You know there is something wrong with your life...

...when you come to the ER with an earache and it turns out you have a cockroach in your ear.

Patience: it's not just a Quaker name

Today I had a patient who came in right before lunch. I thought that I could get everything done in 15 minutes, no problem. And, of course, that was where I jinxed myself. I like to think I'm a pretty good listener, but after twenty minutes of hearing about his entire cardiac history, his heart surgery, his problems getting his blood pressure medications from the pharmacy, even his snowblower, I was completely depleted in body and spirit. And when he started telling me about his wife's problem with her cholesterol medication, I just stood up and started examining him just to get him to stop talking. I thought to myself, this patient isn't nearly old enough to make me put up with his ramblings. Talk to me when you're in your eighties, buddy.

It's times like that when I realize how impatient medical school has made me. I never, ever considered myself a Type A person--you know, the kind of person medical students are supposed to be. I'm an English major, for crying out loud. And yet I see myself becoming more Type A all the time. I'm sure it's the people I'm around all day. When I was on internal medicine, my attending put great emphasis on not wasting a single word when presenting a patient. I definitely learned to be more concise in my speech, which is great. But now I find myself getting impatient with others who waste words when they talk. For a few months after that rotation, Fast and Testimony meeting was hell.

Impatience does have its virtues in medicine. Sometimes things need to be done immediately, and unless you bug the lab repeatedly or call down to radiology over and over again, it's not going to get done. A doctor should be unwilling to put up with delays or excuses when it comes to the health of a patient. Even so, healing is impossible without patience. It takes time for electrolytes to rebalance, bones to knit together, skin to reseal itself. And it usually takes even longer for the spirit to heal. A good doctor has to know how to wait. One of my favorite prescriptions is "tincture of time." Not every medical issue has to be pounced upon with feline ferocity. The body is pretty good at healing itself.

So even though I'm learning the value of impatience, I'm relearning the value of patience, too. Last week, I had a patient who, I soon realized, was going to do a lot of talking. I decided the best strategy would be to let him talk for as long as he liked. The visit lasted an hour and a half, and I could only stop him long enough to ask a medical question every five minutes. Despite all this, it was one of the most interesting and memorable patient encounters I've ever had. There's a time for patience and a time for impatience. I just hope I learn to tell the difference.

Conversation starters

Enough with the dark posts for now (just wait until you get my post on working in the county jail!). Once I was at a party, and in a sudden flash of inspiration I stated with great confidence the theory that any conversation can be jumpstarted by talking about (1) bunnies or (2) peanut butter. I've had less success with bunnies as a conversation starter, but peanut butter does seem to work as an interesting topic of discussion. Creamy or crunchy? Natural or regular? Which brand? With jelly, jam, bananas, honey, apples, or celery? So, here's your topic, commenters. Tell me what you have to say about bunnies or peanut butter.

A story from shock trauma

In January, I spent two weeks on Shock Trauma. The schedule was grueling: overnight call every three days. It seemed that once you had stayed up all night, the post call day went by quickly and then you were up all night again. I always enjoy a good trauma show on TV, and those shows led me to believe that there would be a constant stream of horribly mangled bodies, constant action, gowns and gloves being tossed around as the patient is prepped immediately for surgery. There was a little of that. But one of the very surprising things about trauma was how pedestrian it could be. A gunshot wound or motor vehicle collision could come in and leave the same day. Yes, there were a few times when there was a mad rush, with everyone in the building crowding around the bay, hoping to get a glimpse of the action. But often a patient would come in on a stretcher and the resident would calmly take notice and get up and do what needed to be done. All the same, you remember the sickest patients best. Here's one I remember in particular.

He was an elderly man who shot himself in the forehead. When we looked at the CT, we could easily see the destructive path the bullet had taken through the skull and brain. The pieces of shrapnel glowed brightly, and the ventricles were filled with a gray haziness, the blood diverted from the brain tissue, emptying from the inside. And yet the wound in the forehead was a small, ragged thing, like a burgundy crocus. The patient was put on ventilation, and his vital signs were quite good. But all the same, the neurosurgeons told us there was no hope for recovery; the only thing to do was to allow the family to say goodbye, then stop the ventilation and allow the patient to die.

