In Arduis Fidelis

If there's one thing which still gets my goat, it's seeing a pregnant woman smoke. I know she has the right, and I don't say anything, but it bothers me a lot.

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More drama-ful class than probably necessary today. It's still an outstanding class. Under the heading of 'is this code or is this encrypted', the instructor and I had a chat on our way out of the building, in which it chanced we discussed our lives in such a way that I know she dates women, and she knows I date women also :-). This led me to some thoughts on the word "partner", which has apparently come to mean 'partner of the same gender as you'. I've run across this numerous times-I refer to my partner, and am (usually) asked what he does. Well, she's a graduate student at Brandeis.

Oh.

It's never been the type of 'oh' which means 'you led me to believe...'; it's more often the 'oh' which leads people to examine their assumptions. (We'll skip over the discussion which ensues when I mention my partner's other partner. That's usually more complex. The instructor and I have not, for instance, had that conversation as yet. I doubt we ever will, unless we develop a relationship after the class is over. This is not impossible-she's a writer of some renown in health care policy, which is my soon-to-be-chosen field, and she'd be a good person to know. If for no other reason than that she seems to know everyone in the field, anywhere).

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Nice day for a bike ride. What exactly are all the cops in Cambridge doing on Mass Ave right now?

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There's a job I'm applying for right now which *may* be My Dream Job. It's certainly with my dream organization, which is the Institute for Healthcare Improvement. Wish me luck; I'm writing my cover letter right after this (this was a warmup, y'see).

No, not me; I worked last night, and got enough of the drunk at work.

*Or so I thought!*

While driving home around 12:30am, I chanced to be behind a red SUV (on 93 NB in town) which was driving a bit erratically. Nothing overboard initially, soon it started weaving in and out of lanes badly; not sharp-but-reckless lane changes, but lane changes of the type where the driver would drift into another lane a bit, and then decide apparently at random which lane s/he actually want to be in. Mostly this was the far left hand lane (which I usually prefer also), but not always.

And then it drifted into the jersey barrier, knocking off a few bits of car in the process.

Now, normally I ride my bicycle or my motorcycle to and from work. Yesterday, due to inclement weather both forecast and actual when I was heading out, I drove my car. I count that good because a) I was in a more protected vehicle should this yahoo (or bits of his car) hit me (he did not), and b) I could reach for the cell phone while driving and call the police to report him, which I did. The state police were more than usually efficient in taking the report; I read the plate number to the dispatcher and he said 'Thanks, we'll send someone after him soonest' and hung up. I'm sure I wasn't the only call, or even the only call on this person, but while I've seen (and reported) my share of erratic drivers, this was the first one who *broke his car* while I was watching. And didn't even slow down, although he did pull off at the airport lane (which also happens to peel off the highway into Chinatown), but that was more than a couple of miles from where he hit the barrier.

I love my two-wheeled conveyances, but I was truly glad to be in a car last night.

A little something from The Washington Post.

I think I got maybe half of them. And I was pretty sure _some_ of them had been put there on purpose after reading about the pen being mightier than the sword.

I've seen this in a bunch of places. So...ahem.

"Brakes", n. Things which stop your vehicle, such as the brakes on your bicycle, car, etc.

"Breaks" vt. What happens to your vehicle if the brakes don't work and you hit something.

Thank you for your attention.

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This is the first time I've ever taken summer classes. In college, I always worked during the summer, but that's a different experience than taking classes. I like working better, on the whole. Although I got an 'A' in the class, which was excellent, it was mighty compressed. One hardly had time to digest the last class before there was a new class, with new material, which needed digesting right now. Not because there was *so much material* (which I'm used to-medical school is like that), but because there was *so little time*. On the one hand, I'm glad it's over. On the other, well, I have a couple more classes coming up-one of which is being taught in a week (of 5 hours a day classes), the other in a more reasonable time frame (something like 6 weeks or so), both 2 credits.

And after that...well, I believe I can finish my MPH by December. I'll have to pay for the last semester, but since I've been getting paid lots, and live pretty cheap, I can actually manage that without a lot of difficulty. And then I'll be looking for a job. Hopefully, I'll be making job contacts during my upcoming practicum (which, with any luck, will be with state government or a local consultancy; we'll see what happens), and I can parlay those into something fun. Money takes a back seat to fun, at this point. I can make money doing what I currently do-emergency medicine has always paid the bills and then some. What I want is something I *enjoy*. And I have some luxury in finding that-my current job will take whatever hours I want to give them after I finish; they'll even add benefits if I work over 27 hours a week. So I'll see what happens.

