I got a jump on my resolution for 2008 today and went for a lunchtime run between morning and afternoon clinics. It is stunningly sunny and lovely out today: 40-degrees and bright. I ran from DFM straight down to the waterfront near Peir 66, headed north along the water toward the Olympic Sculpture Park, which I bypassed to avoid the temptation of touching the art. I ran through Myrtle Edwards park along the pedestrian path to a little spot with parallel bars and a sit up platform. A little of this and that on the bars, then back south toward the sculptures again, facing into the bright December sun, which at best seems to rise halfway above the horizon and so far to the south that I was running right into it. Nice though. I wonder how many lux you get on a day like today?

Getting back to clinic took a little more uphill energy, and I started to fade a bit. But reminded myself that lunch awaited, and managed to press on.

Again, I did not touch any sculptures.

Thirty minutes remain now between me and my afternoon clinic.

Today it was easy to keep my resolution. We'll see what happens when the rain comes back.

Who knew rei would be busy today?

What Are the Odds?

I went to the Seattle Aquarium this morning with my girls. A hundred-thousand or so marine animals. I managed one crappy picture of a person.

Seattle Snow

Day off today.

Zoë wouldn't nap this afternoon and it was snowing, so we headed out for a run. There were huge snowflakes falling, covering the connected parks on our usual route but sparing the paths. Nice. Zoë fell asleep in the jogger after about twenty minutes--she needed it. As we dropped from the hilly stuff down to the lake, the snow turned into rain, which was unpleasant. I was dressed for snow, not rain, so I got soaked but pressed on, feeling like I had a lot of stress to get out. We ran along the lake for a couple of miles then headed back up through Mt. Baker Park. Near the top of the hill, the flakes got big again and there was more snow sticking to the grass. Zoë woke as I stopped to take a picture of the snowman (some industrious kid made the best of almost nothing).

We dropped back into our little valley, got home, wrung ourselves out and waited for Brooke and Elliott to wake up from their naps, finished making peanut butter cookies, and drove in the slush--becoming ice--to see Sachi and Travis, who just had baby boy five days ago. I got to see them in the hospital, a benefit of working there, but Brooke and the girls hadn't seen him yet. We took them some black bean soup, cookies, and satsumas. Zoë made a total mess of their place for an hour, and we headed back home for the slow, chaotic descent into kid bedtimes and now my own.

I'm on tomorrow morning early and need some sleep, so off I go.

Tomorrow it'll be fifty degrees and the snowy world of today will be gone. Maybe that snowman will see Monday.

Can't Touch This?

Welcome to the Olympic Sculpture Park. Whatever you do, don't touch the art. Even though you're three years old. And you're outside. And the art is outside, where things touch it all the time. And don't run. Running is fun. So don't do it. Even if you're three, and run at an adult's walking pace. For the love of art, just walk. Just do what the security man in the blue jumpsuit says. No touching. No running. No lip.

And the art that looks like a bench? Yes, the one called "Bench." Can we touch that, Mr. Blue Jumpsuit? How about just with our butts?

I know this is old news, but it's still incredibly annoying. My first impulse was to set Zoë loose and let her run snotty fingers over "Eagle," maybe give "Split" a big hug, or see what "Wake" tastes like. But it was somehow more satisfying, culturally, to grumble in waspy indignance and walk on. I'm glad others have found creative ways to comment.

It is a cool park, though.

Macy's Parade

Yesterday we all went down to the Seattle Macy's Parade. We found a moderately-crowded spot at the end of the parade route and edged in so we could see the floats, marching bands, and assorted oddities that passed by.

I loved the marching bands, especially (though I hate to admit it) the Washington State University band, in town for today's Apple Cup. I've attached a slide show with the few in-focus pictures.



Unlike last summer's disastrous pirate outing, this was actually fun for all of us and we'd do it again. We'll also go back and let Zoë stare at the Macy's windows, which are pretty good this year.

Buyer's Remorse

"Let's go on a cruise! I hear Antarctica is great in November, and I got us a deal aboard a classic ship."

Fast-forward to November 23, 2007, and that slightly newer, larger craft in the background looks like it may have been worth the added expense, no?

But who doesn't like an adventure?

Hairball

I guess this little ditty from this Week's New England Journal of Medicine explains the sudden internet frenzy for giant hairballs I noted earlier today. Again, yuck.

The Inevitable Thanksgiving How-To

This mornings New York Times online features a six-minute instructional video on Turkey carving. Good stuff for the perfectionist looking for "maximum yield" from the holiday fowl. This is the first T-Day how-to I've encountered this year, perhaps because we don't have a television, I spend most of my time trying to read all the stuff on my feed-reader, and reading medical journals. But I do listen to NPR, and those guys always do some cutesy bit, like the Mama Stamberg's nasty cranberry stuff made with soap residue and cat litter. I didn't hear any NPR odes to Thanksgiving food, but that's just because I missed them.

And I missed Martha, and Rachel, and Ellen...

Are people looking for instructions for a better Thanksgiving bird? Yes. A search on my new favorite toy, Google Trends, produced a nice graphic description of turkey cooking searches (seen at right, in real time), spiking on Thursday morning. Most of the "hottest" searches this morning have something to do with Thanksgiving (with the bizarre exception of #11, trichophagia...yuck).

So now I'm off, with Zoë, to do my own last-minute Thanksgiving shopping for stuff I could have bought yesterday if I'd thought it through. I'm making a spinach madeleine to take to my sister's house.

Dry

Thanks to all those who have offered sympathy for our water damage. We were proclaimed dry yesterday by the Wizard of Household Dessication. So we're back in our kitchen (sans floor, just particle board sub-floor).

We did enjoy touring some fun restaurants over the weekend, including Vio's on 19th: total kid chaos, by design.

Well, if he means all this, then I'm in

Another Gated Community

Here's another nice old house opting out of the neighborhood. Enjoy your isolation.

Screwed

Five days after finding a small leak dripping into our kitchen, this is what we've got. We've had plumbers and "leak finders" (think CSI, but better paid), insurance adjusters, and now "water mitigation" specialists. Three silent, serious guys showed up yesterday and started destroying my kitchen walls and floors. There was water places I could not have imagined. They left these droids to dry things out. Noisy droids. Like jet engine noisy. They'll be with us through the weekend, eating our electricity and heating our house to a balmy 85-degrees.

Meanwhile, we're exploring kid-friendly restaurants.

Water

I woke up this morning to the kind of noise that signaled something was not quite right. It was a clack-rattle...rattle-rattle...thwack. It repeated every ten seconds or so and was not associated with squealing, screaming, or crying. It seemed to be coming from the first floor, and was loud enough that I could hear it clearly from the third floor--and it woke me up. At 6:15am, which now was 5:15am, thanks to Ben Franklin and his daylight savings scheme.

There are a lot recognizable early morning sounds. This wasn't one of them. I got up to investigate.

I came downstairs to find Brooke putting bowls under drips and mopping water from the stove top (this was the noise that woke me), while Elliott, now about ten months old, made smaller clacking sounds with wooden blocks. Brooke introduced the scenario by saying "I know you're going to see dollar signs here," and she was right about that, but the first thing I saw was water pooled in the place I intended to make my morning coffee.

