car and waited and waited and waited. This is the point at which I started contemplating the meaning of life. I was becoming more and more convinced that it had a lot more to do with warmth than I had previously reckoned.

An hour after my first call, another trek to the guard station and a call to the Honda Care people revealed that the locksmith had not been able to find me. They would send one again. All I had to do was sit by car and wait for him to show up in 20-30 minutes. They knew exactly where I was. After 45 more minutes spent pondering the meaning of life, I decided that the ultimate meaning in life derived from the possession of car keys of which I was unfortunately bereft.

I caught the night's last bus out of the parking lot, found a hotel room, and had a more successful meeting with the locksmith in the morning. I once again have car keys, and my life is therefore full of meaning. I wish every one of you a life with car keys in possession.

Future Chinese Provinces

2006-10-10T18:42:00.000-07:00

The world now has a new nuclear power in North Korea. To an outsider, it seems like a horrible waste of resources for a country that has a difficult time feeding its own people.

I was recently in the physician's lounge waiting for a case to get started back in the OR. They were discussing the then possible nuclear tests in North Korea. The conversation went something like this...

Orthopedic surgeon: I can't believe we're letting that crazy guy in North Korea get nukes.

General Surgeon: Yeah, we should just send our boys over there to clean that place out.

Anesthesiologist: Except instead of doing like we did in Iraq, we should flatten the whole
country. That way we won't get bogged down.

Cardiac Surgeon: What we ought to do is use several of those neutron bombs and clean out the
whole place.

Anesthesiolgist: Yeah, and then we could ask the Chinese if they need a new province.

General Surgeon: Yeah, and we could offer to throw in South Korea as a bonus.

Me: Its kind of illogical that a country with only 300 million people would be trying
to dictate to larger countries such as India that they can't have nukes.

At this point everyone shut up about nukes, neutron bombs, and future Chinese provinces and began discussing the then pending Georgia/Tennessee game. After the conversation, I think I have a better understanding as to why North Korea might want nuclear weapons of their own. Of course, I didn't live through the Korean war either.

Churches

2006-10-10T18:20:00.000-07:00

Not being near a Mennonite church, I embarked on a church finding quest when I moved here for residency. It was an eye opening experience. Baptists are the dominant force here in the South. I attended several Baptist churches, but never really bonded with any of them. The services were like a weird combination of a Broadway show and a political rally. Very polished Broadway style music, interspersed with pleas for cash seemed to be the emphasis.

For a time, I attended a Christian Missionary Alliance church. I liked the emphasis on ministry and the de-emphasis on doctrines such as eternal security and the admiration of military service that other area denominations had. However, the emphasis on outreach seemed to come somewhat at the expense of the life of the local church and was almost legalistic. I admire their vision and drive, but it wasn't what I needed at this point in my life.

I had visited a Church of Christ earlier on, but was very mortified by the singing. It was Acapella, but would have been much better had there been a few loud instruments to drown out everyone's voices. However, I decided to try another Church of Christ in the area, and have been quite pleased with it ever since. I appreciate their emphasis on holy living. While they have a focus on missions, it is not at the expense of the life of the local body. If you were to close your eyes, and just listen to the music, you could imagine that you were in a Mennonite church.

What I enjoy most there are the new hymns. When I was a child, the more musically inclined song leaders would occasionally attempt to teach us a new song. The music would sort of limp along, but the song would never have any volume, and never reached the majestic concoction of noises its composers intended it to have. At this church, the hymnal is from a different tradition than my own, and contains a number of hymns that I don't know. Its fun to be able to learn them with a group who already knows them well.

Musings

2006-09-23T09:35:00.000-07:00

I read an article recently arguing that the microscope was the greatest invention of all times. I'm not sure if I agree or not. I think the microwave is pretty amazing myself. I remember the first time I looked through a microscope and found a whole new world in it. All kinds of creatures that I couldn't ever have imagined wriggled around on the glass slide -- all contained in a single drop of water. Amazing.

I get the feeling that we have absolutely no concept of what our universe is like. We're rather like goldfish in a bowl trying to describe the planet from our view of the interior of one house. We really have no grasp on how small things actually get or how big the universe actually is. Philosophers postulated that the atom was the smallest indivisible unit of matter. Now we know that an atom is composed of protons, neutrons, and electrons. It turns out that protons, neutrons, and electrons are also composed of even smaller things. We really don't know how small the smallest things are that make up things.

I remember being a kid and trying to understand the universe. My main question was whether or not the universe had an edge. If space did have an edge, that meant that it was finite. However, that begged the question of what was just beyond the edge of space. Surely it would be more space, right? So the other option then is that space is infinite with vast spaces of nothingness extending forever. But that doesn't make sense either. How can something not have a limit? It seems just as impossible that space could extend forever as it does that it could have a limit. It still makes me dizzy, just as it did as a child, to think about it all.

Perhaps our solar system is really like an atom forming the molecule of our galaxy with all of the other atom like solar systems in our galaxy. That begs another question. If our galaxy is really only like a molecule, and is connected to all these other galaxy/molecule thingees, what do all those molecule/galaxy thingees make? That is what I would really like to know. Perhaps we are a single atom in what forms a table leg, a dog, a coffee cup or something else in a dimension that is so big that it entirely eludes our capabilities to grasp the enormity of it.

I feel like a goldfish and am in awe.

Just gotta shake your head

2006-09-17T17:20:00.000-07:00

When the pope recently commented about Islam's history of violence, it was sort of like the pot calling the kettle black. What amused me more about the whole incident was the response of some Muslims in the Palestinian territories. They protested his statements about Islamic violence by bombing several churches. I guess they made a point, huh?

The Day of Mockery

2006-09-06T17:53:00.000-07:00

It all depended, as Dr Head so aptly put it, on whether "mock" is a verb or an adjective.

Dr Head is the cardiothoracic surgeon with whom I spend the vast majority of my time these days. Near retirement, he is an amazing surgeon and a favorite teacher. A few years ago the annual teaching award was named after him and he was banned from ever receiving it again since he had won it so many years in a row.

Today was a day to be dreaded, and hopefully survived with some shred of dignity intact. It was the day of mock orals.

In bygone years, all specialties had oral examinations at the conclusion of residency. Becoming a certified specialist in that field was contingent upon passing one's boards. Over the years, many fields have gotten rid of the oral exam, opting instead for multiple choice tests. Surgery, notorious for lagging several decades behind other fields when it comes to implementing change, continues to require passing an oral exam in order to be board certified. (Though they also require passing a multiple choice written exam.) So therefore, at some point approximately three years from now I will spend half an hour with some big name in the surgical world. He will present case scenarios to me, and based on my answers will decide whether or not it is safe to turn me loose upon the world.

