we can burn brighter

happiness is like a train on a track/coming towards us/stuck still/no turning back

-Florence and the Machine

On a long run with a friend the other day, I was going through all the next big decisions I have to make, all the things I feel I need to figure out about my next steps and how many things I just don't know yet that I feel I should know or need to know soon -

and she just said, Erica.  Listen to yourself.  If this time last year someone had said to you, in one year you will have passed the boards, done well in third year clerkships, be very invested and so satisfied in your relationship with your partner, and be doing yoga and running more consistently than you have for a long time, 

you would say, WOW. I can't wait until December 2011!  

So what is this stress about?

I think sometimes I forget how to just sit with happiness.   I've become so used to having to think three steps ahead that it actually makes me nervous to think that I might just... be happy?

So I think of things that are still not going as well as I think they could, or things that I still don't know, or the next big obstacle or test I'll have to confront.

When really I should be just grateful.

So this holiday season and as I ring in the new year, instead of resolutions, I'm going to focus on being happy and grateful for everything I have experienced this year instead of worrying about the challenges that next year will bring.

To get you in the celebrating mood, check out my new favorite artist Janelle Monae in this video, for more of her check out TIGHTROPE for some MJ caliber dancing.  YESSSSSS.

what makes the biggest difference in your health?

After many months of treating really sick people and watching them take drugs with life altering side effects, undergo procedures with lost of risks, be connected to tubes and pumps and monitors to stay alive, and  return to the hospital still not feeling very good, I truly believe we have to focus more on preventing people from getting to the point where it's clear they forget what "healthy" feels like.  

We learn about all the amazing ways we can fix arteries that are clogged, lungs that aren't opening, knees that aren't able to hold body weight, hearts that are too big to pump well, livers that are too clogged with fat to detoxify our blood, blood pressure that is so high it is shearing off the insides of blood vessels, and kidneys that are too full of sugar to filter well,  and I think: 

and people wonder why our health are costs are skyrocketing?  Why you see a gazillion doctors when you're in the hospital?  Why our health system is going broke?

It's because we aren't protecting health enough.  Maybe it's because the consequences sometimes take years to show up, or maybe it's that our society doesn't promote healthy behavior nearly enough by what's cheap, what's available, how much time we have, but those all pale in comparison to what you do now determines whether or not you are ALIVE in twenty, thirty years, much less whether you are connected to a tube or can keep your leg, or need a kidney transplant.

Especially because so much could be prevented with just creating a slightly more health lifestyle!  

To add onto Michael Pollan's easy food rules - 

here are my 5 easy health rules 

(medical school really has just filled in the details)

1. don't smoke...anything...ever.

2. eat mostly greens and fiberous grains, avoid too much meat and processed food

3. walk (or just move!) as much as possible but at least 30 minutes every day

4. stay connected to a community - any community in any way.

5. get enough sleep (whatever amount like enough to you and is marginally feasible)


check out this awesome video a friend shared with me about the one thing that makes the biggest difference in your health:

in summary, the positive effects of this wonder medicine:

• Knee Arthritis: reduces rates of pain and disability by 47%
• Dementia and Alzheimers: reduces progression by 50%
• Diabetes: reduces progression by 58%
• Hip Fractures: reduces risk of fracture by 41% in postmenopausal women
• Anxiety: reduces by 48%
• Depression: 30% relieved with low dose, even up to 47% with higher dose

