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.