In preparation for this test, the pass rate on which surgical residencies use as a barometer of the efficacy of their training, our program has semi-annual mock oral exams for 4'th, 5'th, and 6'th year residents. Being a newly minted 4'th year resident, I was undergoing this process for the first time. The word "mock" in the title of the event was rather disconcerting. I raised this concern to Dr Head last week who then made the aforementioned comment.

I underwent 30 minutes of examination in 3 seperate rooms, for a total of 90 minutes of grilling regarding the diagnosis and management of surgical diseases. It was a dizzying, whirlwind tour through case scenarios involving severe burn injuries, choledocholithiasis, cholangitis, Boerhaave's syndrome, temporal lobe seizures, gynecomastia, cirrhosis with bleeding esophageal varices, gastroesophageal reflux disease, breast cancer, and Crohn's disease. No case was straight forward. If any complication could occur, the attending guiding the discussion made it happen to see what you would do to manage it. My patient with routine cholecystitis therefore turned into a patient with cholangitis due to choledocholithiasis requiring a series of procedures I have yet to ever see or perform, but wound up attempting to describe in some detail

All of the people in my class taking it for first time, myself included, were certain that we were going to bomb it and make total fools out of ourselves. We spent the last week frantically reading. Upon running into one another in the halls, we'd inevitably quiz each other on some esoteric topic such as the gastrinoma triangle that we've never seen in any patient but were convinced we'd be asked about.

And then amazingly, it was all over. The sky was brighter. The trees were greener. We all had an extra bounce in our steps. I don't think any of us did as poorly as we thought we would, but certainly did not do good enough to pass the real thing which we'll face in 3 years. For the time being it is comforting to know that we can hold our own with people who have been in practice for years in a conversation about complex surgical issues.

Today upon meeting Dr Head after it was all over, he asked me how it had went and whether it had been an adjective or a verb. I gushed that it had all really went better than expected, and that there weren't more than one or two cases where I totally floundered. With his characteristic quick wit, he replied that "They must not have asked the right questions then."

Funny Money

2006-08-24T17:08:00.000-07:00

When we were growing up, my sisters and I always had endless debates about who was more Canadian. Being Canadian was cool, being American definitely was not. Jennifer's main argument was that she was the only one to have been born in Canada. Therefore, in her mind, she was definitely more Canadian than Bethanie and I. However, I argued that I was most certainly more Canadian seeings as I had my American citizenship forced on me at birth, but chose Canadian citizenship when I was of an age to make a decision to do so. However, she never really bought the argument. Perhaps it was due to the fact that she was made an American citizen against her will, fearing that she would turned into a flag flapping in the wind after the proceedings. Little kids aren't always rational.

Oddly enough, none of us now live in Canada. Jennifer now lives in the heart of Yankee-land where they have absolutely dreadful snobby sounding accents. Bethanie has deserted the continent all together, and I live in the world of the rednecks and hillbillies many of whom were probably the Americans with big boats, big trucks, and even bigger egos who migrated to our lakes every summer and who most every one in our town loathed and certainly felt superior to. After all, we were taking their money and all they were doing was taking a few of our fish. They generally made fun of our multi-colored "monopoly money." The exchange rate which made their dollars worth more than ours certainly contributed to their attitude. Their presence wasn't entirely a misfortune since they did leave their dollars behind and always gave locals some good stupid American stories to tell.

Their are many ways in which I still to this day feel like Canada is a better country than the US is. It doesn't generally go around bombing random countries. It is fiscally much, much more responsible having run surpluses for more than a decade now. Parliamentary sessions are much more entertaining than any Congressional or Senate session here in the US. When was the last time you heard a truly entertaining sound clip from a US house of government? (Bushisms don't count.) It is a little bit less individualistic in its focus. It also has not had a history of military conflicts, violations of human rights, and even straight out genocide to the degree that the US has had. In the 1800's Native Americans fled north of the border in the West as did African American slaves. In the 1900's and first part of this century, Canada has not been the global rabble-rouser that the US has.

I'm finally seeing signs that Americans are beginning to see the superiority of their Northern neighbours. In the end it all boils to money. I've long been a fan of the $1 and $2 coins in Canada, otherwise known as the loony and toony. They actually make a pocketful of change worth something. I have this huge jar of change at home that has accumulated simply because it is a nuisance to carry around. My local grocery store recently solved the problem by installing a self-checkout line. You scan the items yourself, and then insert money into a machine to pay for it. On every trip to the grocery store, I bring along a fist-full of coins that I then feed into the money machine. It takes me about five minutes to checkout, but at least I'm getting rid of that bothersome change. But anyway, I digress. Americans are showing by their money that they are recognizing the superiority of Canadians.

I know some of you out their are so blinded by the location of your birth that you are poo-pooing the notion. However, I challenge you to look closely at the new $10 and $20 bills. They're not green anymore!!! They are slowly turning into some hideous green/pink/orange/red color. Its rather awful really. They need to just admit that the multi-colored Canadian money is more appealing and make the switch. Now if they could just get rid of the $1 bill, we'd really be talking.

The heart

2006-08-13T12:22:00.000-07:00

When I was a little tyke, my sisters hatched a plot to send a Valentine's day card to everyone in the entire world. The idea seemed like a good one, so I joined in. Numbers such as 3 billion had no meaning in our brains. For several days we frantically attacked sheets of red paper, drawing numerous patterns and putting plenty of gibberish on them. In our minds, the heart looked liked a V-shaped thing with more blunted tops than a normal V would have. Eventually the idealistic ambition of the plan fell victim to reality and Mom placed all of the remnants of our project away in some manilla envelope somewhere.

How the heart ever came to be given the shape you see on Valentines day cards, I'll never know. It looks nothing like that in real life. At the beginning of the month, I began my rotation on one of the more amazing services we spend time on as residents. For the months of August, September, and October yours truly is on the cardio-thoracic surgery rotation.

My first experience with heart surgery came when I was a medical student. We usually worked with the chairman of the cardio-thoracic surgery department. He was a short man just barely over five feet tall who was about half as wide as he was high. He was rather dwarf-like in appearance, and had a temper to match. Stories of his wilder temper tantrums were passed from one rotation of medical students to the next, doubtlessly becoming hopelessly embellished with each recounting. However, though the intensity that made him a technically good surgeon also gave him a temper that made the entire OR staff live in fear of his shadow, he was a perfect gentleman to medical students. I have two very vivid memories of time spent with him. The first was being given the paddles at the conclusion of a valve replacement. Having watched him cut a heart apart and then put it back together, he handed me the paddles at the conclusion of the case to shock the patient back into a normal rhythm. Up until that point, shocking someone had been something read about in textbooks and described in lectures. When it came down to doing the actual deed, it no longer seemed quite so simple and straight-forward. However, under his guidance, it all went swimmingly and the patient's heart began pumping away like nothing had ever happened to it.