Boring story short, there is water leaking from someplace in the walls of our kitchen. All night it dripped through a ventilation hole into a kitchen cabinet, through the microwave, onto the stove, pilot lights, floor...and the wall behind the microwave and oven.

Last week my friend Dan showed me how turn off the water at the street, so I did that, and the leak stopped. Predictably, so did all the other water in our house. Called the builder, who said call a plumber and if it's he's error (and not a nail I put into the pipes) he'll cover it. Called Dan to ask for a plumber recommendation (now starting to see those dollar signs). Got one. He can come "after Tuesday."

So the water is off. The leak has stopped. And we're waiting to hear what Big Jim the plumber has to say about things. We'll get creative with dining, bathing, and washing clothes this week. It'll be a Trader Joe's microwave experience. We'll shower at work. Elliott can have a bath at daycare. Who knows where Zoe will get her grubby toddler self clean. We could hose her off outside, I suppose.

Good times.

Pirates!

We meant well. It's just that, well, we didn't know.

It's another beautiful July day in Seattle, blah, blah, and we ran out of things to do at home, so we decided to head out for a morning at the beach. Instead of the usual quick trip down to Lake Washington, I suggested that we head over to Alki in West Seattle. Better sand, salt water, marine air...and the pirates were coming ashore today.

Pirates?

Pirates. It sounded like fun. Summer around here means Seafair, a series of events, connected I-don't-know-how into a "fair" of sorts that seems to last most of the summer. We've experienced the events on nearby Lake Washington for several years--like it or not--since it's so close to home. Massive crowds gather for hydroplane races and the air show, featuring the Blue Angels and forcing the daily closure of the I-90 bridge (it's an interstate, and they close it) for about an hour to accommodate...something.

But then there are these pirates. I've read about them, seen them on TV (before we chucked it). They seem to be a group of fairly normal adults who dress up once a year as buccaneers and act like utter twats. We had something similar in St. Louis, where I grew up. The Veiled Prophet organization gave local businessmen a kind of annual costumed release from the bondage of their khakis and needlepointed belts. The big VP event was the debutante ball, at which the masked, heavily bejeweled (and presumably sodden) veiled prophet would welcome young, wealthy, white women into "his court of love and beauty." Not a joke. I went, several times. A willing participant. Filthy, sodden fun. Humiliating. Embarrassing.

These pirates seem less sad, somehow, and less evil. Drunk, yes, but they're pirates, so you expect that. And, to bring us back to the beach, they were scheduled to come ashore--raid the beach--this morning. We're early people these days, so when we arrived, there weren't that many folks around. Vendors seemed to be anticipating big crowds, though, offering ice cream, kettle corn, face painting, and pirate gear--tons of pirate gear. As we walked toward a sandy spot away from the band and the out-of-place pole vaulting competition (more medieval than pirate), Brooke asked "so what do these pirates do when they come ashore?" Good question. "Looks like they sell stuff."

I've heard the pirates used to be pretty out of control, and that they've reined it in a lot recently. A family event, and all that. I don't know how bad phony pirates can be--pretend pillaging?--but I'm kind of sorry to have missed out.

We found a spot in the sand with a view of the gathering "armada," several sleek sailboats flying the skull and crossbones, positioned about fifty meters offshore. The crowd on the beach was much more impressive--thousands of people with kids, dogs, coolers, umbrellas, blankets...and pirate gear. If it were pirates versus spectators, the pirates wouldn't stand a chance. Several of the more convincingly outfitted pirates milled around, making friends. I snapped a photo of Aussie-accented swashbuckler and a gregarious, hirsute Russian guy looking menacing a black hat-and-flag ensemble and Tony Soprano potbelly. In this photo I particularly like the disembodied hand flying the Motley Crüe sign--a gesture with inexplicable longevity.

At this point it was clear that we had made a gross miscalculation. It was a mistake to be here. We should leave. Zoë was behaving poorly and Elliott was tired, hungry, and poopy. We were unprepared. But the pirates were going to do this storming the beach thing and we've been in Seattle for seven years and not ever seen it. All these people were here to see it. It was going to be cool. Worth staying for. We would stay and witness this tradition.

The armada was growing, though it was unclear that these ersatz pirate ships would have the wherewithal to come ashore, much less storm anything. To the east, from Elliott Bay, came some cannon shots. The sloops moored before us had been firing rounds all morning, but these were louder. These explosions were coming from two mid-sized landing craft, steaming toward us loaded with pirates. Here it was. The attack! Everyone on the beach stood. Kids stopped misbehaving and ran toward the landing zone. Parents yelled at their kids to come the hell back, then ran off after them. Small-time thieves moved in to grab beach gear and wallets abandoned by parents chasing kids. The landing craft eased into the beach right in front of the giant inflatable pirate island cum kid playground. And I mean it eased in. Backed up. Re-approached. And the ramp...lowered...and...some...pirates...walked...ashore.

This was by far the worst pirate event I've ever attended.

Feeling duped and frustrated, we packed up our hungry kid and our misbehaving kid and walked down the busy boardwalk to our hot car. Along the way, I passed a sad-faced young woman with a bandana on her head and pirate makeup on. She was standing sullenly against a wall next to a similarly-costumed young man. She frowned and said to him: "I thought there would be cool stuff here. All I've seen is a bunch of angry parents."

Yup.

Happy Fifth of July

I took today off as an extension of yesterday's holiday--a mini-weekend right in the middle of the week. I started with Zoë's swim lesson at Safe & Sound this morning. I'm so proud of how brave she is in the water, especially putting her head under and jumping in--fearless. The goodbye was predictably tearful for us both as I put her on the school bus back to daycare. I suppose I could have taken her home and spent the day with her, if parting was so difficult...

Instead, I spent a glorious day with no children and no responsibilities. I ran two loops around Seward Park, bought salmon for dinner, blueberries, and mangoes at PCC, dropped my groceries at home and rushed out for an afternoon under the sun at the lake. Magnificent. My book and I had a fantastic time. My feet were having a great time when I snapped this picture, but if you ask them now, they'd tell you the time would have been a little bit better with sunscreen.

What did YOU do this morning?

So this was my morning. Two months ago I chipped my front tooth on a piece of mango and have been waiting ever since for the pleasure of an hour tilted back in a dentist's chair, blood pooling in my head, jaw cranked open and secured with a bite block, and a large rubber face condom attached I-don't-know-how to several of my teeth. I was like this for a while, looking out the skylight at...sky. I was sure my jaw had become unhinged and I'd have to spend the rest of the day waiting for an ER doc to give me enough ativan to manipulate it back into its proper place. I dodged that, but twelve hours later my jaw is still killing me.

The day got better. I went from the place of suffering to my clinic to work on a giant stack of charts that needed tending. For about two hours my face continued to be totally numb (I had some fillings replaced too), and I was sure that I was drooling like an idiot while I worked out care plans for patients from the day before.

I spent the early part of this Tuesday afternoon in a weekly lunch meeting, followed by a discussion with classmates outside by the Seattle U fountain. It was a bright, sunny, warm day and I could once again feel my face. Just when I thought things couldn't get any better, they did. Our afternoon didatic session go canceled due to who-cares-why and I was sprung. I took advantage of this found time by going for an hour-long run on Lake Washington.