inspiration enough to get off your computer and go for a run, or even just go pace around the house as you talk on the phone to your sister for half an hour?  yeah, me too.

~~~~~~~~~~~~~~~

"walking is man's best medicine"

-hippocrates

Easy as 123

By the Kaiser Family Foundation, finally an easier explanation of health care reform.  Except it still seems confusing.  Sigh - at least it's a start.  Though I don't know what this is about stopping the huge increase in medicaid/medicare funding to hospitals and doctors - maybe the total amount paid to doctors and hospitals from these programs has increased, but the reimbursement rate has significantly DECREASED per person, and every year congress stalls when trying to decide if they're even going to continue reimbursement.  What a crazy system I've gotten myself into.

http://healthreform.kff.org/the-animation.aspx
Health care reform explained in "Health Reform Hits Main Street."
Confused about how the new health care reform law really works? This short, animated movie -- featuring the "YouToons" -- explains the problems with the current health care system, the changes that are happening now, and the big changes coming in 2014. Written and produced by the Kaiser Family Foundation. Narrated by Cokie Roberts, a news commentator for ABC News and NPR and a member of Kaiser's Board of Trustees. Creative production and animation by Free Range Studios

the pet awesome

so a friend just introduced me to the concept of pet awesomes.

what is a pet awesome, you might ask -

well, it's like the opposite of a pet peeve.  It's something pretty non-significant that makes you pretty happy.

For example, for this friend it was watching guys who clearly work out their upper body in the gym so that each of their six triceps are defined - but can't run to save their lives - try to run and look really, really unathletic (despite their ripped arms).

One reason I like the concept is that it's really easy to come up with pet peeves, but usually just makes you focus on them more and get more and more irritated.

why not focus on pet awesomes and instead, get more appreciative?
(or at least smile more)

some pet awesomes of mine this week include:
*when attendings (the head doctors) take their shoes off under the table during meetings or lectures
*walking in to see one of my patients in the morning when they are deeply asleep and have a really awesome snore going on.  you know the kind that actually sounds like someone sawing wood?
*this older irish man whose medical condition I know nothing about, but as part of his physical therapy, walks laps around our floor using his cane when I'm on night float singing irish folk songs.
yessssss.....

what are your pet awesomes?

for more awesome things, check out this blog that another friend recommended to me called 1000 awesome things.  It's pretty spectacular.



~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"All difficult things have their origin in that which is easy and great things in that which is small"
- Lao-Tzu

photo source

home | How to Live as a (temporary) Nomad

because I like to think I've mastered it a little...

1. yoga podcasts & yoga mat

(it's good exercise and good relaxation at the same time, AND portable)

 I've had a lot of requests for good podcasts and here are my two favorites to check out:

Dave Farmar

Kindii McCollum

for extra awesomenss, play epic music in the background - I like either the Lord of the Rings pandora station or James Taylor (so similar, I know)

2. keep some things constant - like breakfast

I read somewhere that if you don't have to think about your morning routine, you feel much more relaxed going into the day and I think it's absolutely true.
My routine is making coffee in my french press, oatmeal with walnuts, seasonal fruit, and maple syrup, and reading for at least ten minutes.  If I have to wake up 20 minutes earlier to make this happen, I've found that it's worth it.   Things that make this tradition better? Other morning people to share it with, like my friend Lizzie (with popovers, below):

Burlington, VT

3. have something you can "decorate" wherever you are
my mom gave me a teeny vase that I take and put one flower in everywhere I go
I also have a framed photo from my last birthday with me and my tribe of women, and a little one of me and my family.  I just pull them out and put them on the dresser wherever I am and it feels just a little bit more like home.

from anthropologie home

4. get a cell phone charger for your car

I know it seems ridiculous, but I am finally one of those people who needs my phone to operate efficiently.  and because I spend too much time in my car moving from place to place, the car phone charger has let me not worry about using up battery playing surgery podcasts (lectures) on long commutes while also GPS-ing directions to and from new places; boring, maybe, but seriously life changing.

5. stay in touch
I do this by a combo of calling people (especially in between things), making dates whenever I'm in town, email and this blog

Pittsburgh, PA

Pittsburgh, PA

Burlington, VT

Santa Cruz, California

6. reflect often
get a journal, start a blog, go on long walks and 
just think about where you are and where you're headed

Scarsborough, ME

7. get oriented (aka bring your running shoes)
or, if it's more your style, walking shoes.  Nothing like jogging around to get oriented to new places

Wildwood, NJ

8. know your belly
this way when you go somewhere new and make the inevitably crazy first grocery store run, you don't spend a million bucks on things you won't actually eat.  some of my staples include breakfast food (see #2) veggie burgers, beans, tortillas, cheese, salsa, fresh spinach, frozen broccoli
(and of course the assorted local cuisine, as seen below)

Santa Cruz, California

9.  create a tradition
not forever, but just for that place.  Find a coffee shop you like and make it your study spot, go for a long run every Thursday in the park, do yoga on the tennis court on sunday mornings, watch old movies in bed on Wednesday afternoons when everyone else is working and you're post-call, grab coffee with a specific friend every Saturday morning (or mimosas, as seen below)

Burlington, VT

10. figure out what you can control and what you have to let go
for example, I have pretty little control over my schedule these days (hello call until 10pm last night and working 16 days straight) but some of the things I can control is wearing compression socks on long call days/nights so that my feet don't hurt or swell as much or that I always have almonds in my pocket in case I have to miss a meal.

what are your tips for living a life on the move?  
I rarely try to elicit comments from readers, but I would love to hear some for this one!
and for my less computer saavy readers (hey grandpa!), how to comment: go to the end of this post and find where it says "0 comments" in purple and click on it.  It should bring up a new window and you can just type in there.  