The other memory I have of him is watching him in one of the more intense situations I witnessed during medical school. I had happened by the post op area to see a sea of frantically scurrying ants. Perched on several stools above them all was this heart surgeon, neck veins bulging, red in the face, bellering out instructions like the survival of mankind depended on it. Apparently one of his cases had gone bad in the recovery room and had necessitated that he open the chest up then and there. I never found out what had happened and whether or not that patient made it. However, the image of him perched on those stools trying to control the process killing the person in front of him while also trying to captain the frantically scurrying assistants around him stuck in my mind. He was the stereotypical cardio-thoracic surgeon.

The rise and fall of cardio-thoracic surgery is somewhat of an interesting event. Several decades ago, the field was in its prime. Only the best of the best made it into the specialty. The reimbursements were among the most lucrative of all medical fields. There was no end of work. Then came the era of angiography. Cardiologists were given the field of cardiac catheterization by disinterested Cardiothoracic surgeons who had no interest in percutaneous interventions. However, eventually these percutaneous interventions became so effective that the procedures performed by the cardio-thoracic surgeons became required much less frequently.

Though they remain the most competent surgeons there are with regards to technical skills, the field has the feel about it of a lion growing too old to hunt slowly growing thiner and thiner. When I was an intern, two of our graduating chiefs specialized in cardio-thoracic surgery. Though both very competent, skilled surgeons, they had a very, very difficult time finding work at the conclusion of their fellowships. Nobody is hiring cardio-thoracic surgeons any more, and those who are do not pay well. Reimbursements for cardiothoracic procedures have been cut almost in half (without being adjusted for inflation) since the 1980's.

Perhaps we'll eventually develop an implantable device that cardiologists can't insert that everyone will need to have, and the field will have another heyday. However, for the time being, very, very few people in my generation have any interest in entering the field. It is too much work for inadequate reimbursement with ever fiercer competition among cardiothoracic surgeons for the available procedures. Having said that though, nothing else I have done during the last 3 years gives me the same level of awe as seeing a heart stopped, taken apart, put back together again, and then restarted to happily pump away as though it was perfectly normal to take a nap from time to time.

Being painted with the Landis brush

2006-07-29T18:35:00.000-07:00

After being slightly apologetic in my last posting, Jennifer reminded me that "the blog exists for man, not man for the blog." Therefore I should feel free to post as frequently or as seldom as I feel led to. Point taken.

Being Mennonite in a non-Mennonite setting is always an interesting set of circumstances as I'm sure all of you know. The past week or I've been the recipient of many Landis jokes. One of the surgeons who followed the Tour de France very closely and was rooting for Landis was convinced that I have many of the same mannerisms, eye movements etc that he does. He blamed this on our common Mennonite background. Not having seen these interviews, I can't comment.

Then the blood test came back positive for testosterone, and I became the butt of jokes regarding Mennonites and testosterone. His time in the media spotlight has led to many questions from people about Mennonites and what exactly they believe and are. The longer I am here, the more people feel comfortable asking me those questions. I welcome them as a chance to explain my faith.

If you're interested in Floyd Landis, my aunt is acquainted with his family and has had some insightful blogs on his rise and fall. She is at... http://graylaners.blogspot.com/

The Delinquent Hatter

2006-07-19T16:36:00.000-07:00

Ok, I'll admit it. I've been rather tardy with regards to posting here the last few weeks. The month of June and the beginning of July were insanely busy. My time outside of the hospital during this interval has mostly consisted of sleep. I did get a lot of stuff done though, so it certainly wasn't time wasted.

Perhaps the most exciting event of the past few weeks was transitioning to being a fourth year resident at the beginning of the month. Responsibilities in our residency program are divided between junior residents (PGY 1-3), senior residents (PGY4-5), and chief residents (PGY-6). Being a junior resident means that all the mundane tasks involved in running a surgical service are yours to perform. The senior residents job involves supervising the junior residents, communicating important information to the chief residents and the attending surgeons, making decisions about who needs to go to the OR, and vastly increased responsibilities in the OR.

I love being a surgery resident, and the increased responsibility I've been given this year only heightens my enjoyment of what I do. I was on call in the hospital 4 out of the last 8 nights. On only one of those nights did I get any sleep. However, I had the opportunity to do some amazing cases and see some fascinating things in the emergency room. As always, the trauma cases are the ones that most intrigue me.

Trauma is different from everything else we do as surgeons. The rest of our patients are referred to us by other doctors who may or may not be idiots. Unfortunately, doctors that are idiots are much more likely to consult other doctors because they don't feel comfortable making diagnoses and treating the diagnosed disease process. They therefore harass other physicians with meaningless consults. However, if you run a normal surgical practice, you dictate a rather patronizing note to the referring physician saying how delighted you are to have been referred this very pleasant, intriguing patient when in reality you're not thinking any of those things but just need to say them to try to maintain business from that referring physician. That doesn't sit well with me. Then if the patient needs surgery, an extensive amount of energy is put into figuring out whether they're suitable candidates for the proposed procedure. Hours are spent discussing with the patient and family members whether or not it should be done.

Trauma is different. More often than not, if you operate on a trauma patient, very little time passes between meeting the patient and opening them up in the operating room. There are no fake sounding letters sent to referring physicians. Discussions with family usually occur after the surgery, not before.

Working up a new trauma is a very dynamic process. They arrive in your ER only with a tragic story of some misadventure. There is no neat list of medical studies saying that Miss Jones has a biopsy-proven cancer of "x-type" and is at "y-% risk of perioperative heart attack." It is just you and the patient who may or may not be actively attempting to die on you. The diagnostic process of working up and treating an unstable trauma patient is very stimulating and is a test unlike most others of your surgical skills.

I've been following the events in Israel and Lebanon with a combination of interest and horror. War is so incredibly barbaric and is evidence unlike any other of the falleness of humanity. I remember how traumatic it was to be in New York City on September 11, 2001. That was just one attack on one day in the city I lived in. People in a war zone like that in Lebanon and Israel live in it day in and day out. I don't know how you ever cope with anything like that.