From a recent opinion: "Remote in time it may be; irrelevant to the present it is not".

The opinion also holds that the government must hear habeas corpus petitions from the detainees at Guantanamo Bay, as follows (from BOUMEDIENE v. BUSH):

We hold that petitioners may invoke the fundamental procedural protections of habeas corpus. The laws and Constitution are designed to survive, and remain in force, in extraordinary times. Liberty and security can be reconciled; and in our system they are reconciled within the framework of the law. The Framers decided that habeas corpus, a right of first importance, must be a part of that framework, a part of that law.

The determination by the Court of Appeals that the Suspension Clause and its protections are inapplicable to petitioners was in error. The judgment of the Court of Appeals is reversed. The cases are remanded to the Court of Appeals with instructions that it remand the cases to the District Court for proceedings consistent with this opinion.

It is so ordered

Thus giving the big, fat, Supreme Bite Me to the Bush theory of "we can hold whoever we want, for however long we want, amen; we just have to accuse them of a terrorist act and move them to a foreign base."

It'll be interesting to see what happens next. Don't count on an overnight freeing of dozens, though.

Yeah, I spell judgement using the British spelling. I like it better that way.

There are cases which call for the use of the judgement call in ways which can be sort of nerve wracking. One recently-comes the nice older man with chest pain. He'd been in a car accident the previous day, and he had thought, when he had chest pain in the morning, that he was just anxious from the previous day. After an hour of apparently Really Bad Pain, he decided to come to the ED. He drives to the ED-mistake number one. We hustle him in, get him started, and do an EKG. Yup, he's having the Big One. Now, the protocol from there goes: 1) call the cath lab (which is at BMC, requiring); 2) call the bus to take him to BMC ('bus' is the colloquial term for a transport ambulance, as opposed to a city EMS ambulance; there's no difference in level of service); 3) give the patient a bunch of meds, most of which are to thin his blood out to prevent more clotting (the reason heart attacks happen is that you develop sudden clot in your coronary (heart) arteries), and then 4) prayer, Mr. Saavik, the Klingons don't take prisoners. Somewhere in there you tell the patient and his family what's going on, too.

And then the patient says he's starting to have back pain. Great. Why does this matter? Because heart attacks aren't the only thing which cause chest pain, or even EKG changes. And he's been in a car accident recently-not a bad one (he says), but still, it puts him at risk of the bugaboo of chest pain: thoracic aortic dissection. Which, if he has it, will kill him right quickly if you loose the clot with all of the anticoagulation you're giving for the heart attack. Now, clinically, I didn't *think* he had a dissection, but it was among the possibilities. *I* thought he was having a heart attack. But I sweated the transport to Boston and the time to get him into the cath lab. Had I inadvertently offed the (very nice) man because I aggressively treated what I thought he had, while discounting something I didn't think he had?

In the event, the answer was 'No'. (Whew!) The cardiologist I sent him to called me later that morning, full of praise for my aggressive treatment in the face of uncertainty (he hadn't been as happy when I called him to send the patient :-), because the patient had a *very* aggressive clot, requiring extraction (I was impressed-that's the newest thing) and stenting, and after he received those things he was fine. Score!

But I could as easily (in theory) have been wrong. He just *looked* like he was having a heart attack; people with aortic dissections are usually restless, have dry skin (people with heart attacks are sweaty), and in general just look different. How sure was I? Sure enough to anticoagulate him based on my clinical impression. But unsure enough to sweat until I was proven right. But this is why I get the big money; it's easy to say to get the patient involved in the decision, and I do if I can, but the patient in this instance was one of the 'Do whatever you think is right, doc' school, so *someone* has to decide, and in this case it was me. Lucky me :-)

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One of the things you learn in medical school is that often the reason the patient *says* they're here for is not the reason they're *really* here. We used to call it the "Hey, doc, wait..." rule. You go in to see the patient, talk at length about what they say they're here for, and as you're leaving, they say 'Hey, doc, wait a minute...'. So my last patient of the day yesterday was a pleasant lady who'd been in a car accident about an hour ago. Now, when we triage people, we ask them a series of questions, usually in the same bored tone reserved for the questions they ask at flight counters-"Any bombs in your luggage?". One of the questions we ask is if you feel threatened at home; it's meant to screen for domestic violence. And after dealing with the car crash issues, I started to leave, and asked "Any other questions?", like you do...and she got a bit tearful, and asked "Those questions about feeling threatened...does that include verbal abuse?" I admit that the first thought that went through my head was 'Oh, gods, I'm about to leave...do I *have* to deal with this now?" Which of course I did, so I did. Fortunately, she wasn't unsafe physically (to find this out, you basically ask the patient; s/he usually knows better than any other screening tool might decide). So we referred her to the proper authorities, so to speak, and she left a happier person.