Tonight we had some friends over for dinner out on the driveway patio. I'm starting to embrace the driveway more as a legitimate outdoor pastime. We still need plants out there, but I like it.

I'm headed for bed and a gram of tylenol. Reveille at 0530, I'm sure.

Saturday in the Park

Saturday was brilliant. The nicest day of the year, meteorologically speaking, and a day off for me. A predictably early morning--5:30a, I think. Zoë has learned that getting out of bed, opening her door, and coming upstairs to flail around in bed with her parents guarantees her the attention she wants. We've set a 6:00a alarm for her that plays beach surf sounds. Our agreement is that she can come upstairs when she hears the ocean. I'll have to check for conch shells in her bed, because she seems to be hearing the ocean earlier every day. Could be the 5:15a sunrise...

An early-morning trip to Seward Park for a quick walk around the point became more like an expedition. The parking lots were full of cars belonging to people training with the Leukemia Team in Training, so we found some nearby street parking. I forgot the front wheel of the stroller (a Burley bike trailer with stroller conversion--useful if you remember the parts), so we pushed it for three miles on two wheels. Not as bad as I thought, since neither Zoë nor Elliott would ride in it. Zoë was a very big girl and walked most of the way, first running, then walking, dawdling, and flat out refusing the move. Remember that weak, floppy feeling you got when your mom took you shopping? She had that. Eventually we got her back into the stroller with most of her clothes on backwards and made it around the loop in time to get home for lunch.

Just as we completed our walk my pager went off. I've got three moms-to-be due this month, so I've been anticipating the whenever page. A call to triage confirmed that one of my patients, a 24 year-old Vietnamese woman in her first pregnancy, had ruptured the night before (her water broke) and she was being admitted to labor & delivery. She wasn't particularly active in her contraction pattern and my on-call colleagues can handle anything, so I figured I could count on some more family time.

Home, lunch, book for Zoë, nap (for everyone), then that sleepy indecisiveness about what to do with the afternoon. We'd planned to go to Coleman Pool, the outdoor, heated, salt-water pool in West Seattle's Lincoln Park, but with a laboring patient it seemed like a bad idea to be that deep into an activity. We decided instead to explore the new wading pool on Capitol Hill (I could walk to the hospital if called in). That's where I took the picture of Zoë. It's an amazing place. A pyramid of cascading water feeds into a fast-moving chute, eventually spreading out into a lazy trickle down a cobblestone-studded slab. Adjacent is a huge, warm, wading pool, well-populated with kids and probably full of urine. But whatever, it was beautiful Saturday and every kid deserves to swim in a little pee on such a day. We hung out there for a couple of hours, playing in the pee, watching the capoeira dancers do their thing, the guys tying one another up in preparation for some performance, apparently, the parade of man-kilts, tattoos, piercings, musicians, lost children, and lost adults. Pretty great.

Home, dinner outside on the "patio" (our driveway) Brooke's newest bid for some outside space in our city townhouse. She has created a magical little world where we usually just park our car. I put Elliott to bed and then decided it was time, at about 7p, to head in to the hospital.

My patient had been making great progress all day, contracting and painfully dilating all day while I splashed around with my daughter in the pee-pee pool. By the time I arrived, it was just a waiting game. I worked on some admin stuff while I waited, chatted with the nurses, fellow residents, and Carroll, my attending. Eventually, we focussed on the birth event: ninety minutes of pushing resulted in a charming little baby boy. Some stitches, a lot of documentation and orders, then home. Asleep at about one o'clock.

My only regret is that I didn't get a beer on such a lovely day. I'll fix that today, unless the pager starts going again.

Resumption

The cycle now moves back into writing. I've been reading an eye-opening blog by my friend and colleague, Mary Wierusz, about her experience doctoring in Kijabe, Kenya. She'll be there with her husband, Mike, for a month, and will, I hope, post frequently. It has inspired me to put my own thoughts down--though the experience doesn't compare.

It's 7:30 and I have lots to do to get myself out the door and on my bicycle to clinic for a morning of gynecologic procedures, so I'll leave this post as a marker and return for more later.

Not my best day

It started out pretty well. Zoë was up before 5am crying nonspecifically, but I managed to get her back to sleep until 5:30, which is my typical wake up time these days. She re-woke sweetly with a "Daddy, I'm ready to get up now." So we did. She played while I readied myself, then we came downstairs for the usual routine: coffee, cereal, the drawn-out cereal-or-waffles decision, and feeding of the impatient animals.

Then, at about 6:15am, the pager. I figured it was an obstetric patient in labor, but that didn't make sense; I'd be there in a half-hour anyway, so why page? Bad news. The patient whose baby I had delivered last week was in the intensive care unit: unresponsive, intubated, unstable. Two minutes later I was in the car, fearing the worst.

Briefly, my patient delivered a lovely baby boy last Friday evening. The labor had been complicated by some high blood pressures and extremity swelling, causing us to evaluate her for pre-ecclampsia, but the tests were negative so we elected to press on with a normal delivery. I had to use a vacuum to get the baby out, in the end, but all went well...until yesterday.

At risk of blathering on, I'll just say that headache and leg swelling got worse, and by early this morning, she was also febrile and in severe respiratory distress. ER, intubation, ICU. My colleagues were just finishing up her orders when I arrived.

Moments like this make me wish I was doing almost every job I've ever been fired from. I had no words to comfort my patient's husband, and no idea what had gone wrong in the thirty-six hours since I'd last seen my patient. I'm again at the moment of blather, so I'll rein it in.

Her picture looks a lot like pre-ecclampsia AND some kind of infection--certainly something with a big respiratory hit. We don't much like AND kinds of pictures in medicine; they disturb our desire for parsimony. We would much prefer to say that one thing went kerflooey and spoiled a bunch of other things that were going well. In this case, it appears to be a couple of inciting events.

The good news is that she did well today, all things considered. She did not die. At 7am, that wasn't so certain. She's sick. I'm hoping tomorrow morning to see a little improvement.

I have rarely felt worse than I did this morning standing at my patient's bedside in the ICU, wondering what I could have done to keep this terrible thing from happening. I don't ever want to feel that way again.

I stopped on the way home for a bit of Irish whiskey (the Protestant variety, after some debate), perhaps as a way of escape, as my theatrical training would suggest, or maybe to commune with my father, who would know what to say to me now if he were here. Turns out Brooke knew what to say. So did Zoë: "Daddy!!"

It is approaching 10pm, and I'm to be up again early. I'm off to bed once I set up the coffee maker and put a pill in the stupid cat's throat, but I needed a moment to reflect on the day. I'll go read myself to sleep now with a review of the blood supply to the cerebellum in my old clinically-oriented anatomy book.

Tomorrow will be better, right?

Lunchtime. Seventy degrees.

Sunday

Sunday sucks. Unless it doesn't. This one--today--is shaping up pretty well. We turned the grocery chore into a fun trip for Zoë and me, then met with Hilary, Dan, and Felix at the Mt. Baker playground. The playground became packed, so we walked down the hill to the beach and sat for a while in the sun while Felix and Zoë wandered near the water. I've never really spent much time on this beach. When the weather is beach-warm this place is packed, and we usually seek a little more space and quiet, either at the adjacent Coleman Beach or under a big, shady tree at Seward Park. But today was just almost warm, so we had the place to ourselves.

