Sunday, August 28, 2011

Peparing for Irene

How do you prepare for a hurricane? Irene has been my first, so I'm hardly an expert, and since most of the so-called "experts" on television weather have been too hysterical to be of much use, I've been on my own. Oh, sure, they invite you to the same song and dance we're heard since 9/11, have plenty of water and food, an emergency radio and flashlights with batteries, and so forth. But I live on a farm which creates its own set of challenges. There's no shelter three blocks away when water starts rising past the crack under the front door.

The first thing I did was cut up all the downed limbs from the last big blast that blew through last week and stack them in the barn. I figured tomorrow morning, after Irene has left me for another boyfriend up the coast, I'll have even more to keep me busy, so why not get a head start. Forewarned is forearmed or, as we say in Scouts, Be Prepared.

Then I finished mowing the pasture that impersonates a yard around my house. With four to six inches of rain in the forecast and the ground still damp from Thursday's showers, any attempt in the near future is going to be muddy. As it is, the Turners -- people who drive down my dead end lane on the presupposition "Dead End" means something other than "there's nowhere left to go," stop when they realize the sign means what it says and turn around on the grass in front of my barn -- have already left deep ruts like a kid carving his initials in fresh cement. No sense in following their lead.

The next step entailed doing something I've been thinking about for the past three winters. I bought a Coleman stove, one of those single burner jobbies that runs on propane. I considered the more compact model that burns white gas but remembered another Scouting lesson: I hate pumping, Coleman white gas powered lanterns and stoves require fairly regular pumping to keep them burning. If this were the dead of winter, I'd have a fire in the fireplace and cooking over it wouldn't be an issue. But in summer? No thanks, I'll take the stove.

After that, it was off to the local grocer for dried pasta, crackers, and cans of soup to heat up with peanut butter sandwiches. Things that are easily prepared with a pot of water and no fuss, no muss. Why peanut butter? Well, if I have to use the propane stove, it's because the power has gone out. With the number of trees looking for a good excuse to tumble down in a heap like a passel of Green Bay Packers on John Elway (if they could have caught him, that is), power outages are worth anticipating. Besides, I like peanut butter.

And that leads me to the apples. Apples and peanut butter. Whole Foods freshly ground honey roasted peanut butter, to be precise. Talk about ambrosia. Well, the apple wars have started early this year, i.e. the annual foray between the crows, worms, wild turkeys, deer, Freddie, and me, for apples from the ancient trees someone planted here long ago. Who's Freddie? He's a porcupine who rents the space under my barn, though if you ask him, he'd say he owns it. Whatever. Drives the dogs absolutely bananas when he ambles across the front yard at night. I saw him crossing the road yesterday, aiming for a mid-afternoon snack. I called what I felt surely was a pleasant enough greeting, but the little introvert turned round and trotted (I didn't know he could move that fast) back home. Feeling badly because I'd deprived him of the same pleasure I enjoy, I tossed a few nibbled cores and some new ones near his front door. I hope he doesn't mind my fingers.

And that brings me back here. The apples are in the kitchen, sharing the side board with fresh brownies, maple muffins, and chicken cooling for tonight's candle light picnic. All that's left is to write my supervisor and tell him I won't be in the hospital tomorrow, and depending on how badly Irene batters my neck of the woods, maybe not the day after. Last year a white pine with a diameter the length of a meter stick fell across the road and we were landlocked for 48 hours. With only one route to the rest of the world, all it takes is one big tree and a hurricane is turned into an adventure, and I'm ready.

(Photo of apple tree copyright 2011 by the author)

Thursday, August 25, 2011

A Little Boy's Dream

I was four years old when my love affair with fire trucks began. At the time, it was a pumper with a hook and ladder truck and an ambulance that caught my eye just before Christmas. I still have them, battered and scarred with parts missing from good times. I wish I'd taken better care of them since they're worth many times more than what my parents paid on the collector's market. Not that I'd sell them, because, well, you know, they're a part of my childhood. For everything else there's MasterCard. You can't buy memories -- not like these, anyway.

On that Christmas morning, though, I was in for a bit of a disappointment. The only sets left on the shelf were ones without the ambulance and I really wanted the ambulance most of all. How else can you rescue the people, I thought? Someone has to take them to the hospital because they've been hurt in the "fire." It was a childhood fantasy I later fulfilled as an adult when, in my first pastorate, I volunteered as an ambulance driver. Little did I know, either then or as a four year old, I'd end up a medical student seeing patients in a hospital. The most amazing things creep up on you when you're least expecting them.

Kind of like another little boy's dream, the one you see in the photo. It's a 1936 Chevrolet I saw a few nights ago, parked in front of the Knights of Columbus in Old Town, Maine. Of course, I had to stop and take pictures. How could I not? My guide for the best tour I could have asked for, was a tow-headed little guy about seven or eight years old who happily indulged me by climbing into the back to ring the bell. He was able do that, you see, because his daddy, as he proudly informed me, owned it.