~~~~~~~~~~~~~
"Adventure is a path. Real adventure - self-determined, self-motivated, often risky - forces you to have firsthand encounters with the world. The world the way it is, not the way you imagine it.  Your body will collide with the earth and you will bear witness.  In this way you will be compelled to grapple with the limitless kindness and bottomless cruelty of humankind - and perhaps realize that you yourself are capable of both.  This will change you.
Nothing will ever again be black-and-white.
-Mark Jenkins

Stereotypes and Tents

A friend of mine just sent me this awesome article written by Mindy Kaling, one of the writers of the office, about female stereotypes in film that are absolutely ridiculous - but we love them, and maybe crazier, start to aspire to be like them or think we are like them.  For example:

The Woman Who Is Obsessed with Her Career and Is No Fun at All

I regularly work sixteen hours a day. Yet, like most people I know who are similarly busy, I’m a pleasant, pretty normal person. But that’s not how working women are depicted in movies. I’m not always barking orders into my hands-free phone device and yelling, “I have no time for this!” Often, a script calls for this uptight career woman to “relearn” how to seduce a man, and she has to do all sorts of crazy degrading crap, like eat a hot dog in a sexy way or something. And since when does holding a job necessitate that a woman pull her hair back in a severe, tight bun? Do screenwriters think that loose hair makes it hard to concentrate?

Other gems include "The forty-year old mother of a thirty-year old male lead", the "ethereal weirdo" (think juno or the female lead in garden state), and "the skinny woman who is beautiful and toned but also gluttonous and disgusting" (think skinny girl stuffing her face with cake).  I've been on my own sort of stereotype smashing spree because, sparing you the details, I've been getting some pretty awful reactions to my telling people that I am strongly considering the field of ob-gyn. 

the consensus generally seems to be that I'm not going to be a very good mother, a very good surgeon, very good at diagnosing things other than pregnancy, surrounded by mean awful people, and overall pretty miserable with my life.  The field itself is sometimes perceived as being "too estrogen heavy" (helllloooo it's birth, it REQUIRES estrogen) which inevitably results in catty gossip, backstabbing, and comparing who has cuter dansko clogs, right?  NO.  From what I've seen, ob-gyn is not a field of just women, and the women and men in the field are serious, smart, competent doctors who went into ob-gyn because the physiology of pregnancy is like nothing else, because we still haven't figured out fertility, or menopause, and the reproductive cycle of a woman is one of the only topics in health vital to the continuance of our species, so it's been pretty fine-tuned by evolution and involves tons of genes, messaging cascades, and signals.  And  while some of my very favorite ob-gyn attendings were men and many of the people I love and respect in my life are men, I feel a different kind of energy in groups of just women.  It's not catty or gossipy or back-stabbing energy, but strong, calm, nurturing power.  Especially with pregnancy, it feels like going back to our tribal roots, when the birthing process was a tent filled of the women of the tribe who each had been through it or would soon, who had felt twinges in their own bodies that resembled this sensation, who empathized with the feeling of looking at your child for the first time, of the power of that bond, the implications of how the rest of your life will change, that's a lot to hold and I think there's something programmed in women to understand that in a different way.

And if we can bring medical knowledge and skills to the tent, well then, all the better.  

Four Agreements

A good friend just told me about her experience with a physician who saw a lot of highly educated patients whose stress was contributing to deteriorating health.

She said that the first thing he would do would be to listen, and then he would recommend this book:

The Four Agreements, by Miguel Angel Ruiz.