Felix and Zoë contemplate a swim

It got close to lunch-and-nap time (for everyone--maybe Sunday doesn't suck), so we walked back up the hill and headed home. Three-quarters of the humans are now up from nap and contemplating next moves. I'll take Zoë for a run past the same places we spent the morning and Brooke will take Elliott and Yagi out for a long walk, IF Elliott ever wakes up from her nap.

It is sunny and 64 degrees out.

I used to fear Sunday. The last day of the weekend. School tomorrow. I was almost never prepared for Monday, academically or emotionally. Now I quite enjoy most things about Sunday, except the endlessly-expanding white board task list dogging me. If anything on the list of chores can me made fun (like the grocery this morning with Zoë), it goes a long way to keeping my mood happy.

I've also been experimenting with a new method of checking off tasks from the white board: I erase them. You'd think a chore undone would lead to an adverse consequence. Well, no. I haven't noticed a problem yet. I'll report again later on this experiment in doing less.

Well, Elliott may be stirring now. Yes, she is. Mewling, even, so here I go, back to the day.

And my white board is mostly blank.

One of us forgot his house key

We may be stuck outside in the rain, but I can still post. If only someone with a key knew...

Look, no biting!

Well, not for the moment, at least. But watch out.

I didn't have time to go for my camera before this moment disappeared, so I settled for this with my phone.

It'll haunt you, too

Probably Free to a Good Home

Probably free to a good home
(20th & College on Beacon Hill)

Paternity leave, Day number I'm not sure anymore. It's not such a lovely day today as it was the last two (70s-80s, sunny, mountains out...), but still the outside was inviting, so after two cups of strong drip coffee I strapped Elliott to my chest, put a leash on Yagi, and headed out for a walk around Beacon Hill. Our destination was, bien sur, Galaxie, but the route was to be improvised. I've not yet walked through that neighborhood, and was quite pleased with the sights. There are great views of the mountains and across the valley to the Mount Baker neighborhood. The housing in dense and old, mostly. Lots of old craftsman homes from the 1920s, many are well-maintained, but there are a few that need some love. There are also a bunch that qualify as tear-downs.

We wound our way up the hill, following interesting sights and quiet streets on our way to the coffee shop. I spoke with my mom for a while while we walked, and she told me of her afternoon yesterday with Zoë, who is visiting St. Louis with Brooke this week.

Galaxie was packed. I hooked up Yagi out back next to a woman eating her breakfast. He begged until she gave him a piece of sausage. I got coffee--it takes me two at home plus a double-shot latte to get to "normal" these days--and talked with Woody a little about the benefit they're having tonight--wheelchairs for someplace in South America. Galaxie would be a great place for a party (and has a liquor license, which helps), but I'm not looking for a place to host anything these days.

Coffee was to go today, and we set out down the hill by a new route, admiring the sights and looking for the worst houses on great blocks, a buying strategy I'm obsessed with lately, though it will be another fifteen months or so before we're looking for anything. And who knows where we'll be looking?

It rained lightly as we neared the bottom of Beacon and entered the roaring Rainier Valley. It felt nice, the rain, and I let the drops fall on Elliott's head so she could appreciate them too.

We were out about an hour and a half, home just in time to feed Elliott and beat the heavier rain. Now all the critters are asleep but me. I would be too if I were smart, but I'm glad I stole a few minutes to write about our morning.

I love spring in Seattle

Snapped with my low-res phone and posted on the spot (this text added later) on a long walk through Madrona, along Lake Washington Blvd, and into the steep trails of Frink Park, then home via the ridge along 31st near our old home on Norman Street.

Sunny sunday.

Movin' On Up

Many thanks to Hammy over at Ham Salad, one of north shore Chicago's bestest strings, for adding this admittedly inelegant title to the Must Read list. You'll find the Salad on my own Read This list, too.

Algorithmanic episodes

Jerome Groopman has been all over NPR the last few days giving interviews about his new book, How Doctors Think. This morning he landed a seven-minute session on Morning Edition, and recently spoke at length with Terry Gross on Fresh Air. The book sounds like a well-constructed inquiry into the algorithmic processes of doctor think. How do physicians make sense of patients' stories and arrive at a diagnosis?

Or a mis-diagnosis. Groopman discusses the experiences of physicians and patients--even his own experience as a patient, to point out where doctor think goes wrong. The diagnostic process, relies on information from the patient about symptoms, personal and family history, risk factors. Doctors then collect relevant "objective" data (physical exam, labs, studies), and assemble a list, or differential diagnosis we think might explain what the patient is experiencing. Ideally, it's an exhaustive list, and we narrow it with directed studies to rule things in or rule them out. We work hard at it, but for various reasons we don't always get it right, and the consequences can be severe. Dr. Groopman explains to Steve Inskeep on Morning Edition:

"Usually doctors are right, but conservatively about 15 percent of all people are misdiagnosed. Some experts think it's as high as 20 to 25 percent. And in half of those cases, there is serious injury or even death to the patient."

Why do you think that doctors would be wrong that often?

Well, you know, it's very hard to be a doctor. We're working under tremendous time pressure, especially in the current medical system. But the reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab. Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.

We use shortcuts. Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what's wrong. And too often, we make what's called an anchoring mistake — we fix on that snap judgment.

An anchoring mistake? Sounds like what my people call early closure, a very common problem. Making big differentials is hard, and many things influence how quickly we decide we know the diagnosis. Often, it just seems to fit...mostly...more than other stuff. But is our list comprehensive? Did we consider only common diagnoses? Is is time to trot out the rare, eponymous syndromes we memorized in med school but have never seen? Deciding early to attach a diagnosis to a symptom feels good, especially when there are other patients with symptoms waiting to be seen.

There's something about categorization that appeals to me. Calling something anchoring mistake, when you could just as easily call it laziness, gives me a kind of hope. If I miss a diagnosis and because I'm lazy and the remedy is to "try harder," well, I'm screwed. The problem and the solution are both pretty vague, and my fear around messing up again takes over. Fear motivates, for sure, but I would argue the outcomes aren't so great.

If I can categorize my apparent laziness with nifty terms like anchoring mistake (in which I make a snap judgement) or representativeness error (wherein I tell myself that common things occur commonly), my type-A doctor mind has something productive and familiar to do: memorize a list. In this case, knowing the ways my thinking might not serve me well helps me see potential pitfalls in diagnosing and treating--also known as helping--patients.

I haven't read the book yet, but I will. I did, however read Dr. Groopman's article from January 29, 2007 in the New Yorker. The writing is excellent and the examples compelling. If the book is anything like the article, I'll be reading all weekend.

Match Day

The Seattle Post-Intelligencer got it together enough yesterday to show up at the UW School of Medicine Match Day event over in Montlake. The article is a reasonable account of how things work, but I was surprised at the severity of the language describing the experience of medical training, both in school and residency. Some examples:

"The Match" -- a high-anxiety cap to the end of a grueling four-year medical education -- will determine their professional futures, not just where they will live for the next three to seven years, but what specialty they will pursue.

There's a buzz going on, but the excitement has the tamped-down quality of people who have learned to manage anxiety to survive the rigors of clinical rotations, being called out for not knowing answers during rounds and monster exams.