Not a bad day, on the whole.

It's been an interesting week at the ol' medical center, which as usual means bad things for other people.

( The Trifecta of Terror! )

Whew. I've been working a lot of hours this week, and it shows in the tally of weird. Usually it takes 2-3 weeks to get this amount of weird together. One more night shift, then May slows down a bit. That'll be nice. My reduced schedule starts in August, and I cannot wait, let me tell you.

OK, time for the news.

Viewers of this space are reminded that I've been unhappy with my work for a bit. Recently that's been increasing, to the point where it was interfering with the rest of my life; I was constantly keyed up, often angry or ranty about things which, all things considered, are simply part of the life of an ER doc in general (well, some are things which truly *ought* to be better than they are, but let's move on). And I was also feeling unheard by my management when I pointed out not just what was wrong, but the industry standard 'best practices' which would fix these things and how they could be applied at my institution.  It was screwing with my *sleep*.  Now, I've *never* had problems with sleeping; anything which interferes with my sleep is something to which I need to pay attention.

You see where this is going?

I didn't quit, which is in part a statement of how much I like my boss (he and I go back a spell; he was a chief resident when I was a medical student, and later staff when I was a resident. Those relationships from residency are close and meaningful), and in part a statement of 'I need to pay the bills'. Now, as it happens, I *could* just quit, and as long as I got another job within a year (1), I'd be fine; I have savings enough to live on and pay tuition at BUSPH for the year it'll take to complete my MPH.  However, at the end of the year, I'd also be flat broke, and I wasn't so excited about that.  So I advised my boss I'd be reducing my hours quite sharply-I'll be working 12 hours a week, and going to school the rest of the time, as well as looking for a job which I really want, and which doesn't involve working nights, weekends and holidays (I don't mind the occasional weekend or holiday, but I work every other weekend, and am at risk to work every holiday; I want a bit more normalcy to my life for a bit).

I've had to do a lot of adjusting of my life view; I identify *very* strongly with my job, meaning it's a big part of how I perceive myself and relate to the world. Likely that work is going to be going on for a while, but it was pretty wrenching, and put me off LJ for a bit (I've been reading, and commenting some, but haven't written anything in a while).  I suspect it'll be slow going for a while.

So. I'm back. Did I miss anything?



(1) not a problem-the labor market in my business is such that I can have another job (as an ER doc) by making, oh, 2-3 phone calls. Not interviews, mind-phone calls. I have people cold-calling me once a month and sending letters offering jobs 2-3 times a week. ER docs are *scarce*

So a friend recently mentioned at an event I went to that I have been maintaining a bit of radio silence. And it's true, I have been...less than loud, in this venue. There's a lot going on in my life just now, not all of which I'm ready to discuss on what is, in the end, a public forum. I'm fine, my relationships are quite fine :-), and overall, things are progressing in directions I'm happy with, but it's all leaving me somewhat psychically busy, and not terribly posty.

But I did find this, and wanted to share; it's a list of all of the 'employees' of Car Talk, the NPR show from Tom and Ray Magliozzi, right here in Cambridge ('Our Fair City') MA. Some of my favorites:

Director of Cadillac Steering: Toulouse Toutrack
Customer Service, London Office: Sir Leo Mann
Director of Long Range Strategic Planning: Kay Sera

And like that. I used to listen for the Cadillac steering one every week, because it cracked me up every time. I'm a juvenile, it's true, but it makes me just unpredictable enough, without being quite unreliable.

I read Bruce Schneier's blog, and he will regularly mention events where some company's product has been cracked. Today, he mentioned that the London Tube card had been cracked, and I thought I'd click through on the story. And in reading it, it appears that London Transport is just the largest customer of these cards. They're also used in Boston. Sounds like the Charlie Card to me.

So after I got my iPhone (which happened, oh, maybe 2 weeks ago), I was wandering the net looking for webapps, and came across a multitude of them which were designed around David Allen's book Getting Things Done as a framework for how they worked. And I looked at it a bit, and thought "Well, for 9 bucks how bad can it work out?", so I got the book. And while I'm still in the process of reading it, this bit really struck me; while talking about a filing system he recommends and uses (a simple alphabetical system, nothing complex), he says something like "If you do it this way, there are only three or four places anything can be when you go to look for them."