Soon, the patient's son came; he wore a long, wool coat, looking as though he had just left a business meeting. From across the room, I could see the absolute blankness on the son's face; it was the face of someone who cannot begin to fell, who had to see everything in perfect clarity first. And then, only minutes later, he left, walking quickly, his face consumed with grief. Later, the resident told me that when he went to talk to the family, they were arguing. Some maintained that they could never imagine Dad doing something like that, that he had seemed fine. Another protested that she knew something was wrong, that Dad had been preparing for this for the last few months, that he had been giving away his possessions and making funeral arrangements, that it should have been no surprise at all.

The patient was extubated and the curtain was drawn around the bed. Two nurses kept watch at the patient's bedside. Not long afterwards, the nurses started to clean the bay, and I saw that the tracing of the electroencephalogram was flat.

In medicine, it's the small glimpses into the lives of your patients and their families that give your work meaning. From a strictly physiological standpoint, this was a simple case: a bullet, a brain, death. But seeing the patient's son, hearing about the family's quarrel: these conjured up whole worlds of grief and pain that revolved like planets around that hospital bed. One bullet had changed a thousand lives irrevocably. When I think about that, I realize that medicine isn't about the bullet or the brain. It's about those thousand lives that change when you place your stethoscope on a patient's chest or when you scribble a prescription. And it's about the thousand-and-first life that changes: your own.

Happy birthday, Billy!

In honor of my sister's birthday, I went on an F. Scott Fitzgerald pilgrimage here in Baltimore, and here are the results. Fitzgerald had important family ties to Baltimore; he was named, after all, for his relative Francis Scott Key, one of Baltimore' most famous citizens. Some of the most difficult years of Fitzgerald's life were spent in Baltimore. But Fitzgerald seems to have enjoyed Baltimore as well; I found the following quote in an article about Fitzgerald's time in Baltimore:

Baltimore is warm, but pleasant - I love it more than I thought. It is so rich with memories. It is nice to look up the street and see the statue of my great-uncle (Francis Scott Key.) And to know Poe is buried here and that many ancestors of mine have walked in the old town by the bay. I belong here, where everything is civilized and gay and rotted and polite. And I wouldn't mind a bit if in a few years Zelda and I could snuggle up together under a stone in some graveyard here. That is a really happy thought and not melancholy at all.

On 12 February 1932, Fitzgerald brought his wife Zelda to the Henry Phipps Psychiatric Clinic of the Johns Hopkins University Hospital in Baltimore. This is where Zelda completed her novel, Save Me The Waltz.

On 30 March 1932, Fitzgerald left Alabama and stayed at the Hotel Rennert, which stood at the corner of Saratoga and Liberty streets; it has since been torn down. Here's a picture from an old postcard.


From 20 May 1932 to November 1933, Fitzgerald rented "La Paix," a house on the Turnbull estate in Towson, just outside of Baltimore. There, Fitzgerald completed Tender is the Night, and when Zelda was discharged from the Phipps clinic, she came to live there. I read somewhere that "La Paix" was torn down to make room for St. Josephs Medical Center; I went to Lapaix Lane in Towson to see if there was anything to see, but no luck. But here's a picture from the Maryland Historical Society; you can see more pictures, including interior shots, here.


On 26 June 1933, Zelda's play Scandalabra opened for a one week run by Vagabond Junior Players. Here's the Vagabond Theatre, at 806 S. Broadway in Fells Point.


In December 1933, Fitzgerald rented a house at 1307 Park Avenue, in Bolton Hill. It's the house in the middle with the unfortunate dark gray paint job. It was hard to find a spot on the street to take a good picture. There's a plaque on the front that says that Fitzgerald lived there, but since it was between two open windows that look right into the living room, there was no way of taking a picture without seeming really, really creepy.