I'm going to actually read it (just waiting for it to arrive in the mail!), but in the meantime, I wanted to share his outline of the agreements and start to consider how they apply to all of us being better people, better contributors to our world and to each other:

1. Be impeccable with your word

2. Don't take things personally

3. Don't make assumptions

4. Always do your best

What do you think?

10 things I learned in surgery

1. the enemy of good is better (otherwise known as, doing more isn't always the right move)
2. the art of being a surgeon is first knowing when NOT to do surgery
3. when asked a question that you don't know the answer to, first: say you don't know, then say what you do know (as in, we don't know if she's going to recover fully but we do know that her kidney function has returned to normal more quickly than we would have expected).
4.  the surgeon is the head of the team, act like it. thank your team for what they do, and most importantly, tell your team what's going on so they can do their jobs the best they can.
5. how you do one thing is how you do everything, so make sure your values are reflected in all you do.
6. from one of my vascular attendings to a diabetic man who had already had one below-the-knee amputation due to low blood flow from his arteries not working well due to his extensive smoking behavior and diabetes "hey man, you're smoking your leg off" - (aka surgery isn't always the end of a problem).
7. bad news should always be hard to deliver, no matter how much experience you have.
8. the major causes of fever after surgery all start with W:
1) wind (atelectasis, pulmonary embolism), 2) water (UTIs), 3) walking (DVTs), 4) wound (infections), 5) wires (foleys, NG tubes, J tubes, ventilators), 6) wonder drugs (lots of drugs can cause fever)
9. a pulse is more important than breathing.  CPR guidelines just changed to focus on pulse first, then airway, then breathing.  so #1: feel for a pulse, if it's not there, start chest compressions
10. set yourself up for success - in surgery, 90% of the success of the surgery is deciding the approach.  If you don't feel comfortable - adjust something.

You just stop stopping it

When asked how you restart the heart after stopping it temporarily to put it on bypass, the perfusionist said to me:  "It's zen-like, really, you just stop stopping it"

Thursday around noon I scrubbed into my first Cardio case - a CABG (coronary artery bypass graft) surgery on a 74 year old woman who we'll call Elizabeth.  The procedure is done by taking a blood vessel from somewhere else in the body (in this case, the saphenous vein in the leg), disconnecting it from its normal place and reconnecting it to the heart to bypass a clogged coronary artery (artery that supplies your heart).  It's a pretty awesome procedure, but it's also done often enough that the expectations when you have one is that you'll be in the hospital for 4-5 days then go home and have to take it easy for a while during which time you feel so much better because your heart is working well again.

Needless to say, if that was the way this surgery went, I probably wouldn't need to blog about it.  I wrote a five page journal entry of everything that happened and my reactions to it, but I'll spare you most of that and just tell you what I'm still thinking about a few days later.

The surgery started out fine and routine, certainly not light-hearted, but pleasant.  Then slowly but surely everything started to go wrong; we couldn't keep her blood pressure high enough to adequately perfuse her organs, we couldn't get the wound on her leg from where we took the vein graft to stop bleeding, her right ventricle wasn't moving enough to pump blood through to her lungs, her skin was too thin to put stitches in to keep her chest closed.

20 hours and two additional surgeries later, she was left with an open chest where her heart had been attached to an external pump called an LVAD that was pumping blood around her right heart to give it a rest, a ventilator on her face attached to oxygen to make her lungs breathe, a line in her jugular vein, in her femoral artery, in both her antecubital fossas (inner elbows), her legs were stitched together along the whole middle side, like the seam of pants except her skin, she was bruised and swollen from the poking and the fluid and blood we had given her to try to keep blood flowing to all of her organs.

I went home at 4am, exhausted, wondering if she would make it through the night.  The next day I was in the operating room with a bariatric surgeon from 7am until I got a break at 3pm, so as soon as I got out of the OR I went to check on Elizabeth.  She was in the cardiac intensive care unit in the same state but even more bloated and with even more wires connected to her.

