Tag: pediatrics

Curry at Christmas

jono55

What was the most intense year of my seven years of medical school and residency? No contest! It was my junior year in medical school. This was where we were turned out of the laboratories and libraries and shoved with little grace into the middle of a hundred patients’ stories at once. Stories that had predeeded our arrival and that would go on after we’d moved on to another clerkship.

[Definition: a clerkship was a portion of the junior year devoted to a specialty in medicine. A taste of everything, at least nominally to help the student pick out the discipline he or she would specialize in as a resident. The traditional clerkships were surgery, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry. ]

My first clerkship was on surgery, at the ancient Minneapolis General Hospital, a structure left over from the 19th century, with soaring ceilings, twenty-bed wards, inadequate wiring, no air-conditioning to speak of, and a patient population consisting of some of the nicest, some of the hardest-working, and some of the most dangerous people in town.

I loved it.

If you were being cared for on one of those ward there was only a curtain drawn to separate you from the other nineteen patients. There were few secrets to be kept, not when one loud-voiced medical attendant after another came to move or massage or feed you.

For the bookish student that I was it was almost unbearably exciting and completely exhausting at the same time. I would be on call every third night, and be up continuously that night. Next morning I would go to the outpatient clinics to act as if I weren’t half asleep, stumbling from litter to table to bed and seeing what kind of composure I could maintain in this new and desperate life.

The house staff, consisting of the interns and residents, and who were being abused in the same way, often regarded a medical student as yet another problem to be solved. Someone too earnest to ignore but too dumb to trust.

Perhaps one personal example will be enlightening.

I was spending the afternoon in orthopedic clinic, and had been assigned to change a cast on a twenty-two year old woman who had fractured her tibia weeks before. All I had to do was cut off the old cast and put on a new one, since by that time the bones had gone a long way toward knitting. The resident had informed me that the woman in question was a “working girl.” I was actually unfamiliar with that term but a couple of questions brought me right up to speed.

I thought to myself, well, then it’s nothing more than the meeting of two professionals and things ought to go well. I introduced myself, got out the cast saw and within no time at all removed the old and unsightly plaster.

Next I applied wrap after wrap of plaster cast material up and down the lady’s leg from just north of her toes to her upper thigh. If there was a bulge or a dent in this masterpiece I was creating I smoothed it over with a bit more plaster.

And then it was done, a thing of absolutely glistening porcelain beauty on one of the shapelier legs in Hennepin Country, I thought. I stood up and stood back and asked her to walk. The patient got to her feet, tried to take a step, and suddenly burst into tears. I had made a cast so heavy that she could not move it. It might have functioned as a construction pillar for a large department store.

I scurried to get the resident, who quickly diagnosed the problem. He consoled the sobbing lady and then, before he applied himself to taking off this monstrosity and replacing it with a workable version, sent me away for the afternoon. The look on his face was so clearly “Lord, what have I done to deserve this?,” that I did not quibble.

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Only You, by The Platters

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That same year, that same clerkship … a boundary was set for me. Remember I said that I was on call and up all night every three days? Well, on the days I wasn’t on call I would hang around the hospital, looking and listening to what was going on in that great beast. I loved every minute, even those where I screwed up or ran myself into walls. It was just such a vat of ferment.

But after two weeks of that very first adventure in the surgery rotation, I came home at eleven o’clock one night and the patient woman who was my wife was waiting up for me. I can’t quote her exactly but the sense of what she said went something like this:

“You have a wife and a baby daughter who need to see you. You can’t stay at the hospital when you aren’t required to be there and ignore us. If you keep doing that, one day we won’t be here when you do decide to come home.”

At that moment a boundary was set that I knew that I would violate at my own risk. I can’t say that there weren’t a few slips here and there, but there were significant periods of time between them. The problem was that those nights in the old barn that was General Hospital were among the most memorable … ever. So seductive. Such an attraction. Such a world had opened up there.

Aaaahhhhhhh … to be 24 years old again, wearing an ill-fitting scrub suit and eating free but tasteless cafeteria food and drinking free but thin coffee at three a.m. in the company of a cadre involved in fighting some of the best fights ever. Talk about your foxhole mentality … we had it.