There is recognition, too, that as hard as medical school was, residencies, renowned for their brutal on-call schedules, can be even harder.

Well, that all sounds quite difficult, doesn't it? True, medical training isn't easy, but it's not Darfur. There's a language tossed around in the press that creates this mystique of systematic torture by drill-sergeant faculty.

The UWSOM event is quite informal: lots of milling about, tamping down anxiety and eating dry pastries until the envelopes are distributed. You can open your envelope when you want and with whom you want. Some schools parade students in front of a crowd to read their "fate" for everyone. Check out this video from yesterday's University of Cincinnati Match Day event.

I would rather die than participate in that. Sorry, Shannah.

On the residency end, we go about our business on the morning of The Match and wait for a mid-morning page with the list. I got the page as I was strolling home from my massage through a sunny Seattle park. Quite a different scene than in Cincinnati or even at here at UW. I was thrilled with how we matched overall and especially at my beloved Downtown Public Health clinic.

Back to my brutal schedule--last legitimate day of vacation.

What the fe-mail-man brought

Turns out Day Six of "24" is out on disk, the first four episodes, at least. Guess i have my evening planned. Please be wrong, Melanie, please be wrong.

March in Seattle

Out walking this morning I tried to capture these brilliant yellow blooms with my low-res camera phone. Not too impressive, but also gives me an opportunity to figure out how to post directly from my phone.

More vacation

Last week when we decided to chuck the travel plan for this week, I was warned to avoid letting a week at home--on vacation--become a week of chores. Yesterday got a little bit chore-heavy. I like getting things done, perhaps because I like checking things off lists. Actually, I like having things done and making lists, but that transitional period of doing the things on the list...well, not so much.

Yesterday there were a couple of things on the list that I felt I had to do. We got rid of Brooke's desk the other day--gave it to Hilary and Dan for their new house--to free some space for a crib, glider, and changing table Brooke picked up on craigslist. Those things go into the current guestroom, soon to be Elliott's room. The desk is gone, and all the stuff that had been in the desk was on the floor, waiting for me to sort through it. What a lot of junk: about 75% of it went straight out the door, either to the garbage or to Goodwill. There is still some stuff there that I couldn't part with (but should). I created a defer decision pile and made some lame excuse to Brooke for why I couldn't deal with it that moment. She didn't buy it, but she didn't call me on it, either. So there it sits. Overall, I did not enjoy that chore.

Next on the list was to return a bed to Ikea. Brand new and yet-unassembled (but out of the box), we slogged it down to Southcenter (big box retail hell) to get it out of Elliott's room. That was the second unused new bed we unloaded this week. Ikea gave us store credit, since we were beyond the return period and didn't have a receipt. We walked around the store for a while and found some more crap to bring home to replace the stuff we spent the morning purging. New crap, though; the other stuff was old crap.

On the way home the first thing we did was get lost. Happens every time we go to Big Box Hell. After a slow tour of the Valley Medical Center parking lot, we inched onto the freeway and eventually onto the I-405 HOV lane, which moved at about 60mph while the other three lanes literally sat still. Traffic was miserable all over due to accidents and a big police foo-faa over a stolen car.


I hate car life. I would prefer to walk or bike or bus or run everywhere I need to go. But...but...you know I'd like to say now "that's just not practical." But...it IS practical. As Bus Chick points out every day, we've got great public transit. I could easily take Zoë around town on my bike, and the trip from here to daycare and work is all on trails or wide, dedicated bike lanes. And I've demonstrated to myself that running is feasible, having commuted that way nearly all of last year. But then I got a car. Terrible idea! Immediately I started driving, taking advantage of the free parking I have at work and the ease of just getting in and going. I've paid the price with ten pounds gained and physical fitness lost. If I can park a car at work, I can also park a jogging stroller.

Just takes a little planning, which will be easier when I'm not so sleepy all the time. Any day now, I'm sure Elliott will just sleep right through the night. Any day.

Vacation

I'm off work this week. It's good. We thought about going away for a few days, renting a cottage on Whidbey Island or Hood Canal. That would be good fun, if it weren't for Zoë and Elliott and their dueling sleep schedules...well, their awake schedules, I should say. It's bloody exhausting. Weekends turn out to be pretty hard, and three days in a cottage, even in a lovely setting and even with a hot tub, would have been less like a vacation than like work. The alternative was to stay in Seattle, send Zoë off to day care in the morning, and enjoy life with one very portable infant. We can take naps, write, go for walks, get massages, all thanks to the happy two-parent-to-one-child ratio we used to think was so hard. Yesterday we called Sam to babysit for the afternoon, then headed out for lunch at High Spot and a walk. No nap.

Last night, we gave Elliott a bath, which I videotaped and and might post if Brooke can get over thinking our children will end up like the Star Wars kid or that poor Numa Numa Dance fellow. I don't see it happening with the bath video, but maybe with Zoë's "Shake Your Booty" song.

Also last night we completed season five of 24. I love the series, and season five was great, especially Gregory Itzin and Jean Smart as the president and first lady. I've now seen the whole thing through last season, and haven't a clue what has happened this season. I'm pretty sad to read that Melanie McFarland, the most trusted hairdo in TV reviewing, isn't "feeling it anymore." It will be a while before I can start in on season six. What'll we watch next? Back to Entourage, perhaps, so I can dream of being a movie star.

This morning I got in a good long walk with Yagi. Through the I-90 walking tunnel, down to the lake, and along the water while Yagi swam and carried big sticks. I'm off now for a haircut, then to pick up Zoë. Again, no nap. What the hell is going on here?

It's a nice pace. Next time maybe we'll go for the cottage.

Patient Satisfaction

Every once in a while, the topic of patient and physician satisfaction shows up in the press, usually following publication of research or polls. I'm interested in what contributes to satisfaction in the patient-doctor relationship, though I'm not convinced that we need to be satisfied to have our needs met. Or, put another way, offering the best and safest medical care may not always satisfy my patients--or me. There is a lot of research about satisfaction, but no clear evidence that satisfaction matters. It is assumed to be its own valid outcome, though it is hard to measure reliably. There are a couple of fun satisfaction items that have landed in my Google Reader recently.

Yesterday I ran into this Annals of Internal Medicine study on management of patient expectations. The investigators audiotaped 200 medical visits and documented what patients wanted, then asked them later how they felt about the visit. It turns out that 97.3% of pre-visit expectations were at least discussed during the visit. How did these expectations come up? Forty percent of the time patients brought up directly ("I would like _______." Good, solid communication). Thirty percent of expectations came out by having patients mention symptoms. Also good communication; it's my job as a doctor to help people make sense of their symptoms. More than a quarter of expectations came out through "physician-initiated discusson." I'm not sure exactly what that means. Would patients never have mentioned these things if the doctor hadn't chased after it? Or did the doc just get there first? Thinking about this would get me way off track, so I'll drop it.

Regardless of how things came up, expectations were met around 67% of the time, and where doctors weren't comfortable, they did the right thing and suggested alternatives only around 22% of the time. I guess the rest of the time they just said: "Uh, no."