Isn't a situation where the extremes of the fallenness of human nature are being demonstrated an example to demonstrate the other extreme of humanness -- that of being created in the very image of God with the associated ability to show love and compassion? For myself, I increasingly feel drawn to work with an organization like Medecins Sans Frontieres. Time alone will tell where the Lord wants me. In any case, as the Psalmist said, pray for the peace of Jerusalem.

Stethoscope History: The True Version

2006-06-27T19:08:00.000-07:00

OK, so I'm on call tonight and I'm bored. I suppose I should be happy that no new trauma patients have rolled in. However, I'm in the hospital tonight on call and have nothing to do, so I'll post my second blog for the night.

After posting that last piece on the history of the stethoscope, I decided to do a little research to see what the true story is. It is all rather interesting and can be read by going to the following
link... http://inventors.about.com/gi/dynamic/offsite.htm?site=http://www.antiquemed.com/tableofcon.htm

Especially interesting is Dr Laennec's description of it. A link to his 1821 "A TREATISE ON DISEASES OF THE CHEST AND MEDIATE AUSCULTATION" is included on the site and is well worth reading. I also very much enjoyed the many photographs of various stethoscope models that you can see on the site.

The Sad Stethoscope Saga

2006-06-27T17:44:00.000-07:00

I once read that the stethoscope was invented in France. Up until its invention, physicians assessed the cardiac and pulmonary noises by placing their ear directly on the chest of their patients. As the story goes, a certain French family had a daughter who fell ill. They took her to the local doctor, but refused to have her assessed in this manner, as they considered it indiscreet. He eventually circumvented the problem by inventing a very, very rudimentary stethoscope. Personally, I doubt the veracity of the story. I find it much more likely that some nasty, decrepit, foul-smelling, TB-ridden patient coughing up nasty luggies walked into the office of some aristocratic doc somewhere and wanted to be examined. In an effort to maintain as much distance between himself and the patient as possible, the doctor then invented the stethoscope.

My last stethoscope was a nice Littman with the standard black tubing that I paid about $80 for. It was functional and worked very well. I had purchased it about a year ago, so I had not had a lot of time to get to know it and become attached to it. Despite this lack of attachment, I still very much regreted losing it a few months back. I have no idea where it went. I probably mislaid it somewhere in some ICU. In any case, its gone.

My mourning over this loss was relatively short-lived and by the next day I was back to being my normal cheery self. Perhaps my heart had been prepared for this loss, thereby blunting the trauma of the experience, by the loss of the stethoscope preceding that one. It had also been a Littman with black tubing. It was a higher end model, and was somewhat more elegant appearing. It had been my very first stethoscope. One of the on-campus medical groups put all of the first year medical students names in a hat, drew mine, and gave me the stethoscope.

I became rather attached to it over the ensuing five years. By the end of its tenure, the ear pieces were cracked, the bell was occasionally falling apart, and the tubing was permanently molded into the conformity of its position in my coat pocket. However, there was no way I was parting with it. Every patient I had done a physical exam on as a medical student and then as an intern was listened to by it. I was emotionally attached.

Then disaster struck. It mysteriously disappeared. I can't imagine that anyone would have stole the thing from my pocket, as it was no longer very attractive appearing. Maybe it had become colonized by some super-bug type of bacteria that ate through the rubber and metal and just simply vaporized it. In any case, I was somewhat depressed by its loss, and kind of moped around for a week.

I recently entered another contest for a stethoscope. This one was even supposed to be monogramed with the winner's name. I almost didn't bother filling out an entry form. It was 5 whole lines of information. That takes way too long to write down, and I no longer have that sort of attention span. After I handed my entry form in, they handed it back saying that I had missed a line and needed to put some sort of contact information in it. Yeah, I guess that would sort of be the point of filling that out, so I did.

So anyway, my good luck with stethoscope giveaways has prevailed, and I will soon be carrying a stethoscope around with me again. Though this one sounds like it will be fancier than its predecessors, I'd still much rather have my very first one. However, this one will have my name on it, so perhaps when my early onset Alzheimers strikes again and I lose it, it just maybe may find its way back to me.

Laundry, Matchmakers and Admitting Defeat

2006-06-17T13:01:00.000-07:00

Of all the household chores that I do, laundry is my very least favorite. I love cooking. I know how I like things to taste, and can generally make them taste that way. I don't mind cleaning, but perhaps that because I don't do too much of it. If you let things get grimy enough, then its very rewarding to clean them and see the dramatic difference. However, laundry is the bane of my existence.

Fortunately, being a surgery resident, I can wear scrubs almost every day at work. Those go in the hospital laundry hamper and are cleaned by someone else. Its a very liberating thing. Upon beginning my residency, I very quickly learned that I ran out of socks and underwear first, and was therefore forced to do laundry by the lack of those items. Fortunately, that problem was easily and economically remedied by simply buying enough of those items to last a month at a time. This therefore reduced my trips to the laundromat to once a month.

The necessity of those trips was now dictated by the presence of clean dress clothing in my wardrobe. Every Wednesday morning is deparmental Grand Rounds. This is a mandatory dressup occasion. That and church attendance are my two dress up events in the week.

I don't ever iron anything. I'm not good at it and I hate doing it. Generally specimens that I iron have areas that are very neatly pressed, and other areas that look like I was playing a game of twister. This therefore accentuates the "twister" areas, rather then making people realize that I at least made an attempt at ironing.

When Bethanie, my sister, recently visited me, she asked if I had an iron somewhere. This drew a blank stare. After a bit of a search I discovered the thing. So anyway, my pants and shirts aren't necessarily the most tidy things ever seen. That is until recently.

The other Wednesday morning after Grand Rounds I stopped by the trauma intensive care unit to get a cup of coffee. This is my general custom in life, and serves to make both me and the remaining day more interesting.

My wardrobe generally has a hierarchy. The pants that are neat and non-wrinkled are worn first. As the time to do laundry again comes ever nearer, I resort to wearing more and more rumpled clothing. Shirts are irrelevant because collars are generally wrinkle free and the remaining cloth can be masked by a sweater.

The pants that I was wearing that day had not been treated mercifully by their experience in the washing and drying machines. They looked a little bit like they had been in a trailer that was destroyed by a tornado. However, they were the last pair of clean pants that I had so they had to do.

The trauma unit is staffed mostly by 50'ish year old women who sort of fill an aunt like role in the lives of surgery residents. I walked into the break room to fix myself a cup of coffee. Their first comment upon seeing my garb was, "Hans, we need to find you a wife."