The surgeon was just coming by to talk to her family again and invited me to come to that discussion, so I went with him and heard Elizabeth's two sons and their two wives (who happened to be sisters, oh Maine) tell the surgeon that their mother would never have wanted to live like this.  Before deciding to have the surgery, she had decided her code status would be "Do Not Resuscitate" specifically to avoid this situation.  However, the surgeon did not want to accept that they would stop trying and just kept repeating, "we've done almost everything, but there are still a few things we can try; her left ventricle looks great; it's not likely but there's a small chance she will recover in some way; I can't say definitely that she won't have at least some turnaround"


I wanted to scream at him: they're saying that's not good enough - that some turnaround or a small chance that she will recover in some way is not enough of a reason to put her through this suffering.  They're saying they are ready to stop all this intervention.  But he kept pushing it: we can give her more blood, we can run some more tests, we could maybe do another surgery.  To Elizabeth's family's credit, they cried and lamented but they were clear - she would not want this.

When talking about it with another one of my attending from the trauma surgery service later that day, he described this behavior of surgeons: when they don't seem like they are listening and they just want to keep pushing even though it's time to stop, as Tunnel Vision.  He said, and you want them to have tunnel vision sometimes because it takes such focus to take a vein out of your leg and sew it to your heart and have you walk out of the hospital a few days later able to breathe and move again.  But this same focus sometimes makes it hard to see the person as a whole person, as a whole life, instead of just the organ they're working on.  This attending and I also talked about how to have conversations with families where you give them information that their family member is dying - how it should be straightforward, as objective as possible, laying out the options as clearly as possible, and how you should mostly be listening.  The biggest thing, he said, is that it never gets easy - even when you've done it thousands of times, it's always hard to tell someone that someone they love is dying.  And it should be.

the matrix

In my world right now this makes so much sense:

"So [given your extensive training and how hard you work] in your heart of hearts - why do you not quite feel like [you know everything]?

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about."

- Atul Gawande 

at a graduation speech to PhD and MD candidates by Atul Gawande

getting stuck

today I was first assist on a below-the-knee amputation on an older man with diabetes.  It's a pretty brutal operation - as in, they actually use an actual bone saw, a very large knife and it's less possible than I thought it would be to precisely cut off the muscle in someone's leg.
But somehow I do have the stomach for surgery -  so even though at moments it seemed like a halloween trick gone awry,  I was able to focus on how fascinating it was to identify and technically interesting it was to  isolate the three major neurovascular bundles in the leg (sort of like tubes containing nerves and the blood vessels that supply them).

the attending sutured the muscle/fascia layer because that is the critical layer for holding the operation together

but then he let me suture half of the skin line.

I've just started feeling more confident in my suturing and yesterday I got to suture a lot, 

so I was feeling almost confident

until I stuck my own finger with the needle.

this is not an uncommon thing in medicine
in fact, the first thing that happened was that the scrub tech, the circulating nurse, and my attending all empathized with me and told me how many times they had been stuck

then they told me to take off my gloves and gown and go wash my hand with bleach
I was escorted from the OR to another building in the hospital to start the "needle stick protocol".
this consisted of me walking into the employee health center and being immediately ushered into a small room (they were expecting me because the OR had already called them), filling out a report about what happened, hearing what would happen from there on out:



1. The patient would be told that one of the health care workers in his surgery had been exposed to his blood, would he consent to be tested for HIV, HepC, and HepB please?  (he said yes) Would he please fill out a survey outlining his risk factors? (his wife did, he was still waking up from anesthesia)
2. I would fill out these incident reports.  One would be filed with employee health and one I would take to my supervisor.  Because I'm a med student and don't have a medical health record number, I would also have to create one of those.
3. I would have to have five tubes of blood drawn from the lab downstairs, now.
4. the nurse on call tonight would call me back with the results of the patient's STAT HIV test.
5. they would call me tomorrow with the results of his other tests and by Monday with the results of my tests
6. if I had any questions, I could call them.  If the tests were negative there was nothing else to do. If they were positive - well, there are more tests.
So I did.

I am really really lucky.
Less than two hours later, they called me with his previous lab results (all negative), and his risk factors ( blood transfusions in the hospital only - very unlikely to contain HepC or HIV), and later this afternoon called me with the results of his STAT HIV test - negative.
The nurse on the phone told me that I could breathe a big sigh of relief -
but that she'd still call me with all the rest of the test results.

Talking on the phone with the manfriend, he sounded almost more worried than I was, realizing for the first time that if we are both going to be doctors we are going to be at greater risk of contracting some pretty serious diseases.  And maybe more importantly, how will we organize our careers around this - will we try not treat people with more easily contractable incurable illnesses like HIV/AIDS? (hopefully we will treat them just the same as anyone else)  Will we wear more layers of gloves?  Will we be better about getting vaccines?  Get serum tests for transmissible diseases every year?  Or maybe just try hard not to think about it too much and carry on with what we've decided are our respective callings?