And what about satisfaction? "Patient satisfaction and trust remained high, regardless of whether expectations were met." So what can I learn from this study? Should I worry about what patients expect? If expectations aren't related to satisfaction, well then what is? And does satisfaction matter? I know plenty of people who aren't satisfied with their doctors, but they keep going.

Item number two showed up in Family Practice Management's March News & Trends, reporting on a Consumer Reports survey. I've pasted the clip in green below with my comments along the way.

The good news for physicians: The overwhelming majority of patients said they were "highly satisfied" with their doctor and that their health improved under their doctors' care. In addition, 77 percent said their doctors treated them with respect and 67 percent said they were patiently listened to and understood.

Already this seems more useful than the Annals piece, as they ask whether patient health actually improved. I'm also happy CR asked about respect, but shocked that so few doctors listen to and respect their patients. CR presents this under the good news header!

The bad news for physicians: The majority of patients said their doctors never talked to them about the cost of treatments and tests.

I hate talking money with patients, and frankly feel ill-equipped to do it. I know tons about tests and treatments, but very little about what they cost. My ePocrates handheld reference gives me some info, but I can't predict what insurance will cover and at what rate. I saw a patient in clinic one day with chest pain. It wasn't his heart, but when I shared with him some chest pain (i.e. heart attack) warning signs that should prompt him to call 911, he began to quiz me on on the costs of ambulance transport and emergency care. I had no idea what to tell him, and felt bad about it. I know money matters, but I just don't have the answers.

In addition, patients had these complaints:

• 74 percent said their physicians had not asked about emotional stress.

• 24 percent said their physicians made them wait 30 minutes or more.

• 19 percent said they couldn't get an appointment within less than a week.

I cannot believe that there are still non-surgeon physicians who don't ask about stress. The second two complaints above are systems issues, and inexcusable. I think making patients wait around to see a doctor demonstrates a real lack of respect for the value of their time. Patients don't have all day to hang out in clinics, waiting to be seen. Also, having to wait a week when you're sick or when your kid is sick and you're worried is just plain wrong. Who wouldn't go to the ER under those circumstances? Same day or next day access isn't that hard to provide; we should be doing it.

Patients weren't spared from the criticism, however. The most common complaint, shared by 59 percent of the physicians surveyed, was that patients don't follow prescribed treatments.

Sure. But I haven't done my back exercises in months, so I get that it's not always easy to do what you're told, even when you know it will help.

Other physician gripes included the following:

• 41 percent said that patients wait too long before making an appointment.

Or are they just waiting for their appointment?

• 32 percent said patients are too reluctant to talk about their symptoms.

Except emotional stress, which we don't want to talk about.

• 31 percent said patients request unnecessary tests.

Bloody internet.

• 28 percent said patients request unnecessary prescriptions.

Bloody advertising. In this case, I refer back to the Annals paper, which reminds us that it is important to negotiate with patients. We shouldn't offer wasteful or harmful interventions to patients, even if they want them. We should offer alternatives that address patient concerns and hopes.

Two more publications on satisfaction, and I still have no good idea about it's value, or even what it really is. I do know there is value in listening and respecting patients, getting them in when they need me and seeing them on time. And I'd like them to feel healthier.

But satisfied?

Pain on the Brain

Recently, my residency program has been working on how we help patients with pain. Honestly, some of this comes from the great frustration the doctors and staff at our three clinics feel with "pain patients." It feels like patients with chronic pain take up a lot of our time and energy, and we end up not helping them very much--they still have pain. Stuck in our doctor brains is the notion that if something is wrong, we should be able to fix it, or at least help patients fix it. So when things don't get better--the pain is the same or worse--over months of treatment, we get frustrated, and so do our patients.

One of the most difficult issues revolves around pain medications, specifically narcotics. Treatment of chronic pain with opioids (commonly vicodin, percocet, oxycodone, and methadone in our clinics) has a long history, and opinion about its value and safety seems to swing like a pendulum. In primary care settings, the pendulum has swung into the "avoid narcotics" zone over the last several years. There is a lot of well-founded concern for the long-term safety of narcotics, and for the harm we do to patients by creating dependence on these medications. But that's not what really makes us uncomfortable.

It's a trust thing. Misuse of narcotics--overuse, diversion--is a reality, and doctors are justifiably nervous about the possibility that the potent medications we prescribe might be used to feed addiction or for monetary gain. There's good evidence that this happens, even among patients we believe to be using narcotics appropriately. We can't be sure, and we're not comfortable with a sham therapeutic relationship.

Unfortunately, that anxiety about trust sets up a difficult relationship with patients when they come to us with pain. When I hear a patient report low-back pain, my differential diagnosis always includes inappropriate drug-seeking behavior. There is no other complaint that sets off these kinds of alarms. I find that when this suspicion come up, I might test a patient with a few non-narcotic suggestions, like physical therapy, but these maneuvers only contribute to the discomfort and don't clarify anything. Worse, failure to embrace physical therapy as the best idea ever and suggest, perhaps, a short course of vicodin ("I had some left from a procedure and they seemed to help") puts the patient at risk of being branded as a drug seeker--the pseudo-addict.

All of this has been stuck in my sleepy head recently as I've done this narco-dance with a few new patients and worried a lot about how to wean the few patients of mine who take opiates chronically. The residency pain task force is doing it's thing, and will certainly produce some helpful resources for my patients, but I'm not good at waiting, and the folks I care for have pain now.

A couple of weeks ago I put together a five page "Menu of Treatments for Low-Back Pain" for one of my patients. I had hoped to use some chronic disease management techniques to create a plan with her that would be as transparent as possible. I created the menu from the collected works of the Cochrane Back Group and offered it to her as a way to start us both thinking about how to help her to a tolerable level of pain. The menu concept is popular in managing chronic diseases like diabetes and hypertension that require patients to change behaviors. It gives people options and lets them choose what they think they can do. It is important to build the menu around goals--another chronic care pillar--and so we spent some time discussing what she hoped to accomplish regarding her pain. I thought it went well.

Mind you, in several visits we haven't touched on her hypertension, diabetes, or hyperlipidemia. And I haven't gotten close to talking about preventive care: pap smears, osteoporosis, etc. Missing these things is another hazard of chronic pain.

Okay, so I started this not to whine but to describe a chain of events and some hopeful developments. The back pain menu was a nice little organizing moment for me. There are heaps of options for patients with pain. For any given intervention, the data might not be thrillingly positive, but most of them work for somebody, and in combination, I have to believe that we can find a way to decrease pain.

We've also got resources in our own clinics. Like chronic disease management techniques, cognitive behavioral therapy techniques have a place in the management of chronic pain: one's process of thinking-feeling-behaving is vital to one's experience of pain.

As an exercise in organizing these ideas into a practical approach, I'm working on a web-based collection of resources. The Pain Page will catalog evidence-based interventions for pain, local resources, patient perspectives on living with pain, media coverage of related issues, and how our work as physicians and patients relates to regulatory bodies.

I hope this will help my colleagues, patients, and me build together a transparent and effective structure for collaborating on a problem we all would like to handle better.

Galaxie

I have two daughters, ages 2 years and 2 months. Brooke and I live in moderate-to-serious chaos most of the time. When Zoë (2 years) was born, our social lives sort of disappeared, as did pursuit of things like exercise, backcountry travel, and consistent sleep. We got some of that back over two years, then it all went to hell again when charming Elliott appeared on the scene last December. Two years ago I would say to close friends, "I just want some tiny piece of my life back." This time around I don't entertain that same wild idea. No desire, no suffering.