Read that again. "...only three or four places..."

For longer than I can think about, I've thought I would be better off with some sort of filing system. The biggest obstacle was that I couldn't for the life of me come up with one that I was fairly sure would result in being able to find everything I wanted, when I wanted it, on the first pass. And now comes Organization Guru, who says it's OK to have a system where you might have to look in three or four places before you find what you're looking for.

Dude, this obsession with perfection and perfectability really has to go. I hadn't realized how much 'perfect' stood in the way of 'good' in that part of my life.

I'm liking this book so far, in that it proposes a system which is, perhaps not Perfect, but probably Quite Good, and more likely do-able than any Perfect System. Bulletins as they happen.

or, what I did on my winter vacation.

We chose Puerto Rico primarily due to low flight time; there is a direct flight from BOS which takes four hours, leaving us more time to actually, y'know, be on vacation. And since we were doing this primarily to get a break from the winter's short days and cold temps, we wanted maximal time in the sun.

It's been a mixed bag of a vacation. I'm glad we came, but I don't think I'll choose Puerto Rico again unless ( some things change. )

It is really marvelous how revealing one's deepest fears to a person who you know will handle them (and you) with the care they are due makes them look, after a brief time, like the silly things they are, whereon they blow off into the closet whence they belong.

This shouldn't surprise me anymore, but it still does.

It's been a crappy week. I'm looking forward to a better one coming up Real Soon Now.

Sometimes, the phrasing is *just* right. Without further comment:

"In the G.O.P. primaries on Super Tuesday, John McCain
emerged as the likely Republican presidential nominee
after winning California, New York, New Jersey, and other
"blue states"; Mike Huckabee won states in the South, and
Mitt Romney won states in which he has owned a
home.

...rode the 600.

Here's a bit of advice for the moment. Do not become critically ill in the City of Boston this week. There are *no* critical care beds anywhere in the city or south of it (didn't call up north, because it's too long a drive, but I doubt it's any better there). How do I know this? Because I called just about everywhere, looking for one for my critically ill patient for whom we didn't have a bed, either.

Addison's disease (primary adrenal insufficiency) is rare but potentially very fatal in the face of otherwise mild diseases, meaning that if you have Addison's and get simple diseases, like the flu or a cold, you can become critically ill. It's important to recognize, because usual supportive care won't fix the problem; you need to replace the missing adrenal steroids, and it can be difficult to recognize early on.

So comes now the nice 31 year old woman with (I later discovered) Addison's, with altered mental status (unconscious, unresponsive), and a temperature of 105F. Well, altered mental status and fever is meningitis until proven otherwise, so she got the whole meningitis protocol; she got megadoses of bug juice, and a lovely spinal tap. Then I had a chance to chat with her parents, and they brought her only medication; prednisone, which she takes every day. There are only a couple of things for which someone that age would take prednisone once a day, and Addison's is one of the most likely, so let's assault with megadoses of steroids. And let's find a bed for her which is not in the ED.

So I call the nursing supervisor. Nope, no beds for me at my place. OK, NEMC (parents first choice): nope. BMC? Negative. BIDMC? Sorry. BWH? We have three waiting, thanks, try somewhere else. MGH? (I always call them last, because the answer is usually no). They have 6 waiting for their ICU's. I even tried one of the local community hospitals: no joy there, either. Didn't try St. Elizabeth's (didn't occur to me at the time; I doubt they'd have had anything either, and in retrospect I could have-but it's getting far away for the parents). So she hung out with us for the rest of the evening. By morning she was doing somewhat better hemodynamically, but there's some concern about her eventual neurologic recovery.

One of the lessons here is that of 'surge capacity'. It's somewhat like the French Marshal Petain replied to Churchill when asked about the 'masse de manoeuvre' in 1939 during the German invasion:Aucune; there isn't any. If something bad really does come along, we are hosed for hospital and critical care capacity; there is barely enough for the routine surge of everyday illness, never mind the need to care for many victims of something bad. Potential for bad form.

The Whine Quotient today is about 8, corresponding to a Whine Alert Level of: Orange.

That is all.

When I have attacks of my own personal anxieties, they are usually about people I care about meeting with some unfortunate fate (usually traumatic, often a car accident) while I'm at work, and me not being able to get to where they are because I can't get anyone to relieve me at work. Now in fact, I'd probably have coworkers vying for the opportunity to relieve me, even the pregnant going-to-deliver-on-February-20th one, but my anxieties are not easily swayed by reality.