A few blocks away, at the corner of Bolton and Wilson streets, is a small park named for Fitzgerald. There's not much there, unfortunately.


Fitzgerald stayed at Johns Hopkins Hospital nine times. The first was in August 1932, when he had a tentative diagnosis of typhoid fever. He would also be hospitalized for alcoholism and chronic inactive fibroid tuberculosis. Fitzgerald wrote half a dozen stories about Hopkins, including "One Interne."


Zelda suffered a relapse and returned to the Phipps clinic on 12 February 1934. On 19 May 1934, Zelda was transferred to Sheppard-Pratt Hospital outside of Baltimore.


In September 1935, Fitzgerald rented an apartment at the Cambridge Arms on Charles Street. This is now Wolman Hall, a residence hall at the Johns Hopkins University Homewood Campus. In 1937, Fitzgerald left Baltimore for good and went to Hollywood.


And that concludes the tour. Apparently there's a book on Fitzgerald and Baltimore out there, so I'm going to see if I can get my hands on it. And of course, if you come to Baltimore, I'll show you around myself.

Since Beth linked here...

...I ought to have something new to say. So I'm doing two months of rural medicine in Williamsport, Maryland, and every afternoon my preceptor and I go to the county jail to see inmates. Let me just say: when you're missing half of an ear, there is something wrong with your life.

So this is six months old...

One of the things I love about coming home is that I get to catch up on all of the movies I've missed and see what's out right now. Usually, I'm too busy to see many movies at all. So, in celebration of the art of film, here are some short reviews of what I've been seeing:

Pirates of the Caribbean 3: At World's End

I think the Ask a Ninja ninja is right about this one. It's basically the same as the second one, but it makes less sense.

Shrek the Third

I've never been a big fan of the Shrek movies. The first one was way too talky, like a bad episode of Friends. And the whole fractured fairy tale thing has been done to death. This one has its funny moments, but if you've seen the trailer you've seen them all.

Flushed Away

I'm a big fan of anything Aardman Studios puts out, and this one was clever and fun. Even though the movie is CGI, it still had a lot of the charm of the stop-motion animation in Aardman's other movies. I loved the albino lab rat turned henchman and the singing slugs. The movie moved too fast, though--you don't get to catch your breath until more than halfway through the movie.

The Devil Wears Prada

I watched this movie for two reasons: Anne Hathaway and Meryl Streep. It's incredible to see Streep create the character of Miranda Priestley, especially in one scene where we see the character's vulnerability.

Music and Lyrics

This movie isn't laugh-out-loud funny, but you get to see Hugh Grant do the Hugh Grant persona and Drew Barrymore be completely insane. The actress playing Cora, the world famous pop diva, is great; not only does she sing and dance, but she portrays the character as sexy, innocent, demanding and spiritual, all at the same time. And I'm still humming the songs from the movie.

Brother Bear

I had avoided this one because I assumed all of the Disney movies of the last few years were crap. But I enjoyed this one: the animation was beautiful, and the moose brothers were hilarious.

The Last Holiday

I watched this one because Queen Latifah is awesome. Too bad she couldn't star in a better movie. It took a couple tries to get through it. Lame.

Happy Feet

Good animation, fun music.

Sushi conveyor

This video makes me happy. The description on YouTube says, "We placed a camera on a conveyor at a Tokyo/Asakasa sushi bar (near the Nakamise Shopping Arcade). It was about midnight and the place was packed with great people." Be sure to watch it before moving on to the rest of the post:

It's almost a perfect piece of film: the concept is stunningly simple, but the results are amazing. As the camera moves along the conveyor belt, we essentially get a long pan shot, and we never know what we are going to get: customers smile at the camera or continue to focus on their sushi, a child points towards the lens, a waitress picks up stacks of plates, we see a long shot of plain walls only to suddenly find ourselves in the kitchen with hands busily preparing food. There's a new surprise at every turn the camera makes. It's an incredible glimpse into the lives of people who live thousands of miles away. You only see these people for a few seconds at a time, and yet you somehow feel that you know them. It becomes a metaphor for life: we see so many faces that go by so quickly, and yet they all register and make their own little impact.