Given that sort of threat, I decided that my days of washing my own pants were over. I settled on a solution somewhat less complicated than getting married, as suggested by the trauma nurses. Though it goes against every Mennonite gene in my genome, the local laundry/dry cleaners has a new customer. Its money well spent. Shoot, I might even be able to get away with doing laundry every 2 or 3 months now.

End of Year Festivities

2006-06-13T08:04:00.000-07:00

So the year is now winding down. It is one of the best and most melancholy times of year. The chief residents are nowhere to be found most days, already absent from the hospital in spirit. Of this year's class, 2 are doing plastic surgery fellowships, 1 is doing a colo-rectal surgery fellowship, and one decided that the surgery residency thing was all a big mistake and is doing an anesthesia residency instead.

While all of us are very excited to be advancing on into the next year, it is sad to see these guys leave. I've spent three years with them now, and they become some of your best friends. Its a friendship forged by spending many long nights together hovering over the bed of some critically ill patient, mucking around in someones innards, or just hanging out in the lounge. Its kind of like being at NYP, where you periodically get a new staff crop rotation.

In any case, I'm excited to be starting my fourth year here. Practically speaking, it means that I will now be a "senior" resident having graduated from being a "junior" resident. It all means more time in the operating room, less time in the emergency room, fewer pages from nurses whose main motive is to write "MD aware" in the chart, etc.

So far I have been away from town when the new residents arrive. There is definitely a transition that takes place from being a medical student to being a resident. Most people take about a month or two to make that transition. This year I'm assigned to be on one of the busiest general surgery services for the month of July. It should be fun.

Gadgets

2006-06-08T18:47:00.000-07:00

A year ago, I lost my palm pilot. It is kind of like an accessory brain, so I was rather lost without it for a few days. However, what bothered me more than losing it, was losing the 2 weeks worth of surgery cases that I had recorded in it but not entered on the website that tracks our operative experience.

With the end of the academic year approaching and my book money unspent, I finally broke down and bought another one. I was amazed at how far the technology has advanced since I was shopping for one a couple of years ago. It arrived in the mail today. It plays music, it can connect to the web, it can store microsoft documents/presentations plus all of the stuff that my old one used to do. Now if I could just teach it to do dishes and laundry...

A taste of heaven

2006-06-06T06:52:00.000-07:00

I am currently suffering from severe withdrawal, having just returned from the annual SVS (Society for Vascular Surgery) meeting. It was wonderful. Attendees and speakers come from all over the world to discuss the latest and greatest in the field. The range of individuals attending is truly mind-boggling. You have residents and medical students who are high on potential, but low on actual experience. Then you have others who are truly legends in the field of vascular surgery--people like Dr Parodi (he invented the endovascular stent graft repair of abdominal aortic aneursyms, turning a huge operation into a relatively minor procedure), Dr Greenfield (invented the Greenfield filter that is inserted into the IVC to catch clots thereby preventing their embolization to vital structures), Dr Rutherford etc, etc, etc. Its all kind of like getting to heaven and listening to Moses give a presentation on leadership, or Joshua speak about battle strategy, or Noah talk about ship-building and care of animals on cruises.

Not only that, but the food was unbelievable. I still don't know which fork I should have been using first, but in the end the food all got to the right place. The best part about it all is that the SVS paid my surgery program for me to be there, thereby making the whole thing free. That's also kind of heavenly, isn't it?

Mennonites, Medicine, Faith, and Worldliness

2006-05-25T20:36:00.000-07:00

The following email is something I posted earlier tonight on MennoMed, a group of conservative (relatively speaking, of course) Mennonite health care workers and students. Feedback is welcome.

The email's query about Mennonite patients looking for Mennonite doctors brings up another issue that I've been thinking about some. There is a Mennonite surgeon in SC who advertises in the Budget and has a fairly significant Mennonite patient base. As I get closer to being finished with residency (Ok, I'm only half-way there, but still), I spend more time thinking about what I want my practice to look like after I'm done. I don't think that I want a practice with primarily Mennonite patients. Doesn't that limit both my ability to be a witness to non-Mennonite patients, as well as the ability of Mennonite patients to witness to non-Mennonite health care providers? We've had several Mennonite patients at this hospital, and they have almost always left a very positive impression for faith on the staff that have provided with them. I strongly believe that we're called to be "in the world" while remaining "strangers" in it.

John 17:13-19

"I am coming to you now, but I say these things while I am still in the world, so that they may have the full measure of my joy within them. I have given them your word and the world has hated them, for they are not of the world any more than I am of the world. My prayer is not that you take them out of the world but that you protect them from the evil one. They are not of the world, even as I am not of it. Sanctify them by the truth; your word is truth. As you sent me into the world, I have sent them into the world. For them I sanctify myself, that they too may be truly sanctified."

I Peter 1:1

Peter, an apostle of Jesus Christ, To God's elect, strangers in the world

I Peter 2:11

Dear friends, I urge you, as aliens and strangers in the world, to abstain from sinful desires, which war against your soul.

In fact, worldliness isn't defined by whether you're relating to people inside or outside of the church. When people within the church are acting like humans rather than children of God, they are worldly.

I Corinthians 13:1-3

Brothers, I could not address you as spiritual but as worldly—mere infants in Christ. I gave you milk, not solid food, for you were not yet ready for it. Indeed, you are still not ready. You are still worldly. For since there is jealousy and quarreling among you, are you not worldly? Are you not acting like mere men? For when one says, "I follow Paul," and another, "I follow Apollos," are you not mere men?

What does this passage say about the ever present divisions and quarreling among Mennonites? A nearby church recently went through some quarreling and divisions. It is dismaying when Christians act like "mere men," and the church becomes worldly.

I think where we as Mennonites run into trouble, is that we equate not "conforming to the world" to not being "in the world." Therefore, when the world gets into the church, the significance of what has happened isn't recognized.

The older I get, the more I think that existentialism (To use a dirty word, though I use it in the sense that Kierkegaard meant it as a Christian and the father of existentialism), is at the core of faith. Our faith is existential, in that its basis is rooted firmly in relationship. If we do not have a relationship with Christ, we will become worldly regardless of whether or not we're in the world.

2 Peter 2:20

If they have escaped the corruption of the world by knowing our Lord and Savior Jesus Christ and are again entangled in it and overcome, they are worse off at the end than they were at the beginning.

Relationship cannot be seperated from actions. I John 2 clearly shows that "knowing Christ" leads to "keeping his commands." In keeping with that theme, I John 4 is a beautiful chapter. Like so many of John's works, the existential nature of God and faith (ie love) is linked to works.