Old Town has a special connection for me which I discovered the same evening, when I noticed a sign on its outskirts identifying it as the home of Old Town Canoes. We paddled Old Towns when I was a Scoutmaster on white water canoeing trips in Southeastern Oklahoma. And there I was, driving through the place where they were made. I don't know, it just struck me as sweet, and it brought back very pleasant memories of sunburns, campfires, and friends far away.

Anyhow, back to the fire truck. Walking around it I noticed a plaque that told me everything I needed to know about the person who owned it and why. If you look closely you can see it, right there on the passenger side. It reads simply, A Little Boy's Dream. Yeah, you guessed it. Daddy wanted a fire truck when he was was young and promised himself one day, when he was all grown up, he'd have one for his very own. And now he does and he shares it with his son.

Who shared it with me.

(Photo copyright 2011 by the author)

Wednesday, August 24, 2011

Doctor's Notes

Before going much further, I feel like I should apologize for not having written anything lately. The past seven and a quarter days I've been working with the hospitalist service and that includes the weekend. It's probably self-indulgence, but truthfully, our work as students doesn't end with a punch of the time clock. Anyway, thanks, as always, to any and all who've come by to see if there's anything new. I've got the next four days off and I'll try my best to make up for my laxity of late.

What's that? Oh, the hospitalist service refers to physicians who are employed by a hospital for the sole purpose of providing inpatient care. My current rotation entails spending a week to ten days working with one of them -- it's a bit like an apprenticeship -- and learning internal medicine under their tutelage. The two weeks prior were spent with family medicine residents seeing their assigned patients and it's to their service I'll report once again this coming Monday.

As healthcare delivery has changed over the years, it's pretty rare to see a family doctor or any kind of doctor, for that matter, admitting and then following their own patients in the hospital. There are still a few, mostly family practitioners in the hinterlands of upstate Maine or other remote locations, who do it the old-fashioned way, but they're a vanishing breed. For the most part, patients are evaluated in the ER and then transferred to the responsibility of a hospitalist who oversees their hospital stay.

And that's where my fellow students and I come in. We'll report to the Emergency Room, take a detailed history from the patient and/or their family members, complete a physical exam in the company of a resident or attending physician, and then become a member of their treatment team as long as they're inpatient. Sometimes the H & P (history and physical) has already been done when we arrive for rounds (morning report) and we just go on from there.

My first two weeks I spent learning how to write a clinical note. That may not sound like much, but really, it's huge. The clinical or chart or progress note -- they're all basically the same thing -- is how doctors talk to one another about a patient's condition, symptoms, and so forth. Even though I got the basic format down during my psychiatric rotation, writing a note for internal medicine takes practice and I practiced a lot. I didn't have nearly as many patients to follow as I did this past week, so I had time to write and rewrite my notes over and over to make sure I had something worth leaving in the chart.

This past week my task was slightly different. Having gotten accustomed to writing notes that were legible and covered all the clinical bases, now I had to figure out how to turn them out faster in order to keep up with my attending. But you can only write so fast before legibility gets tossed out the window and a student's note has to be readable in order for a supervisor to evaluate our thinking process. So, you learn the art of brevity, writing what is truly necessary, and generating a plan of treatment that specifically addresses a patient's symptoms that particular day. Pragmatics take precedence over literary perfection.

It's a matter of taking one step after another, one step at a time. That's really how a rotation like this one unfolds. To be of any value at all, you've got to be able to communicate about patients and since your note is a critical element in the process, you start there. It's not dramatic, no one's going to page you at the end of the day with an offer of a guest spot on Gray's Anatomy. But once in a while, an attending reads what you've got to say, decides you have a good idea, and adds the medication you suggested or obtains the consult you recommended. And right then, you got to do something good for someone. And that's really cool.

(Creative Commons image entitled "Doctor's Note" by keitamiyoshi via Flickr)

Tuesday, August 16, 2011

Stuck in the Trenches

A British trench near the Albert-Bapaume road ...
If we could hop into Mr. Peabody's WABAK (pronounced Way Back) Machine -- remember Mr. Peabody and Sherman, the dog and his boy from The Adventures of Rocky and Bullwinkle? You can see original episodes on Hulu, revealing Bullwinkle to be not nearly as stupid as he was depicted in the movie, definitely an insult to tall people with big antlers everywhere. Anyway, if we could enter the WABAK and take it way, way, way, back -- hold on, it wasn't that long ago -- to my high school days, we'd find Dylan's The Times They Are a'Changing was one of my favorite songs.

As a fairly normal teenager with a fairly normal desire to separate from parental influence and declare my independence, I particularly liked the second verse:

Come mothers and fathers throughout the land,
and don't criticize what you can't understand;
Your sons and your daughters are beyond your command,
your old world is rapidly agin';
Please get out of the new one if you can't lend a hand,
for the times, they are a'changin. 

Naturally, this drove my father crazy, which was not my conscious intention -- unconscious is another matter. In some ways, though, I'm the same person now I was then. Not that I'd attempt to drive my dad crazy if he was still living; we'd gotten long past that conflict of interests by the time I was in college. What I mean is, I haven't lost my sense that change is a pretty good thing and it's even better to try and keep up with it.