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This Christmas Eve Robin and I were by ourselves. We did leave the house to drive to the village of Ridgway (population 1200) at suppertime, where our favorite Thai restaurant was keeping its doors open. There are several Thai restaurants on the Western Slope where we live, but the very small one in Ridgway has an artist in the kitchen.

They are not afraid to charge what they think their food is worth, and the Mango Curry was $19.95, which is high for such a dish in this part of the world. But what a curry!

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As I left the restaurant, I grieved that I hadn’t been able to completely empty my bowl, and had left an ounce or two of broth behind. But my lips had already passed from intense capsaicin-induced pain to complete swollen anesthesia and I feared that the rest of my face would follow suit.

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You Always Hurt the One You Love, by the Mills Brothers

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We had one of the best Christmas Days this year, compliments of three good friends. All of the food dishes that Robin and I had prepared turned out well, the weather was impossibly beautiful, and the conversations ranged from the historically interesting to the nitty gritty of today’s politics.

All five of us were liberals, two being Independents and three Democrats. At some point one of the our guests said something to the effect that when things are this bad there is nothing to do but hunker down until the bad guys go away. Give them enough time and they will implode, they said.

It was at exactly that point when the patriot Patrick Henry, whose words American schoolboys have had to learn for centuries, took over my body and began to speak. I began to make statements, outline resistance strategies, and make impassioned pronouncements as to the need for and the what of such resistance using words I only dimly understood and information to which I had little claim.

It is in vain, sir, to extenuate the matter. Gentlemen may cry, Peace, Peace but there is no peace. The war is actually begun! The next gale that sweeps from the north will bring to our ears the clash of resounding arms! Our brethren are already in the field! Why stand we here idle? What is it that gentlemen wish? What would they have? Is life so dear, or peace so sweet, as to be purchased at the price of chains and slavery? Forbid it, Almighty God! I know not what course others may take; but as for me, give me liberty or give me death!

Patrick Henry, March 23, 1775

When my mouth finally shut for a moment, there was no one more startled than I. I began to back off from what I’d said, and admit that there was no reason at all to listen to any of it because I was a known widely as a repeatedly convicted peddler of rampant nonsense. The rest of the group then settled down and lips that had tightened relaxed. When we parted amicably at the end of the evening and were still friends I silently thanked the gods for stopping me before I ruined what shreds of a reputation for probity that I still had.

But then Mr. Henry returned to say one more thing: “Well, Jon my boy, you’re a fainthearted patriot and that’s for certain. But give me a bit more time … I’ll make a bloody rebel of you yet.”

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Smoke Gets In Your Eyes, by The Platters

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Adrenaline Junkie

jono55

I woke last night out of one of those reality-based dreams where for a moment or two after waking I was still half in it. It went like this.

A friend and colleague of mine who was working with me in pediatrics called me on the phone to tell me how my patients were doing. At the time I was out of town bicycling somewhere with Robin and staying in a small cabin.

As he was talking I became overcome with guilt and worry. When he told me that baby Murray was doing okay I thought who the heck is baby Murray and why haven’t I been going in to see him? How long have I been AWOL? Whatever am I going to tell his parents now when I do make rounds tomorrow? That I’ve been ill? Away on a vacation?

I got up and walked into the kitchen with a head full of miseries but as I was filling a glass with water I realized – Hey! I haven’t been practicing for twenty years. There is no baby Murray that I have been neglecting. It was a dream! I am off the hook!

I might also add that the colleague who had called me died eleven years ago.

But some of the emotional charge of the dream is still with me as I type this. Whatever chemicals are released in such a fight or flight fantasy-drama take time to dissipate. But they are being tempered by the huge sense of relief that came over me when I fully realized that I had done nothing wrong and there was nothing that I needed to atone for.

I’m not one to parse dreams looking for why this or why that or any kind of meaning. The fact that my brain is not wholly in my control becomes obvious every time I sit down to meditate. As I am trying to clear my mind that gelatinous ball of mischief keeps on spinning yarns and making stuff up. I assume that it loves when I go to sleep because it can then create scenarios without being interrupted.