And said anxieties are often exacerbated by having to deal with death at the end of my shift, as I did the other night. I had a crappy day not because of any sporting event, but because everyone who was *not* watching the game was in the ED, and they were all sick. I think we admitted upwards of 10 people in the three hours between 6 and 9. Just those three hours; there were others we admitted, but they were before or afterwards. And at the end of my shift comes the radio call: 91 year old, family heard a thump, found him basically dead. EMS did the usual things, which didn't work, as usual. My coworker is overwhelmed with the living, so I volunteer to deal with this (it doesn't take long to determine a 91 year old is dead and pronounce him, and she can talk to the medical examiner and the family when they arrive or call; EMS had already all but told the family he wouldn't make it). I go in to the trauma room, in comes the patient, dead as advertised, and I duly pronounce. (For the record, there aren't any formulaic required words; when I pronounce someone dead, the way you can tell is that I ask the room at large "What time is it"? so we a) all know the patient is dead, and b) all agree on the time of death, so I can ask later to put it on the death certificate, because I always forget). I fill out the record and head home. And on the way home, the anxieties hit. Not the crippling, disabling type; I don't get those. Just the type one gets because one has been reminded of mortality, and realizes that the people one is closest to could be next, no matter how you feel about them. The world doesn't care that there are people who fill my world with joy and light just by being in it; that remind me every day that it's OK to be just who I am, complete with flaws and foibles, but I do care, and sometimes I worry about them.

I don't worry about dying myself-I shall, in due course, and while I will miss the place, no doubt it will get on without me as well as it did before I came along. But I do worry about people I love dying, whether I ought to or not, and sometimes that worry is closer to the surface than I like. Like that night.

I'll be fine; I've dealt with this before, and likely will again, and I've also been fortunate that, so far, no one really close to me has, in fact, died.

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In other news, there's this from Harper's Weekly

British scientists announced that it
would soon be possible to convert female bone marrow into
viable sperm cells, hastening the obsolescence of men.

Great. Just great. Science marches on, boys.

You know, one interesting thing in my job is watching the evolution of 'mental health'. For instance, here's a kid who punched a wall; not a repeat offender, not a problem kid, no 'diagnosis', didn't threaten anyone, didn't threaten himself. Not a big deal, I wouldn't think; a counseling session or two do discuss 1) what's bothering him and 2) appropriate ways of expressing anger, and perhaps some sort of school consequence (suspension, or whatever they're doing nowadays instead of detention, since I gather that's gone the way of the dodo). Apparently, though, I am wrong; punching a wall calls for an ambulance and a hospital ED and an evaluation by mental health. Who have unsurprisingly come to the conclusion that the kid was angry and has not yet developed good ways of expressing his anger, and he maybe needs some counseling. And maybe a suspension in order to drive home the point that expressing his anger in this way is socially unapproved.

I would mind somewhat less (although not a lot less-it seems like a waste of the emergency mental health workers time as well) if sending him to the ED didn't require a medical workup, as well, although thankfully if one is clueful, one can limit the medical workup to the bare essentials. But still-medical workups cost money, to the system if nothing else. In a just world, we'd charge the school he came from; there ought to be consequences for them, too, for overreacting like this.

which I'm not sure if I have any, but nevertheless. Under the LJ cut is a program BU is putting on to interest kids in science and engineering. Since I'm interested in science and engineering, and some of my friends are as well, I thought I'd pass the word.

( Here's the announcement )

I know nothing about this other than what you see, but BU is unlikely to put something like this on unless they think it has some serious value. So, word passed. Back to the remainder of your day, already in progress.

So I have a camera.  I don't use it as much as all of that, but periodically the mood strikes, and I go take pictures.  And when mud_puppy and I were on our way to her place last night, she mentioned how pretty it was in our neighborhood, with the snow stuck to the trees and buildings and everything made fantastic and different.  So after dinner I went home and took some pictures.  And rather than clutter up your page with them, feel free to wander over to Flickr (http://www.flickr.com/photos/docorion/) and have a look, if you like.

Mostly I do this for fun; I'm not particularly good, but I like odd landscapes and looks.  I figure I'll get better if I do more, and I might eventually get interested enough to learn some more formal stuff.  I almost did that this past year, because I really liked the work of an artist I saw, and he had a card noting that he would be teaching classes at his studio in October.  Then I was busy in October and didn't do it :-(