I'm probably thinking about this because one of my housemates showed me his ipad over breakfast yesterday and it was the first time I'd seen one up close. Out loud, I wondered, tongue in cheek, if I shouldn't genuflect in its presence. Have you see one yet? They are something. Steve Job's crew outdid themselves big time. Surf the web, watch movies, make a phone call, you can even connect with your home computer and work on files at a distance. In the words of Will Smith at the helm of an alien spacecraft (Independence Day, 1997) "Man, I have got to get me one of these!"

The willingness to embrace and even promote change expresses the essence of the term, "liberal," or so I was taught in high school. Conservative, in contrast, was about preservation, and holding onto what's good about the past. A wise person, I reasoned, does both, since history forms the basis for whatever lies ahead. So, on the drive home yesterday -- turns out I had the day off, as well today, and it made no sense to spend the time up north when I could more comfortably spend it here with sleeping dogs around my chair -- I began thinking about something Jesus said. "The Sabbath was made for humanity, not humanity for the Sabbath."

The context for his statement was a conversation involving the religious leaders of his day, some of whom accused him of violating the laws concerning Sabbath observance. He countered by saying, the needs of people outweighed tradition. It was a pretty radical assertion, especially to make before a group of people who depended on maintaining tradition for a sense of meaning and purpose. Suggesting something else might take precedence, naturally drove them crazy.

Just then I switched the radio station and came upon a message from James Dobson's Focus on the Family, one of many contemporary organizations that seems intent upon codifying behaviors as either acceptable or unacceptable, and doing so on a religious basis. I thought about comfort and discomfort with change and it struck me that it's easier to become entrenched in what one believes than to expand one's beliefs to accommodate new ideas. Once we're entrenched, we have limited options for maneuvering.

Recognizing that none of us possesses the absolute, final word about anything and any description of ultimate truth is partial at best, might help. Not that there isn't a final word or an absolute truth, but how we speak of it reveals more about us than the truths we espouse. Even if we deny the existence of absolutes, that says something about us. I guess it's just hard to see that sometimes. Especially if we're stuck in the trenches.

(Image of unknown licensure via Wikipedia)

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Sunday, August 7, 2011

Internal Medicine: One Week Down

Downtown BangorThird year clinical rotations are great opportunities to discover what you don't know. For instance, I thought, like many other well-intentioned medical students, that "internal medicine" was concerned with illness conditions too severe for the family practitioner to manage. You referred to an internist when the waters were swirling and you didn't want your patient going under a third time. Oops, there goes another of my misconceptions. Internal medicine means simply the practice of adult medicine. Family docs treat families, pediatricians are all about kids, OB/GYN's manage women and babies, and psychiatrists -- well, they try to keep everything on an even keel, how's that? Except family docs treat adults and pediatricians may treat young adults, so that throws simplicity out the window.

Once upon a time, internal medicine would have been my first rotation, but as it stands, I've spent time in a rural family practice (loved it), pediatrics (really loved that), and psychiatry ("you make me feel like dancing, I wanna dance the night away" ~ Leo Sayer). I've also done a stint in osteopathic manipulative medicine (a wonderful experience) which, for us DO types, ties pretty much everything together. I guess I've come back to where I might have started.

So, what kinds of things can you encounter in IM? The same ones you do in kids, the kids are just bigger, is all. And there are some you don't as much. Heart disease is more common in adults, hypertension and the effects of lifestyle -- alcohol, drugs, overwork. Cancer, clearly something the world would be far better off without, is there, too. Adults have responsibilities and being sick means being under stress, which only complicates the healing process. Internal medicine (and pediatrics and family medicine and...) is one part physical and two parts psychological and spiritual. People who are sick need hope. Come to think of it, so do the rest of us.

Where do I see my assigned patients? Since this is a hospital-based rotation, the inpatient unit, ICU, and rehab. If one of them is undergoing a procedure, I'll follow along to observe and learn and provide moral support. You see, students possess in relative abundance, something the residents and attending physicians have in short supply, i.e. time. We also have some measure of freedom about how we choose to use it. Talking to patients, forming a relationship, is one of the best uses of our time. If you've never been a patient yourself, or even if, like me, you have, this is a chance to find out what it's like for them to be in their shoes. Moral support may seem small in comparison to writing treatment orders, but from the patient's perspective, it's huge.

It's also important to spend some of that "abundance" talking to nurses and not simply about the patients you have in common. Nurses know things, things you want (and need) to know, too. When you're trying your heart out to do well, to develop some measure of competence, and to avoid doing anything that should never be done in the first place, having staff members who watch your back is priceless. Besides, it makes life more pleasant and we can all use some of that.

I mentioned in a previous post how I wanted to learn more psychiatry in the course of learning internal medicine. One week down, I think it's impossible not to. Osteopathic physicians are intent upon finding the person in the midst of their illness. Patients aren't problems to be solved, though their condition may pose many, nor are they incidental to what we do like a spot on an X-Ray that turns out to be a clasp on a hospital gown. They're the why for all of medicine and any occasion to work them teaches something about why they tick the way they do. I suppose you could say I'm learning how to keep them ticking as healthily and hopefully, as long as they can, before the clock strikes twelve.

(Public Domain image of Downtown Bangor, ME via Wikipedia)
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