Anyway, how are things with you? I am just peachy here.

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Do I miss practicing pediatrics? Yes. No. Actually I’m still doing it, just secretly. If there is a person standing in front of me who is talking about some puzzling symptom their children are dealing with my mind takes the facts and runs with them, working to come up with a set of diagnoses. Happens automatically. Like a ChatGPT that is never off duty.

But, and this is a big one. I have no medical license any longer (too expensive to keep as a memento) and my clinical skills are -shall we be kind – rusty. Only if one of the diagnoses that I have come up with is a serious one that deserves being explored right now do I speak at all. And then I recommend that they see their physician ASAP. Otherwise I nod and listen without really listening.

I loved the challenges of emergency situations. This was when my variant of adrenaline junkie came into play. When you don’t know yet what is going on but you know that the clock is running and you get the chance to take everything you have learned up until that moment and bring it into play to try to solve a very high-stakes problem … that is a real high, my friends.

But there are those times when the clock runs out too soon and there is a crash to deal with. A version of depression mixed with self-recrimination sets in. I never learned to handle the losses well, but lordy did I love the wins.

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Fearless, by Pink Floyd

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By any account you are to read, except those emanating from Club Cluck, No Kings 2 was a dramatic and positive event. Prompted by the unholy mess that the New Fascist Party is making of our country, we found ways to rejoice in the feeling of solidarity that comes from finding thousands upon thousands of people who, like us, are shocked at our leaders’ bad behavior, ashamed of what is being done in our name, and resolute in taking the steps needed to replace this regime with thoughtful, firm, and honest leaders.

We are figuratively marching toward Washington DC right now. And we can already hear the mewling of the cowards there as they stare into crystal ball after crystal ball trying to find one with a good future in it for themselves.

Perhaps one day we will need to march there in person to show them where the door is and to turn them into the street where they can spend the remainder of their lives snapping at each other in dishonor and disgrace.

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Screenshot
Screenshot

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I was introduced to Sister Rosetta Tharpe way too late in my life. Here’s a link to a recent article on Substack with a whole bunch of videos of this amazing musician.

She told the truth about her craft in a way only the greats dare to: “These kids and rock and roll—this is just sped up rhythm and blues. I’ve been doing that forever.” And she was right. Before Presley shook his hips, before Berry duck-walked, before Little Richard shrieked his way into immortality, Sister Rosetta had already been there, guitar in hand, voice like a hurricane, planting seeds in soil that would grow the rock and roll forest.

Bill King, Substack

BTW, if you need more, there is way more. All you have to do is go to YouTube and type in her name. Riches will flow into your life.

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There is record of only one protestor being arrested during the national No Kings event, and that was a woman in Fairhope, Alabama. She was carrying a sign that read NO DICK TATOR! However, it wasn’t the sign that got her arrested, but her costume. If there is to be a No Kings Hall of Fame one day, surely this courageous and resourceful lass will be one of the very first to be inducted.

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Wish You Were Here, by Pink Floyd

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Medicinae Doctor

jono55

I realized recently that I hardly ever recount “doctor stories” in this blog. I have them, of course, after more than 35 years in those trenches. They tend to accumulate. Any line of work where you bump up against humanity in stressful situations will do that. Jobs like teacher, firefighter, law officer, soldier, etc. Each of them has their own set of stories, and mine are no more interesting or precious or enlightening than anybody else’s. Their only claim to fame is that they are mine, and meaningful to me in one way or another as a result. Here are a couple.

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A Love Idea, from Last Exit to Brooklyn

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The small collection of patches and bumps and lumps on one’s skin that show up from time to time when one is young becomes a deluge of keratosis this and precancerous that as aging takes its toll on the dermis.

My dermatologist has even farmed out this tedious part of his business to a specialized PA so that he can devote himself to far more remunerative tasks, like fat freezing. Cosmetic procedures seem to be where it’s at if you want to buy a condominium of respectable size in a desirable location.