I John 4:16,17
And so we know and rely on the love God has for us. God is love. Whoever lives in love lives in God, and God in him. In this way, love is made complete among us so that we will have confidence on the day of judgment, because in this world we are like him.

So any way, that all got rather long-winded, but my point as it relates to seeking God's will for my career is that God calls us to show Him to the world by being in it. I think that I can best meet the calling by interacting with people who do not know Him. Having said that, I am not trying to criticize people who desire to have a practice comprised primarily of Mennonite patients. Doctors like Nolan Byler can fill a very special and important role in those communities. That gets back again to the existential nature of our relationship with Christ, and therefore His ability to give all of us different callings while using the totality of the end result to build His church.

Anyway, I guess I ought to bring this to a close. I'm on call tonight, and have NOTHING going on. Its the kind of thing where if I try to sleep, I'll be hounded endlessly with calls whereas if I stay awake and write really long messages, they'll leave me alone.

Hans

Southernisms Part 2

2006-05-25T18:01:00.000-07:00

A co-worker relayed a story confirming the wisdom of Dr Aderhold's observations regarding the tendency of Southerns to say "ink pen" rather than just plain old "pen" like the rest of the English speaking world.

She was recently at the bank completing a transaction. The teller asked if she had a pin. She couldn't figure out why the bank teller would be asking her for her account's pin number. After several phrases of confused miscommunications were exchanged, my co-worker realized that she being asked if she had a "pen," not her bank "pin." This could have all been avoided had the teller used "ink pen" in keeping with the local customs.

Looky Johny did it!!

2006-05-19T18:34:00.000-07:00

My sisters, both being smarter than me, are graduates of Ivy League schools, or should I say an Ivy League School. I shelled out comparable amounts of money, but attended the non-Ivy league school down the street. Jennifer, my youngest sister, celebrated her graduation from Columbia's school of Occupational Therapy (OT) this week. Due to the benevolent donation of tickets by classmates from afar whose families were unable to make the trek, the Burkholder clan and associates were able to all attend. The event was a bit more light-hearted than my overly pompous medical school graduation. Instead of a boring Nobel prize winner talking about something irrelevant to our lives, they had a spirited, enthusiastic commencement speech delivered by an OT.

I'm proud of both of my sisters. They've both accomplished so much academically. Jennifer's graduation marked the end of 6 year's worth of training. In a specialty more competitive to enter than medical school, and more difficult to stay in once accepted (just under 10% of her starting class didn't make it through the program) she made it all look like a walk in the park.

Speaking of which, my favorite Chattanooga park beckons....

Thinking ahead...

2006-05-04T17:53:00.000-07:00

I'm at the point in my residency now where folks are starting to ask me what I plan to do when I'm done in another three years. Until this point, I've been going through the phase of ruling things out. I definitely don't want to do either plastic surgery or vascular surgery. It is unfortunate, as they make up to three times what other surgeons make. However, I don't want to deal with either patient population. Vascular patients are for the most part rotting away starting at the digits and moving proximally. They are very depressing people to take care of.

That leaves the other main surgical subspecialties such as oncology, colo-rectal, cardiothoracic, trauma, and pediatrics. Pediatric surgery is OK, but taking care of the syndromic children can be less than fulfilling and constitutes a large proportion of that population. Cardiothoracic surgeons can't find jobs right now due to the increasing proportion of cardiac patients being treated by cardiologists with cardiac stents. Harlan has told me that he'll never shake my hand again if I do colo-rectal surgery, so that's out. Plus, a small but significant proportion of that patient population has somehow made their rectum the focus of their significant psychiatric issues, and expect you to fix their rectal problems (which are more in their heads than not.) Oncology patients are usually sweet, however, I don't find palliative work rewarding. That leaves trauma.... and I love it.

It has really become a trauma/critical care/emergency surgery field. Basically you're a general surgeon with extra training in being a general surgeon. They are the surgeons other surgeons consult. Last week contained one of those moments that reinforced that direction.

I was called to evaluate a young man admitted by the medicine service. He was obviously very sick, and was going to die in the next 30 minutes unless we figured out what was going on. My best friend from within my residency year level had caught wind of the consult as well, and showed up. Together we figured things out, and decided that he had a surgical emergency. Though it was a diagnosis neither of us had seen before, we got him down to the operating room, found an attending surgeon to help us, and did the case. We were right and fixed the problem. Had we not of intervened, he would have died within the hour. There are few other fields in surgery that provide that kind of gratification. I was on cloud 9 for the next 2 days.

A number of people at the hospital have suggested that I consider doing surgical critical care/trauma. We'll see. I have yet to do my trauma chief rotation. That involves dealing with a lot of NOG's (Non-Operative Grief). Most NOG's are drunks that did something stupid, have a laceration or something and just need to sober up. They can be very frustrating patients to take care of. So maybe I'll change my mind after a couple of times being up all night with NOG's.

Southernisms

2006-05-01T17:08:00.000-07:00

My first experience with Tennessee English that I can remember came when I was driving through the state about 10 years ago with my sisters. We had stopped at a Subway for lunch. What was normally a smooth process of saying whether or not you wanted black olives, lettuce, pickles, etc on your sub turned into a series of "What did you say"'s. It definitely wasn't English.

While I no longer find the Southern Appalachian dialect incomprehensible, it does still have its oddities that I fail to understand. One of them, until today, had been the name for a "pen." Instead of asking if you need a pen, Chattanoogans will ask you if you need an "ink pen." I've always had to fight the urge to respond, "No, I'd rather have a water pen," or something else along the same sarcastic line.

Saturday I was rounding on the ICU patient census with several other doctors, and one of the nurses asked Dr Jeff Horn if he needed an "ink pen." At the end of rounds, I asked Jeff if it had ever struck him as slightly redundant ... rather like asking for wet water or cold ice. It hadn't ever struck him as odd before, but he agreed that it was a linguistic oddity. He advised discussing the matter further with our local expert on Southernism's, Dr Bob Aderhold, a Georgia redneck otherwise known as the "puff ader." Monday morning, I ran into Ader in the SICU, and presented my troubling linguistic problem with the "ink pen" to him.

Without hesitating for even a second, he confided that he had also been troubled by the redundancy of the term. In fact, he had almost lost his faith in the efficiency of Southern English as a result of these thoughts. However, one day the necessity and importance of saying "ink pen" rather then just plain old "pen" dawned on him, leaving him with a lasting peace of mind. The simplicity and logic of the argument left me dumbfounded.

He explained, if you don't say "ink pen," how would your audience know that you don't mean a "straight pen, a bobby pen, hat pen, or even a dog pen or bull pen?" He has a very valid point.