This article caught my eye because it explains some of the very scary things that can happen to med students, and yet is still very inspiring.  I'm reading Abraham Verghese's In My Own Country right now, which is about his own experience treating the first patients with HIV and it's making me think a lot about the balance between protecting yourself and providing good medical care.

~~~~~~~~~~~~~~~~~~~
"But we also agreed that what made the difference in life was not how well you succeeded;  it was how well you failed, how many times you picked yourself up
and put yourself back in the fray."
- Dr. Dietrich 
who contracted HepC from a needle stick as a third year medical student, 
see the article above

Home ?

Normally this is not really a photo blog.

But it's been a rough six months of moving around every 7 weeks 

(heyyy third year of medical school) 

that sometimes it feels like I'm always too far from everyone I love

so here's a photo blog reminder (for me, and maybe for all of you?) that my concept of Home has become an incredibly fluid concept that has less to do with location 

and more to do with the people I'm with

(if you click on the photos, they should open bigger in another screen)

"Oh home, let me come home

home is whenever I'm with you

oh home, let me go home

home is when I am me and you are you"

- Edward Sharpe and the Magnetic Zeros

because they are the best - my best friends came to visit me in Maine

and yes, that's the ocean behind us

(Maine)

getting ready to run... at midnight, before we have to wake up at 4am
and I think we still needed to pack.
what is wrong with medical students?
(Florida)

a quick jaunt back to Vermont to run a half-marathon - no big deal

(Vermont)

 finally with my fam

(Massachusetts)

summer break!

(Massachusetts)

 PLP Charlie and I reunited and hiked to waterfalls

(Vermont)

Burlington Farmer's Market - what a beautiful scene.

(Vermont)

 Rachel came to visit me finally!!

(Vermont)

Finally in the same place as Krista!

at a country fair no less, how perfect!

(Maine)

 Visiting Grace at her new beautiful apartment (we match)!

(Massachusetts)

Charlie and I demonstrate my favorite camera pose - the screaming eagle atop the summit!

(New Hampshire) 

Is there anything better than a kiss on a mountain?

(New Hampshire) 

We rolled out of the tent to watch the sunrise - 

what adorable sleepy men.

(New Hampshire)

the wind was crazy on the ridge

(New Hampshire)

 but it was beautiful - where else do you see colors like this, I ask you?

(New Hampshire)

which way did we hike?

(New Hampshire) 

(New Hampshire)

there's a few missing, so stay tuned, I might add some more!

Surgery at the End of Life

I've been thinking a lot this week about how strange it is that so many people are choosing such serious interventions for medical problems that are likely to not be their cause of death.  Don't get me wrong, we can do really amazing things with surgery and interventions now that save lots of lives and maybe even more importantly, improve the quality of life for so many people.  But it still seems like mostly, surgery should be an option of last resort.  Maybe this is more striking because I'm seeing all the patients in the ICU and in the hospital after surgery and recovery can be such a brutal process that it seems like, especially at an older age, surgery would be something you would want to avoid unless it was going to really make a difference in either the quality or quantity (or both) of years in your life.
Sometimes I wonder how much of it is just us not wanting to NOT be able to do something.  Like I said at the beginning of this surgery rotation, the really good surgeons are the ones who know when NOT to operate.

Check out this interesting article in the Times about how common surgery is at the end of life.

Dr. Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine. “No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.” Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea." Instead, Dr. Jha said, “we sent him to the O.R.”

Stay Hungry Stay Foolish

An extraordinary individual who changed the way we see the world and each other.

"your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma - which is living with the results of other people's thinking.  Don't let the noise of others' opinions drown out your own inner voice.  And most important, have the courage to follow your heart and intuition.  They somehow already know what you truly want to become.  Everything else is secondary."

Steve Jobs' obituary in NYT

Gift from the Sea

an excerpt from a reading at a wedding my friend Rachel went to recently (and she so graciously sent to me because she knows me well and knew I would love it - thanks Rachel!!)

EXCERPT FROM "THE GIFT FROM THE SEA"
~ By Anne Morrow Lindbergh ~

When you love someone, you do not love them all the time, in exactly the same way, from moment to moment. It is an impossibility. It is even a lie to pretend to. And yet this is exactly what most of us demand. We have so little faith in the ebb and flow of life, of love, of relationships. We leap at the flow of the tide and resist in terror its ebb. We are afraid it will never return. We insist on permanency, on duration, on continuity; when the only continuity possible, in life as in love, is in growth, in fluidity - in freedom, in the sense that the dancers are free, barely touching as they pass, but partners in the same pattern.