When a new patch shows up and looks benign to me, I use the OTC freezing kits you can buy almost anywhere. And for smaller lesions this works. But these rather wimpy tools are leagues away from what I had access to when I was a practicing physician. Back then I could call for a sturdy stainless steel thermos bottle containing liquid nitrogen, which was at a temperature of 320 degrees below zero. Now there’s a freezing agent with hair on its chest! (Note inexplicable use of archaic and sexist phrase).

There was a moment in my professional life when I had been on call too often and up at night too many times in a row and I said to my former wife (a registered nurse): “This is really too much. What would you think of my going back and taking a residency in dermatology?” Her answer took the wind out of that particular sail: “Why would you want to leave medicine?”

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From The New Yorker

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The New Yorker magazine of February 13 has in interesting article on space travel, including the fact that Musk and Cluck are excited about the prospect. I share their enthusiasm. In fact, I am so excited that I think this awesome pair should have the honor of being the first to make that voyage, and I suggest next Tuesday as a departure date.

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L’Enfant, from The Year of Living Dangerously

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An intern on pediatrics has been assigned the duty of being on call at the University of Minnesota Hospital on Christmas Eve of 1966. At sign-out rounds it looks to be a quiet evening. No known disasters are looming, and any patient who could be discharged is at home with their family. It is a cold night in Minneapolis, with temperatures already below zero by supper time.

At 1900 hours there is a message from the emergency room. A sick infant, daughter of two graduate students, is waiting to be examined.The history is a brief one. The child has been ill for less than 24 hours, with symptoms of fever, poor appetite, and increasing listlessness. The examination reveals a generalized light pink rash, a neck that resists flexion, and the “soft spot” on the baby’s head bulges slightly.

The frightened parents are informed of the likely diagnosis and what must now be done quickly. A spinal tap reveals pus cells but does not give further clues as to the organism responsible. A sample is sent for culture. The working diagnosis is meningitis, etiology as yet unknown.

Treatment is immediately begun with what is called triple therapy – penicillin, a sulfa drug, and chloramphenicol. (This was at a time when the number of antibiotics available to a physician was very limited.)

The baby is moved to the infant ward at 2100 hours and at 2130 suffers her first cardiorespiratory arrest. The intern is able to resuscitate her using chest compressions and mouth-to-mouth breathing. But there is to follow a second and then a third arrest. To the last one there is no response. Shortly after midnight resuscitative efforts are abandoned. The intern drops into a chair, exhausted, beaten.

In the morning the laboratory reports that they are growing the bacterium Neisseria meningitidis from the baby’s spinal fluid. Common name = meningococcus.

All personnel who came in contact with the child during its brief admission are advised to take antibiotics to try to protect themselves against developing the disease.This is implemented by placing a large jar of sulfa pills in the center of the infant ward, with dosage instructions taped to the side of the jar. Everyone was to help themselves to what they needed.

The intern reflected on his part in the resuscitations, grabbed a handful of the tablets and stuffed them into the pocket of his uniform. He turned and left the area. There were rounds to be made.

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Such was the state of the art in 1966. So primitive by standards of only a few years later. There were no pediatríc ICUs, few antibiotics, and little existed of equipment that had been downsized to where it was suitable for use in the care of very sick babies. For example, intravenous infusions were gravity-fed, with infusion pumps not yet on the horizon, so maintenance of a working IV was an art form.

And that big jar of sulfa tablets … the self-prescription … looking back that seems more like practicing medicine in a war zone. Perhaps that was what it was.

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The Wings, from Brokeback Mountain

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Genghis Noem

jono55

Things to feel positive about when each day seems chockablock with disheartening news.

  1. We are learning so much about our own country’s constitution through the efforts of those who are attempting to subvert it. Knowledge is power so that’s a good thing, right?
  2. While eggs at City Market now average above a daunting $9.00 a dozen, it means that chickens all over the country are now earning enough that they no longer need to work two jobs and can spend more time with their families.
  3. February is hump month vis-a-vis the weather. Get past it and we are coasting downhill into Spring, which is a swell time. Very swell.
  4. If you are reading this you probably don’t have the bird flu.