What Kind of American English Do You Speak?

2006-04-26T16:59:00.000-07:00

It appears as though my time in Chattanooga has not been a good thing...

Your Linguistic Profile:

60% General American English

25% Dixie

10% Yankee

5% Midwestern

0% Upper Midwestern

'>http://www.blogthings.com/amenglishdialecttest/">

What Kind of American English Do You Speak?

Meeting the Famous

2006-04-26T09:19:00.000-07:00

Have you ever met someone for the first time after years and years of knowing of their existence? That was my privilege this past weekend when I attended a Mennonite medical conference in Ohio. I had emailed people like Troy Schrock and Dan Freed for years. It was nice to be able to put a face to the names. Since I kind of new them by email, there were no big surprises in meeting them.

What was a surprise, was hearing one of the speakers talk whom I had never met before. His name has almost become a buzz-word in Mennonite circles, and he is someone who is known or known about by almost everyone in these circles. I was therefore eager to hear him speak to see what the fuss was all about. The speakers up to that point had mostly exceeded expectations, and the ensuing discussions certainly did.

He spent the first 5-10 minutes explaining that he really didn't have anything to say, didn't even know exactly what he was going to say, but that what he was going to say was true. He then spent the next 30 minutes in a rambling discourse, the focus of which was mostly his own present existential experience of what he had just said moments prior. This made for many long pauses, and came across as disjointed and a false attempt at humility. This all of course proved his introductory statement that he didn't have anything to say, making it true, as he had predicted it would be. Then, in a last minute attempt at redemption, he spent the last 5 minutes saying a few things that actually were fairly profound and will be included in my next day of reflection in order to ponder and digest them further.

His speaking style was quite different from what I expected. I think I expected something more down the lines of a talk by John Patrick, MD. Instead it had the aura about it of a contrived attempt at humility. Perhaps the speaker was just having a bad day, and was off his game. Perhaps my expectations had been raised too high due to years of hearing his name mentioned in awe with the certainty in the speaker's voice that he would surely be one of Christ's apostles were Christ selecting them today. Perhaps his content and style were just so far above my feeble mind, that I failed to appreciate them, but now you'll accuse me of false humility.

Remodelling Joys and Woes

2006-04-17T15:43:00.000-07:00

I've been working on remodelling my bathroom for quite some time now. Seeings as I'm on research now, I thought this would be a great time to get the project done once and for all. I had long ago despaired of being able to do it all myself, so I got a contractor to give me an estimate. We agreed on the number of greenies to be exchanged, and I felt relieved. Finally the thing was going to get done.

It was not to be. He then called me and asked me to let him know when I had the fixtures. No problem I thought. I'll just take a little trip down to Home Depot and pick out what I wanted. I snuck away from work for the afternoon today and paid a visit to the Home Depot store. I didn't like the floor models/prefab stuff they had available, and wanted to speak with a sales associate about getting something with a few minor changes. The person to talk to was Tammy. She plunked about 10 catalogues in my lap, handed me a business card, and headed for the hills. I hadn't intended to spend quite that much time pondering bathroom vanities. I had envisioned telling her what I wanted, spending about five minutes ordering it, and then I would do the leaving.

I lugged my catalogues ought to the car, and thought maybe I ought to write Warren Buffet to tell him that he might want to rethink his Home Depot investment. Since the Lowe's store was just around the corner, I decided to give them a chance to do better. Their floor models were more what I had in mind. However, they didn't really stock any of them, and you had to order them in. I informed a sales associate that I would like to proceed with doing that. He hemmed and hawed and finally told me that he really didn't know what that involved. I really needed to talk to "Brian," he said. Unfortunately "Brian" wasn't their that day, and would be available between 12-9 the following day. However, I was there today, and didn't feel like coming back the following day to see Brian. Besides, he would probably just shove a bunch of catalogues in my arms and usher me out the door.

I stewed on the matter all the way home, probably raising my systolic blood pressure a good 20 points or so. The afternoon had been wasted. Instead of writing the article for publication in the Journal of the American College of Surgeons that my program director has been eagerly awaiting, I had spent the afternoon being foiled by friendly bumbling sales people. Then it dawned on me. Neither Home Depot nor Lowe's had what I wanted in stock. That meant that they had to get it shipped from somewhere. Why couldn't I just skip them and get it shipped to me from somewhere rather then having it shipped to them and then to me? So here I sit in the local coffee shop accessing the internet via their wonderful wireless connection.

The nice thing is that there is a wonderful array of vanities available via the internet. There are things that look fabulous but could really only be afforded by someone like Bill Gates. There are things that look tacked together out of lumber scavenged from shipping pallets, but that even the poorest college kid could afford. Then there are all those things somewhere in between. Can you say goodbye Home Depot and Lowes? Good riddance in my mind.

These guys need a better PR person

2006-04-08T18:22:00.000-07:00

I'm in favour of immigration, and know people labeled "illegal aliens" who I think ought to be given citizenship in this country.

This week the status of these people was in the news, and I found myself praying that maybe life will be made better for some of these people. They also seem to have hoped the same thing, as marches were held in different parts of the country supporting more aggressive immigration reform that would be favourable to illegal immigrants.

Jane and John Doe. Jane and John Doe are not inspired to feelings of patriotism when they see a crowd of people waving some other country's flag. If these people really want to convince the American public that they ought to be given American citizenship, they should leave their native country's flags at home, and buy some American flags to wave at their march.

Think about it. Would Canadians feel inclined to give Canadian citizenship to a bunch of Americans waving American flags on Bay Street in Toronto?

That's my opinion, and I'm sticking to it.

Not above the law

2006-03-29T11:13:00.000-08:00

A few weeks back, I was driving home from work. One of the benefits of starting work early and getting home late, is the lack of traffic.

Recently the road people completed construction of the highway going from 4 lanes to 6 lanes. Traffic normally goes about 50 mph now along that highway, but the speed limit is only 30 mph.

You guessed it. I was doing about 50 mph, and being the lone car on the road, was a rather conspicuous target for the police car stationed a block or two from my house. I figured I was had, and I was. The officer told me he was going to give me a ticket for going 50 in a 30 zone, and went back to his car to write the ticket. I sat in my car and stewed, wishing that he would have at least had the grace to write it for a 45 or 40 rather than 50 mph speed.

My guess is that police officers usually feel somewhat guilty about ruining your day when they give you a ticket, because in each of the three or four instances that I've been the recipient of their attention since my driving career commenced many moons ago, they always try to make conversation with you after handing you the ticket and be pleasant. As the recipient, I've always just wanted them to hand the ticket over, and get out of my life. I was feeling this way towards this officer at the moment as I sat in my car and stewed while he wrote my ticket.