The only real security is not in owning or possessing, not in demanding or expecting, not in hoping, even. Security in a relationship lies neither in looking back to what was in nostalgia, nor forward to what it might be in dread or anticipation, but living in the present relationship and accepting it as it is now. Relationships must be like islands, one must accept them for what they are here and now, within their limits - islands, surrounded and interrupted by the sea, and continually visited and abandoned by the tides.

photo credit

Coaching

last night I was on call and around 4pm, a young guy came in with a gunshot wound to the knee.  Before I knew it, I was four hours into my first vascular surgery with the young guy on the table, both legs sliced open on the medial (inside) side).  The two surgeons I was working with were using a vein from one leg to take the place of the severed artery on the other leg, called "grafting" an artery for a bypass.  

I learned many things last night about vascular surgery and about vascular surgeons.  In their own words, these attendings said that vascular surgeons have to have the biggest egos, secondary only to cardio-thoracic surgeons (the men and women who operate on hearts and lungs).  They also are perfectionists - and need to be.  So I was surprised when near the end of the case around midnight, I was handed 0 nylon on a needle driver and forceps (big tweezer-like things that surgeons use to pick up skin to suture; suture = to put in stitches) and told to stitch up one of the groin incisions.  But I did.  The entire time, one of the attendings asked me questions about the physiology of the vascular system (for example, "what would I feel if I had accidentally attached this vein graft to the popliteal vein instead of the popliteal artery?"**)  while the other coached me on better technique for suturing.  Both of them were incredibly focused on details (appropriately for their profession) which is not typically my strength.  However, paying more attention to the details (where  your shoulders are facing, how far onto the needle driver you arrange the needle, locating each layer of fascia before creating a fasciotomy) ended up making such a huge difference.  

They say in surgery, if it feels like you're struggling to do something, you need to change something - because the best surgery is when everything is in line.  The change can be something as easy as switching the angle of your wrist or walking to the other side of the table or adjusting the light.  There are millions of things we can adjust but sometimes we think that they're just details.  But surgery has definitely taught me that the details truly matter.  Especially when learning, it's so important to learn the details before getting a gestalt.

On that same note, a few great friends sent me an article from the NewYorker by Atul Gawande, another one of my favorite doctor-writers: Atul Gawande, who writes about  how after their training is complete, surgeons (and maybe all doctors, maybe all professionals) operate without much supervision, without much continued assessment, and miss out on much improvement simply because no one is watching them and coaching them on how they can be better.  He relates this to professional athletes - who even though they are deemed the top of their fields, have other people who watch them as they cannot watch themselves, and help them improve.

Dr. Gawande also talks a lot about teaching styles and coaching teachers, another profession that is trained and then sent off into the world to manage on their own.

A great excerpt:

"Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short. This is tricky. Human beings resist exposure and critique; our brains are well defended. So coaches use a variety of approaches—showing what other, respected colleagues do, for instance, or reviewing videos of the subject’s performance. The most common, however, is just conversation."

In the vascular surgery last night, it took so much of my brain power to both answer the questions and try to suture correctly that I don't think I even breathed the whole time, but afterward I felt like I had a greater understanding of what I need to learn to be a better doctor, moving more comfortably into "conscious incompetence".

**answer: no pulse because pulse is created by the resistance in arteries - and veins don't have very much resistance.  You would feel a thrill, which is a whooshing of blood past really quickly, instead.  If you listened to the graft, you would hear bruits, which is the sound of blood going by very quickly.

human touch

A ted talk by one of my favorite doctor-writers:

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 "wasn't that the definition of home - not where you are from, but where you are wanted?" 

-Abraham Verghese

on call pocket

I dumped out my pockets in the middle of my call today to change scrubs and was shocked at all the things that came out.  so I took this picture.