And then yesterday, out of nowhere, this great experience came up. The four of us headed out on Saturday morning to the Galaxie café, a Beacon Hill coffee shop opened recently by our neighbors, Yen and Jeff. The place is great! It was quite lively, good coffee, pastries. The sandwich menu looked fantastic. But don't take my word for it, read the P-I review. There were also a bunch of kids there, and Zoë had a great time with the other kids and toys.

The interior walls are decorated in Beacon Hill murals, and the entire south wall is a building-by-building map of the neighborhood. Local customers can put a pin in their house--and there are quite a few pins. We called our friends, Sachi and Travis, to walk down and join us. They did, but I don't think they put a pin up. Next time, perhaps.

Best of all, it was a chance to do something social--in public--as a family. Brooke and I never really got to hang out in cafes much together before we had kids, which I kind of regretted. Now we can. And we'll be back there next weekend.

OB-RAMA part II: Noon - 5am

My last post got a little long on the details of fetal heart tones without actually saying much. This account of the rest of last Thursday (and Friday) will be mercifully thrifty...you hope. After delivering one vacuumed baby on Thursday, I found myself with a dilemma. I'm supposed to be on a General Surgery rotation this month, but my OB patient was a priority and I missed the morning. Missing the 5-7am portion of the GenSurg day is like missing most of anybody else's day--the rounding and planning all happens then so the surgeons can get to the OR and do what they do. I'd missed rounds and a considerable amount of loitering, but there was a noon morbidity & mortality conference beginning just as a wrapped up my post-delivery work. I like the way surgeons do M&M, and lunch was provided, so I went.

Maybe a mistake, looking back.

I discovered that I was to be "paired" with one of the interns who is also a medical school acquaintance of mine. Let's call her Tatum, which happens to be her name. I wasn't thrilled about being teamed up with Tatum, or with the idea of "shadowing" an intern at all. I've been an intern, completed my internship, and enjoy the rhythm and responsibility of my second year much more. Interns have crappy hours and few choices. Surgery interns have horrendous hours and buckets of scut packaged in an oppressive hierarchy. It's not my world. I'm okay visiting for a bit, but not so much with Tatum as my guide. But what can you do?

I got a brief explanation of the team structure from Tatum and an offer to go to the OR to scrub for a case. I declined, thinking I'd rather spend time learning about the patients on service. I'm also just not that interested in hanging out in the OR holding retractors. Instead, I familiarized myself with the in-house patients, returned to my postpartum mom & babe duo, and did some paperwork. Tatum and I had divided up her patients among us for the morning--I was to see half of them (about six) before 7am.

At about 4:30pm Brooke called to see if I could pick up Zoë from daycare on my way home. I said yes and made one last call to clinic to check in. Our nurse there told me that another of my pregnant patients was having contractions and was on her way in. It doesn't take long to assess whether a woman in active labor and needs to be admitted, so I walked up to OB Triage to wait for her. Annabella (not her name, but the surgery intern is definitely named Tatum for real) arrived a few minutes before 5pm. She was still shy of getting a room by my evaluation, but I thought she would be in active labor after a couple of hours of walking, so I sent her out and picked up Zoë as planned, knowing I'd be back shortly.

My colleague Sharon examined Annabella when she returned, determined she was "active" and got her a room. I was back before 8pm, and based on my exam, I calculated that she might deliver at about 2am. I'd be there until 3am, at least, and had clinic the following afternoon, which I don't like to cancel. Based on that, I figured I should do something about the morning (rounds and retractor holding), which might be my only chance to sleep, keeping in mind that at 7am I'd be over my duty hours for patient care, with at least ten hours of care still scheduled.

As an R2, I have a variety of responsibilities and frequently have to prioritize them in unfortunate ways. Occasionally clinic gets canceled due to a delivery. Everything can get canceled if I'm "goated" to fill in for a colleague who is unable to work. In this case, I was looking at three responsibilities, a duty hour conflict, and no sleep for nearly 40 hours. It didn't take long to figure out that if something was going to go, it would be "shadowing" a surgery intern for the morning and doing half her scut. Even if it were an intern I wanted to hang out with, I'd have made the same choice.

Here's what I did. I paged Tatum at home to let her know that I'd be up all night with a delivery and wasn't planning to see her patients in the morning--apologies. No skin off her nose, I figured: she'd be rounding on those patients if I weren't "shadowing." Shortly after I sent my text page, Tatum paged me back with a number. I called, and spent the next fifteen minutes listening to poor Tatum go on about my priorities and my work ethic, asking me what I intended to get out of my GenSurg rotation and grilling me on where I'd been all day.

Was she fucking kidding?

She wasn't. I'm not one to pull rank on anyone, it's not really what my people do (my people are family doctors, not surgeons). But holy shit! I couldn't believe this intern was giving me the third degree about my work ethic. I was at work. She was home eating pudding pops for all I know. After several minutes of actually indulging her line of questioning, I stopped and said, "Tatum, why are you giving me a hard time about this? Have I created some new work for you?" No! She's frickin' lazy and was pissed that she wouldn't have me around to do half her work for her. Argh.

That got me pretty riled, and I stayed that way for a while. I got it together for the delivery, though, which didn't happen until after 3am. Like the delivery the morning prior, it required a vacuum, but unlike that one, I figured out the vacuum myself. One pop-off and then a smooth delivery on vacuum attempt #2. Minimal tearing. Healthy mom and a healthy baby: that's pretty much my whole job.

I was done with the post-partum paperwork at 4am, and was on my way home when I decided that I would make one gesture to Tatum and anyone else on the surgery team that would call me weak and lazy for cutting out on a morning of doing someone else's busywork. I rounded on the damn patients from 4-5am, wrote notes, and sent Tatum a dawn page letting her know I'd done some of her work and that she should not ever put us through such an annoying conversation again.

That was 5am, which brings me to the end of the story, basically. The rest is pretty boring. I slept some, rounded on my moms and babes in the hospital, and spent the afternoon in clinic. It's now Saturday night and I'm off until Monday, when I'm back on the General Surgery team and will either face a hostile crowd (for being lazy & weak)...or no one will have noticed my absence.

OB-RAMA: Thursday, 4:30am - Noon

Last summer I posted about a long day (or two) of continuity deliveries (meaning my own pregnant patients laboring & delivering, as opposed to someone else's patients). I had another extended day of moms-to-be becoming moms this past week.

I woke up, sort of, on Thursday morning to my pager doing the single-beep-and-vibrate thing at about 4:30am. It was my colleague, Jessica, holding down the inpatient service on nights (I was on the week before). She had one of my two post-dates patients in triage, in labor and in pain. She was moving over to a delivery room. I told her I was on my way, but that I'd be moving slowly. And I did. Move slowly. I think I fell back to sleep for a bit, then got in the shower, tossed on some green scrubs, and headed out. I felt a little bit guilty leaving Brooke to wrangle both Zoë and Elliott, but what could I do? It's my job.