I think this video is also interesting from an aesthetic point of view. This video was created by a single, simple artistic act: placing a camera on a conveyor belt. Everything else that happens in the video follows from that simple act. The creator does not exert any control over what happens after that except to determine when the video ends. The characters, setting, soundtrack all come directly from the environment without any editing. And because the creator is willing to give up control over the video, the camera is able to capture a captivating portrait of life in the sushi restaurant that is both strictly objective and yet poetic. I think it's wonderful that the camera is at just the right height to capture the patron's faces but low enough to focus on the hands of the people in the kitchen, and I love how the camera has to refocus at times on new objects, just like a human being does in an unfamiliar place. And all of this is due to chance. I think that's incredible artistic economy, that so much can come out of doing something so simple and amusing as putting a camera on a sushi conveyor belt.

It's true that on first viewing the ending is abrupt: wouldn't it make more sense if the camera came full circle, literally, and the creator lifted the camera off of the conveyor belt? Cut to black, the end. But actually, I think the abruptness is in line with the aesthetics of the video; by choosing an ending, the creator would impose meaning on the video and thus crush the gentle portrait of life that the camera has already created. For all we know, someone might have disturbed the camera or the battery or memory may have run out. At any rate, the ending fits in with the rest of the video; after the first seconds everything, including the ending, is due to chance, and yet everything that the camera records is transformed into something transcendent. That's why, for me, this video approaches art.

I could go on forever--I am an English major, after all. I'm curious to see how others react to this video. Is it just a gimmick, or is there something more to it? I think I have my answer; like I said, this video makes me happy.

The inner English major

My brother has some great posts up right now about embargoing restaurants and satiating the inner English major. I like what he says about the need to write:

So it seems there's something about writing. Writing something that you care about and hope that others care about as well. The only answer? The inner English major. A gremlin that lives in your appendix, behind a small typewriter, generating "Text", hoping for recognition. Your English major needs an output like humans need food or shelter or cable television.

There really does seem to be some part of us that feels the need to write. I mean, everyone and their grandma has a blog these days. It doesn't seem to matter whether anybody reads it or not; we just keep writing anyway. I wonder if that has something to do with the orange button right below the text box where I'm writing this that says "Publish Post." We don't just want to put words on paper or on a screen: we want to share those words with others. Sure, there will always be the types that write only for themselves, like my freshman English students who were terrified of sharing their writing with me or their peers. But like I would tell my classes, what's the point of writing if you're not going to share it with someone else? That's what writing was invented for. Everyone has something they want to tell the world; writing lets us have our say without being interrupted and with better logic and grammar.

When I was a kid, I used to think about how I would write about certain events in my future autobiography. And now that I'm blogging, I find myself thinking throughout the day about what would make a good blog post. I'm always writing in my head, tinkering with arguments, perfecting pithy sentences, discovering metaphors and similes. I'm sure it's a common affliction. This blog is a good way to get some of that thinking out. And of course, the magic of writing is that the act itself gives you new ideas and new ways to express them.

Well, I wrote some grand concluding statements to really bring this post to a stirring close, but I have a barbecue to go to, so there's no time to make them sound less stuffy and pretentious right now. So that's it for now. Moral of story: write, or your appendix will burst.

Man, I have to go to bed. But first...