the contents of my pockets today include:

- 1 surgery book

- 2 pagers (trauma pager and my pager)

- glasses

- pen

- stethescope
- watch (bc you can't have it on when you scrub)

- gum (gotta have fresh breath in the OR)

- extra gloves (just in case)

- sutures (to practice in between surgeries)

- spare change (for breakfast, coffee, lunch...)
- splenda (also just in case?)
at some point I also had a coffee mug but I put that down somewhere.

kinda crazy, right?

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"may your pockets be heavy, may your heart be light
may good luck pursue you each morning and night"
-an irish blessing

focus on the fraud

just a quick little post to tell you about an op-ed in the NYT about how medicaid and medicare (not to mention all of us taxpayers who pay for these programs) are swindled out of billions of dollars each year because of health insurance fraud.  this editorial calls for the US and state governments to crack down on these false claims, securing the collapsing system from at least one side.  I like it.

from the article:

But before charging consumers more and eliminating valuable services, we should be much more aggressive in recovering money stolen from these taxpayer-supported programs. According to some estimates, health care fraud is a $250 billion-a-year industry, and about $100 billion of that is stolen from Medicare, the health care program for the elderly, and Medicaid, the insurance program for the poor and disabled.

There are many ways to defraud taxpayers. For example, a hospital chain can buy drugs at a steep discount and then bill Medicare for high sticker prices. Doctors can bill for procedures that never happened, or for drugs that were supplied to them by pharmaceutical companies free of charge, or pharmaceutical companies can promote a drug for risky, unapproved uses.

Recovering billions of dollars from these ruses won’t solve the problem of rising health care costs, but it’ll go a long way in helping to reduce waste and protect services.

Trick Yourself Into Faster, Higher, Better ?

If I put you on a stationary bike in front of a video game screen with an avatar riding a bike and told you that the avatar would be going at your own personal best pace - would you try stay with it?  Would you beat it?  What if that avatar was actually riding a bit faster than your best pace, but I didn't tell you?  Do you think you'd still beat it?

A recent article sent to me by a good friend says that if the avatar is only going 2% faster than your best - you will beat it. It talks about research being done to show that we can actually trick ourselves to be faster and push harder than we ever have before - which is sort of what we do in races and competitions.  As a self-proclaimed runner who is always recruiting new runners (!!) I tell people that one of the hardest parts of running - especially marathon training - is getting used to the idea that you don't have to stop when your mind or body says you should.  Once you do this just one time - keep running after your body/mind has told you to stop - it's incredibly freeing because you realize that you are more powerful than your thoughts or signals.  But sometimes this motivation involves playing tricks on your mind like, I am going to run as hard as I can because maybe I'll rest at the top of this hill.  Then when you get to the top of the hill, picking a new place you're going to "stop".  These mind tricks are also how in competition we make ourselves go faster - not "I need to go faster than I previously have" but "I need to beat that person".

The experiments explained in this article are fascinating and makes me wonder what sorts of mind tricks I'm playing on myself - not only in my life as an athlete (which maybe more consists of tricking myself into running at all), but also as a medical student.  I find myself picking out the narratives that keep me motivated all the time.

From the article:
In their laboratory, Dr. Thompson and his assistant Mark Stone had had the cyclists pedal as hard as they could on a stationary bicycle for the equivalent of 4,000 meters, about 2.5 miles. After they had done this on several occasions, the cyclists thought they knew what their limits were.

Then Dr. Thompson asked the cyclists to race against an avatar, a figure of a cyclist on a computer screen in front them. Each rider was shown two avatars. One was himself, moving along a virtual course at the rate he was actually pedaling the stationary bicycle. The other figure was moving at the pace of the cyclist’s own best effort — or so the cyclists were told.  In fact, the second avatar was programmed to ride faster than the cyclist ever had — using 2 percent more power, which translates into a 1 percent increase in speed.  Told to race against what they thought was their own best time, the cyclists ended up matching their avatars on their virtual rides, going significantly faster than they ever had gone before.

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"Work It Harder Make it Better

Do It Faster, Makes Us Stronger

More than Ever Hour After

Our Work is Never Over"

-Daft Punk lyrics to Harder, Better, Faster, Stronger

(such a good workout song)