Sure enough, after a few minutes, he came back to my car and handed me the ticket.

"So, ya comin home from work?" he asked.
"Yes." I replied trying to be curt.
"So, where do ya work?"
"Erlanger." I replied.
"What do ya do there? Are you a doctor?"
"Yes"
"What kind of doctor?"
"I'm a surgery resident."
"Well why didn't you tell me that before I wrote you that ticket? I might show up there someday with a bullet in my chest, and I don't want you to see me come rolling in spraying blood out of my chest, and think, 'Hey, that's the guy that gave me a ticket.'"

At that point, he had me warmed up to him, and I laughed and told him that I didn't think that should have made a difference in his decision whether or not to give me a ticket. We then had a nice conversation about his son who is applying to medical school. I left feeling in a good mood, and I think he had assuaged his guilt about giving some poor motorist a speeding ticket.

The Power of "Thank You"

2006-03-12T14:24:00.003-08:00

We all have things at which we excel, and others at which we absolutely stink. The same is true for the variety of tasks that confront surgery residents. For example, my knot tying skills are not what I'd like them to be. I'd love to get my knot tying time down by at least a third. On the other hand, I absolutely rock when it comes to putting in central lines. So while I might be a wee bit behind some of my peers with regard to knot tying abilities, I think I could smoke most of them when it comes to central line placement. That is why the events of the other night were mildly distressing.

For the uninitiated, central lines are big IV lines that range anywhere in size from about the diameter of a pencil to about half of that size. There are six sites where they are commonly placed: Right or Left Femoral, Internal Jugular, or Subclavian veins. Internal medicine doctors at our institution generally access the femoral veins. They are the least scary lines to place in terms of immediate complications. However, since the femoral vein is located in the groin, this anatomic position is the most prone to infection, and therefore is not the site of choice for most surgeons. They therefore usually place subclavian or internal jugular lines which are located in veins just beneath the clavicle or just lateral to the trachea respectively.

Sticking a needle, approximately the length of a coffee stir stick, into someone's neck or chest is not a natural thing to do. The first few times you do it, you half expect your mother to show up and give you a speech about not giving other people ouchies.

As an intern, we are required to do 10 central lines prior to being accredited to do them unsupervised. The surgery lounge has a big chalkboard where a running tally is held for the first few months of the residency year. This is egged on by the senior residents, who of course are eager to have the interns signed off on lines so as not to be the victim of quite as many late night "line supervision calls."

My intern year, I was running neck and neck with another resident for the most number of lines. The prize for being the first to be signed off on lines was a 6-pack of beer, which I naturally found very motivating. He beat me out by a day for that tenth line. I'm still disappointed that someone else won. I don't drink, but my cat would have enjoyed the beer, and would probably have been amusing drunk, but I digress.

My whole point was, central lines are something that I enjoy and that I am good at. I can usually get them in on the first needle stick. This is important because you can kill someone putting a central line in, and the probability of doing so is directly related to the number of times you have to sink a needle several inches long into their body.

Recently I gave a patient a pneumothorax (collapsed lung) putting in a subclavian central line. Because the lung sits right beneath where the vein is that you're aiming for, it is one of the more common complications of central line placement, with an incidence of 2-3%. It was only my second pneumothorax out of the hundreds of central lines that I've placed, so I'm well below the national average so to speak. However, anytime you have a complication, it rattles your confidence a little bit.

Enter Mrs F. into the picture. (as is the case with any medical story, lots of details have been changed so as not to violate confidentiality laws) She has had more central lines than a month has sunsets, and is therefore a "hard stick." Her existing line seemed to be clogged, and it had to come out. That takes away one of your five placement sites, since you don't want to put a new line into an old site. Furthermore, the femoral veins are not desireable places to place a long term line as previously described. That gets Mrs F down to three appropriate sites for line placement. All three remaining sites have scars from previous lines serving as a roadmap for where the underlying vein probably lives.

The problem is, veins don't like participating in human pincushion projects, and eventually scar up and may even clot off entirely. Poor Mrs F. She had to have a central line placed because it is literally her lifeline. A complicated series of events made her GI tract useless, and she therefore is solely dependent on TPN (supplied through her veins) for her nutrition.

Well into this central line attempt, I had failed miserably at line placement in two of the three desirable sites. A dotting of skin puncture wounds provided evidence of my efforts that would have embarrased even the most incompetent of medicine residents. Even when in the vein with the needle, the wire would not thread: evidence of internal venous scarring. It was all very frustrating, and with each needle stick I worried more and more about causing my third career pneumothorax.

Presenting two pneumothoraces at the same week in the weekly Morbidity and Mortality conference would have made me the butt of a few jokes such as "any assasination attempts planned today?" However, the real reason I was worried about giving the patient a pneumothorax was the fact that she had a long anticipated vacation planned for the following day with her daughter. Her being able to go on this vacation was conditional on having a source for nutrition, ie the line I was attempting to place. I was beginning to have visions of her in the hospital the next day with a chest tube bubbling away while her daughter enjoyed the sunny coasts of Florida without her.

With a quick silent prayer to the Lord for better success at the next site and an apology to the patient for the need to continue to play the human pincushion game at yet another location, I proceeded to prep my last available central line site. Thankfully, my syringe feeled with nice venous blood on the first stick. A vampire is the only creature, mythical or actual, that could have felt more joy at the site of blood. Central line in place, I informed Mrs. F that we were done, and that I was sorry that I had to play the human pincushion game so long with her. Then she did something that no patient had after a procedure for quite some time, and that made me want to go somewhere and cry. She said a heart-felt, genuinely appreciative "thank you."

The chest x-ray showed no collapsed lung, the line terminated at just the right place (just an inch above her heart), and she is now somewhere on the highway with her daughter on a brief escape from a life dominated by her myriad medical problems. I also don't have to present two pneumothoraces in one week. However, what meant more to me than all of that, was the fact that she said "Thank You," and conveyed the sense that even were she to miss her flight the next day instead spending the anticipated vacation staring at a hospital ceiling, she still meant it.

Hans

2006-03-09T17:30:00.000-08:00

No blog is complete without a representation of the author somewhere on the site. I decided this image was as good a likeness as I was going to find.

Having enjoyed Dorcas Smucker's blog, and wanting to avoid spamming people with form letters, I decided to establish my own site where updates would be available to those on my mailing list who wished to read them.

Enjoy,

The Mad Hatter