My patient, let's call her Frances, was dilated to 8cm when I arrived at the hospital, but the baby was still high in her pelvis. She had an epidural block, so she was comfortable, but neither she nor her husband could really rest, for they were both nervous and excited about what was happening. I got a little nervous too when I saw the fetal heart tone strip, which showed some prolonged rate decelerations, indicating that the umbilical cord was being compressed with each contraction. Decels themselves aren't alarming, and the cord compression variety are fairly benign, but these things were going on for longer than I would like. I chatted with my attending, Jay, about my options for managing this situation. He reminded me that in general there aren't that many options for managing labor, which is both a blessing (fewer decision to make) and a curse (in medicine it's nice to have options). The basic choices here were to start an amnioinfusion (put some saline into the uterus to create a bigger pocket of fluid around the baby) or do nothing. Amnioinfusion is one of those interventions that the evidence says doesn't do a whole lot of good in most situations but is fairly harmless. If these were actually cord compressions, it should help. So why not try, right? I also took a moment to curbside an obstetrician, who helped me feel better about infusing.

It helped! She labored on with a happier strip and eventually got to full dilation (10cm) and the baby descended nicely. Time to push, which she did, with coaching, for about an hour before the decels came back. Again, not terribly alarming, but we thought we'd feel better if we could just deliver this baby into the world and free her from being compressed every two minutes--clearly she did not dig the squeeze. Jay and I talked about a vacuum assist and got the OB involved to help with placement, as the baby's head was still a little high. A novice with the vacuum, I got two attempts (or "pop-offs"), then, by previous agreement) handed the vacuum over to more experienced hands. Frances pushed and we pulled and out came a lovely baby, who immediately enjoyed the change in atmospheric pressure. With nearly all vacuum-assisted deliveries, there is some tearing of maternal tissues, and this was no exception. A few stitches and that was that.

Then of course, paperwork. A delivery note, post-partum orders for mom, a newborn exam, note, and orders and the odd surveys, code status declarations, and face-sheet (billing) stuff that litters the chart.

It was noon when I finished that, and this post is long enough, so the day will continue under another post.

Status-post

Well so much for 3am posts all week from the land of night float on the family medicine service: Swedish blocks blog access on it's servers. Booooo. I could have worked around it by writing a Google document and posting it, but I didn't. How did I spend my time? Well, there was plenty of patient care to be done, and once I switched from day-alert to night-manic, I was able to focus pretty well. But all work and no play...you know?

I took advantage of the hospital network's streaming video access and checked in nightly on both the Daily Show and Colbert Report. Last night I jumped from Comedy Central to ABC and watch the last two episodes of Lost, which look pretty good online, the non-skippable ads notwithstanding.

Every space needs ambiance, right? I dig the new lighting in the Gumby Lounge and each night killed the overhead fluorescents in favor of mellow area lights. Greg Parker clued me in to Soma FM a few nights ago, and the selections there became the background of the space for the duration of the week. Not so much an office but a working lounge. Many thanks to Anneliese and Sarah for the improvements!

The theme of the week at SFM was viral syndrome. Especially among the interns. Seems like most of us were hit with fever, malaise, myalgias, diarrhea, URI symptoms--am I missing anything? I got lucky, or maybe it was a combination of luck, hygiene, and voodoo. I made sure to disinfect the lounge nightly (especially the phones and keyboards), wash and gel my hands, and took liberal doses of echinacea with zinc and vitamin C. Seems to have helped thus far: I figure I'm in the window for a couple more days before I can call my evasive maneuvers a success.

I did spend one night on my own due to Maria's illness. Far from being a burden, it was actually quite fun. I took advantage of my solo-status to (a) feel confident in my medical decision making and (b) look up everything. Many thanks to UpToDate and my trial of ePocrates expanded version for helping with differentials and treatment options.

Thanks to my colleagues on the service and around the hospital for making the week fun, too!

Now for the return to daytimes. This is the worst part--several days of sleepy, surly confusion. Fortunately, it's a long weekend, and being alert at night can actually help Brooke get some sleep--I'll cover some of the nighttime attention Elliott needs.

Bloomin' Seattle

Inspired by a recent post by Bus Chick, I snapped this (phone camera) shot a few minutes ago near my house in the Rainier Valley. I saw lots of tiny blooms on my walk to and from Dahlia Spa. Seeing new blooms in Seattle means that it must be February. The days are finally getting a little longer, and soon we'll all be making vitamin D again. It turns out to be just about the nicest day in recent memory here: thin cloud-cover and a mild 57-degrees as I write.

Tonight I begin a week of night shifts on the SFM inpatient service. The transition into nights is always tough, but easier than returning to days. No one much enjoys my cross attitude during the days that follow night float. Fortunately for my family, it doesn't happen that often.

If I'm lucky, I'll get some good posts in over the next several nights. A hospital at night is a strange and wonderful place--so is the company one keeps. More from the other side.

Gellin'

Hand gel has been all over the news recently. Last week a study appeared discussing hand sanitizer technique--apparently it matters (I'm looking for that link). A bit appeared this weekend about the growing recreational use of alcohol-based gels in prisons (my search for Purell Appletini actually yielded something). And there's a new nicotine hand gel on the market (PubMed searches reveal no research on the stuff).

Makes me wonder what can't be delivered with a little gel?

And what not to eat

Raw cougar. Seems a Washington deer hunter dined on feline sashimi platter last fall and came down with a case of trichinosis. The story in the Seattle P-I doesn't go into much detail about whether feast was an al fresco bid to ward off starvation, an drunken hunting lodge dare, or a holiday buffet. It would appear that the hunter acted alone.

So cook your cougar, y'all (try the green chili).

What to eat

For a while now, I've been working my way through Marian Nestle's What to Eat, a 636-page examination of what's in your grocery store, aisle by aisle. Nestle looks closely at the relationships between the food industry, government dietary regulations, and dietary recommendations. It's a great read, but slow going, at least for me. Along comes Michael Pollan with an essay in last Sunday's NYT Magazine that essentially covers the same ground in many fewer words (there are 177,825 in Nestle's book). Here's how Pollan's essay opens:

Eat food. Not too much. Mostly plants.

That, more or less, is the short answer to the supposedly incredibly complicated and confusing question of what we humans should eat in order to be maximally healthy. I hate to give away the game right here at the beginning of a long essay, and I confess that I’m tempted to complicate matters in the interest of keeping things going for a few thousand more words. I’ll try to resist but will go ahead and add a couple more details to flesh out the advice. Like: A little meat won’t kill you, though it’s better approached as a side dish than as a main. And you’re much better off eating whole fresh foods than processed food products. That’s what I mean by the recommendation to eat “food.” Once, food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket. These novel products of food science often come in packages festooned with health claims, which brings me to a related rule of thumb: if you’re concerned about your health, you should probably avoid food products that make health claims. Why? Because a health claim on a food product is a good indication that it’s not really food, and food is what you want to eat.

We spend a lot of time poring over the details of what's in our food. I like Pollan's idea that most of the stuff we eat isn't really food. The food pyramid, macronutrient diets, mono-/poly-/un-saturated fats, omega-3s, anti-oxidants. No wonder my patients (and my colleagues) are confused. I'm going to start giving much simpler advice to my patients who ask about diet: "Eat food. Not too much. Mostly plants."

We'll see how that goes.