Tonight I went to hear the Baltimore Symphony. It's sad to say that this is only the second time I've been since I've been in Baltimore. And to be honest, I wasn't all that excited about the first time I went. But this is the first season with BSO's new conductor, Marin Alsop, and I had heard good things. And the BSO did not disappoint. They played Jennifer Higdon's Fanfare Ritmico, Elgar's Cello Concerto with Alisa Weilerstein as the solo cellist, and Dvorák's Ninth Symphony. I was glad to see that the hall was fuller than the last time, and there must have been newcomers in the audience because there was enthusiastic applause between the movements. I think that's a great sign. One of the highlights of the evening came after the concert, when Maestra Alsop, Ms. Weilerstein, and the conductor for the first piece on the program, Rei Hotoda, sat down for a Q&A with a sizable chunk of the audience. A lot of people wanted to talk about women in music, given that Maestra Alsop is the first woman conductor of a major American orchestra. Maestra Alsop really impressed me as someone who cares deeply about music and and does everything she can to make classical music accessible, welcoming, and enjoyable to the entire community. The classical music world needs as many people like her as they can get.

I did have call today in the psychiatric ER. The theme of the day: people coming off a cocaine high get very depressed and suicidal. But some of them just want to get admitted so after a few days without cocaine they can leave the hospital and get high on a smaller and cheaper amount of cocaine. It was kind of funny how easy it was to see right through one of the patients. Despite claiming to be suicidal and depressed, he sure acted irritable and defensive, especially when we brought up cocaine use. And of course just as we were walking out of the room, out of nowhere he claimed to be homicidal. Sorry, buddy: try better next time. I can see how psychiatrists can get jaded. But I'm glad I'm learning to pick out the liars and the fakers. It's hard because the whole therapeutic relationship is based on trust, and you have to assume initially that the patient is telling the truth. But there are clues that tell you that something's not right: inconsistencies in the story, symptoms that don't make sense, even just a gut feeling. So watch out world--I have my eye on you.

Weird Japanese game show

Man, I feel terrible, but this really made me laugh.

Violence and mental illness

Last night when I was on call, a new patient came to the child psychiatry unit. She had been threatening to kill her family and in fact had stabbed her teacher with a pencil. She is nine years old. When the resident and I went to the unit to write admission orders for her, I was curious: what does a homicidal nine year old look like? It was almost surprising to see that she looked, well, like a nine year old girl. She was tall for her age and thin; she wore a hospital gown that fell down to her feet, and she had wild, thick curly hair. She reminded me of a figure in a Pre-Raphaelite painting. She asked the nurse for a rubber band for her hair in a timid voice, and when the nurse asked her what kind of cereal she wanted, she said "I don't know" like any child who doesn't know what she is allowed to have. When I left, she was eating her cereal alone at a table in the darkened unit, lit only by a single ceiling light.

I've been thinking about violence and mental illness ever since I had a bipolar patient on internal medicine who would get very irritable and once started making very threatening moves as if he was going to harm me. On the psychiatric ward right now, we have a patient who spent 20 years in jail because she burned her house and her sister was killed in the fire. I spent some time looking for information about the link between mental illness and violence; it's a controversial issue and and it's difficult to find a consensus. This is just a blog post, so I'm not going to try to summarize everything I found, but there are some important points to make. While there is increased risk of violence in patients with mental illness who abuse substances, patients with mental illness who do not abuse substances have the same risk of violence as other people who live in their community. In addition, patients with mental illness who receive inpatient treatment are no more violent than people in their community after discharge from the hospital. In fact, it is more likely that patients with mental illness will be the victims of violence than commit violence themselves. And when people with mental illness do perform violent acts, the most likely targets are family members or friends, not strangers. For more information, check out these articles from the New England Journal of Medicine and World Psychiatry.

Mental illness already carries a huge stigma, and much of that stigma comes from exaggerated notions of the link between mental illness and violence. As one of the psychiatrists told us on the first day of the psychiatry rotation, "There is always the possibility that an encounter with a psychiatric patient will turn violent, but you'll find that most psychiatric patients are nice people." Indeed, the patients I'm working with are good people who have to live with a very difficult disease. I've mentioned Mr. E, who has schizophrenia; he's a kind, gentle person and one of my favorite patients I've had all year.