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Kristi Noem has been confirmed as Secretary of Homeland Security. While that is not great news for the U.S. as a whole (she has an unfortunate tendency to shoot creatures who displease her), within seconds of that confirmation we received a phone call from a lifelong South Dakotan who was so ecstatic to be rid of her as governor that her joy could not be contained.

Before she gained renown for blasting away at her pets and livestock she was already famous for mostly ignoring COVID in South Dakota and for getting herself barred from all Native American reservations in her own state.

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[Some people have an antipathy toward poetry. Perhaps it might help to think of a poem as sometimes serving as a hone, sharpening their senses and appreciation for what was already there in front of them. Here is one by a pediatrician/poet, written in 1921. ]

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Winter Trees

by William Carlos Williams

All the complicated details 
of the attiring and 
the disattiring are completed! 
A liquid moon 
moves gently among 
the long branches. 
Thus having prepared their buds 
against a sure winter 
the wise trees 
stand sleeping in the cold.

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From The New Yorker

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On the subject of pediatricians (you didn’t know we were discussing them?), long ago I had a mentor named Henry Staub M.D. who I met only after my formal pediatric training was completed. Henry was a children’s physician, an ardent community activist, and one of the kindest people I’ve ever met. As a young man with Jewish parentage he, he had left Nazi Germany just in time to avoid being drafted into the army and thus discovered.

There is much of what I became in my own professional life that I took on from Henry by osmosis, but there were two sayings of his that I still think of frequently.

“The best doctor is the one that hurts the most.” On the surface this might seem paradoxical, but what he had observed was that there was a strong tendency to be “kind” to sick children, and for that “kindness” to delay discovery of sometimes serious illness.

For example, suppose that a child presented with symptoms that might be early signs of something really damaging. If the patient had been an adult, there would have been no question about doing the required but often uncomfortable testing, but in this case the physician decides to wait and watch for a while, to be certain that investigation is required since the patient is so young. However, in not wanting to cause pain to the small one the doctor instead sometimes hurts it far more by delaying diagnosis and proper treatment.

The second was a brief description of his own hypothetical professional journey, and was always told with a smile at the end. “I went into pediatrics because I didn’t like adults. After a few years, I didn’t like children, either.”

But Henry did love children, and was their constant advocate. Not for just those in his practice, but the larger community as well. A wise guy.

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“I heard a very good joke yesterday, someone said: ‘Musk is not a Nazi, Nazis made really good cars.’”

Stephen Fry

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Hypnotic. Beautiful. Don’t worry that you can’t understand the lyrics. No one can.

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I believe myself to be living in a revolutionary time, where many of my long-held standards and beliefs about my country are being dissected and discarded, their fragility revealed, the spider’s web of a platform on which they rested found to be riddled with gaps … easy pickings for the unscrupulous.

One one hand there is the thuggery and brutishness of MAGA, a collection of the benighted if there ever was one. On another hand there is the aging creakiness of the Democratic Party leadership, which seems unable find the laces on its Louboutins in order to tie them properly and so to get on with the people’s business. Yet another hand says a pox on both those houses. There are other “hands” as well. We may only have two official political parties but there exist oh so many constituencies.

One of those constituencies is the most influential of all, and that is that of the extremely wealthy. This one is actually more powerful than any of the parties.

In the old days (anything more than one election cycle ago) those people ran the country and the world but much preferred being invisible. These days the one percenters have not been not just taking blatantly more than their fair share of everything, they have used their fortunes to stack every deck they can get their hands on to perpetuate and increase their privilege.

Our history shows how easy it has been to pit us one against the other so that we would ignore their machinations. For instance, in our Civil War there were 620,000 deaths. While slavery may have been the spark that started the whole bloody mess, only a very tiny fraction of the men who died in either army had ever owned a slave. So why would a threadbare farmer from Minnesota travel a thousand miles to shoot at threadbare farmers in Virginia? What was their quarrel?

Who told them that taking up arms was the proper thing to do?

Guess.

So if there is a revolution coming, count me in. I may not mount the barricades as nimbly as a couple of days ago, but if nothing else I am more dangerous because I have good eyesight and less to lose.

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No Banker Left Behind, by Ry Cooder

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