I've always been touched by reading about the relationship between British writer Charles Lamb and his sister Mary. From my longtime companion, the Norton Anthology:

When he was twenty-two his beloved sister, Mary, ten years his senior, broke down under the strain of caring for her invalid parents and stabbed her mother in the heart. Upon her recovery, Mary was released to the care of her brother, who devoted the rest of his life to her and to their common household. Mary's attacks recurred, briefly and periodically, and when the terribly familiar symptoms began to show themselves, Charles and Mary would walk arm in arm and weeping to the asylum, carrying a straitjacket with them.

Even in a short passage like this, it's clear how much love Charles had for Mary. I hope that in our society, we can learn to show the same kind of love to those with mental illness. After all, all of us will encounter mental illness, whether in ourselves, a loved one, or a coworker. I hope we all take the time to educate ourselves about mental illness so we can treat these people in a helpful and caring way.

Important instructional video

Came across this and had to share: how to kiss someone passionately. Don't forget step three: confidence!

Music and mortality

When I was a kid, my mom would tell me that she wants Mendelssohn's Italian Symphony and Holst's "Jupiter" from The Planets played at her funeral. Nothing gloomy or mournful; she wants to go out with a bang. So every now and then, I think about what I would want played at my funeral. Of course, my first thought is something consoling and comforting; if I can get Brahms' German Requiem or Faure's Requiem performed, that would be incredible. Of course, that fantasy includes fitting a choir and full orchestra into a Mormon chapel, so unless I find a trove of lost Aztec gold or something, I don't think that's going to happen. If I go with music that's life-affirming and joyful like my mom wants, I'd go with Schumann's Rhenish Symphony, Dvořák's Carnival Overture, and the finale from Bartok's Concerto for Orchestra. Seriously: you are doing yourself a grave disservice (wow--worst unintentional pun ever) if you are not listening to these pieces on a regular basis. It's like musical Lexapro!

All the same, the best music I ever heard at a funeral was at my grandfather's. Several of his grandchildren played musical numbers, including me, and two of his friends sang "Goin' Home". My grandmother said that Grandpa would have loved it. I can't think of a better way to express your love or to commemorate a life than through music. So listen up, future children and grandchildren. Any of the pieces above will work great for my funeral. But I have a feeling that the recently dead are very sentimental. So let the smallest child sing something simple and from the heart, something like "I Am a Child of God" or "Nearer My God to Thee." I will probably cry disembodied tears and feel once again the pain of separation from you. But music bridges worlds--after all, the resurrection will be signaled by a trumpet call. Let me enter immortality with the music of mortality in my ears.

Keep in mind, though, if Mom/Grandma beats me to the other side, I'm not hanging around in the rafters at the funeral. I'll be on my way to meet her at the Great Hot Tub in the Sky. I hear they have awesome virgin margaritas there!

P.S. Speaking of music and death: I had a patient on surgery who was in the ICU and couldn't talk because she had a tracheotomy. In her room, there was a stereo which played a CD of Baroque favorites on repeat, nonstop, day and night. The same 50 minutes of music over and over again. A human being can only listen to the Four Seasons so many times. So, future children and grandchildren, if I'm in a coma or intubated or demented or what have you, please bring me music to listen to, but please, please bring me more than one CD! Trust me--I have plenty at home!

A schizophrenic can teach you a lot

My favorite patient right now is Mr. E, who has schizophrenia. Just on Friday, he was telling me that he has 100 hearts and 12 crowns from 12 countries. He also has the cure for AIDS and cured his own diabetes. But today he's doing much better, and he made a really insightful comment in our community meeting: "Healthy thoughts make healthy people." I think that's a pretty good summary of the field of psychiatry, not to mention a good rule for living.

Blogging

So today I helped my grandma get onto my aunt and uncle's blog for the first time. She was thrilled, of course, and it made me think again about my poor neglected blog. So here I am again. It's hard to get something like this going, especially when you have no time. But maybe I'll take another stab at it.