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Venio [Feb. 14th, 2012|02:53 pm]
Ruling the bends.
It's good to be back.
How are all of you?
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(no subject) [Jul. 22nd, 2010|05:30 am]
Ruling the bends.
Find A Way

Suicide is one of those topics spoken about almost casually: hanging from the end of a rope, bloated and facedown at the bottom of a pool, in the master bedroom with an open bottle of seroquel - and did you watch the Italians get their heads handed to them this morning in the World Cup? Still, after every time-of-death pronounciation there's more than a few solemn moments before everyone starts to shuffle out of the room, time enough for everyone to contemplate their mortality. I have a ritual for these chasms: a methodical exhalation followed by the mantra of I'm glad that wasn't me - neither an invocation of hate nor of pity, but existing at a liminal space between hope and relief.

From a medical standpoint suicides are a relatively straightforward affair. Contact the appropriate authorities, inform the family, be wholly reverent and professional but otherwise wash our hands of the affair. Our business is with the infirm. And it is when suicides obligingly shift - a change of heart prompts the gun barrel to change by a few degrees or a knife is paused midway down the forearm - that we are given the most work. Often the emotional weight of a suicide doesn't prompt consideration of an intention gone awry. And this is the problem - our bodies, unlike our fragile emotions, are designed to withstand some of the worst insults of a suicidal intent. They survive bullets through the skull, slashed arteries, prolonged deprivation from oxygen - enduring massive traumas and emerging wrecked but alive. The iron resolve of biological survival combined with

Some of the things I have seen are almost supernatural to watch, even if they are scientifically sound and chillingly repeatable. A patient tried to end her life with a shotgun and tried to stop at the last second - blowing through her jaw, sending bone fragments and lead shot into her sinuses and hard palate. Medical staff replaced three-quarters of the blood in her body1 while surgeons carefully cauterized the bleeding vessels, wired her jaw back together and packed what remained of her face with gauze. Heroin overdoses have been put on ketamine drips by anasthesia to wake up forty eight hours later, groggy but free from a potentially lethal opiate withdrawal.


An elderly suicide was brought in once for trying to end his life by putting a gun to his chest and trying to destroy his pacemaker. He succeeded - shattering his clavicle with the first shot, bullseying the pacemaker with the second - but EMS brought him in before anything else happened (apparently one can survive with a broken pacemaker - a body's resilience is astounding). We later learned that this was the second pacemaker he'd been through - for reasons unknown to us he'd destroyed the last one as well, had it replaced and lived with it for quite some time before attempting a repeat performance. And this is the thing that gets me about medicine - the cilice constantly abrading away at my sense of duty. It is this: in many situations health care pits a system's overtly finite resources against the surplus of human will. With noncompliance2, obesity, suicide - it frustrates me that while we can change human physiology we cannot ethically change behavior.

Medical care is not cheap. The cost of a pacemaker - installation, inpatient care, a thousand other billable expenses - can exceed $50,000. Go through three of them and you've more than taxed a system that is supposed to provide services for both the indigent and the affluent.

My current philosophy is this: You are (will be) my patient. It is not my place to worry about the cost of your care, or the strain that might be placed on society if I order more expensive tests to confirm my diagnosis. I readily concede that this is an indefensible, childish, myopic stance: in a system where resources are finite a set of rules will evolve to determine how those resources are shared. So at some point perhaps I will have to become both a physician and an economist - and piss off a lot of patients who will hold me up as a symbol of a dysfunctional system. And part of my resistance to rationing care comes from this aversion to dislike: I don't ever want to be told that I'm not doing enough to fully treat a patient. Somewhere along the line, however, this will break down.

At what point do I let a suicide go unchallenged?

1. The average human body contains 5.6 liters of blood. This is not an insignificant amount.
2. Noncompliance = medical jargon for a patient that does not take their meds. Often this can be perjorative, but the true causes vary wildly - sometimes patients have 25+ (!!!) medications to take in a day and trying to get through all of them seriously taxes their willpower. Other times, patients believe that their own judgement supplants that of their physicians - and days later they wind up in our emergency room. Again.
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(no subject) [Apr. 6th, 2010|04:05 am]
Ruling the bends.

In two hours I get on a plane to Los Angeles. My first real vacation in more than nine months. If you're in town, give me a buzz.
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(no subject) [Feb. 24th, 2010|04:14 pm]
Ruling the bends.
Tabula Rasa (2/2)

To close out this set of entries: For the rest of my life, no one will care about the C- I got in organic chemistry or the A- in quantum physics exactly one year later. And that's just how I want things to be.
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(no subject) [Feb. 7th, 2010|03:14 am]
Ruling the bends.
Tabula Rasa (1/2)

Two days ago, I got into medical school.


I haven't been sleeping much at all since then. What little I've had was uneasy and short, punctuated by surreal nightmares that left me waking up covered in sweat. It's almost as though a strange cocktail of hormones has been released into my bloodstream. I'm sleepless but running on all cylinders, awake despite the insomnia and tearing through days with an absence of purpose that sickens me.

Call it a mini-vacation. Or prison. Your call.

Work is nonexistent; my research protocol has been written and I am waiting to meet with my mentors before a final copy is submitted to an ethics committee. I spend hours reading at my desk, on the couch in the living room, propped up in my bed with a pillow at my back. I go for runs in the freezing weather outside and wear polypropylene tights and a wool balaclava when the temperature dips into the 'teens. When it's too cold to go running or the sidewalks are iced over and dangerous, I spread a thick towel on the wood-panel floor and do push ups to The Black Keys. I watch movies - Medicine for Melancholy, Summer Hours, Conan The Barbarian; no thoughts to the future save those to kill time until the next hospital shift.

It feels like summer vacation. More specifically: summer vacation during the gap between high school and college. That time was, like this one, filled with the security that I would soon be going to college and didn't need to worry about the present. I spent a lot of time on the beach, played more Goldeneye than was healthy, and quietly left the house in the small hours of the morning to hang out with my first semi-serious girlfriend. When I wasn't slacking off I remember being really, really bored.


So: Maybe lostcosmonaut is onto something when he wrote about writing things down and then those things actually happening. So, like him, maybe all I need to do is write down Give me something to do, Cincinnati in an eye-poppingly large font and my days will be filled with events. Manna from the heavens and all that.

At the very least it could get warmer.
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(no subject) [Jan. 13th, 2010|09:45 pm]
Ruling the bends.
Exit Wounds

It's a lazy Sunday and I'm in a trauma bay watching an army of scrub-clad grunts go to work on a limp victim. The room is brightly lit, with fluorescent lamps making the star-shaped droplets of blood on the floor shine like patent leather. There is no music, no soundtrack to the madness; only the rustle of clothing and the deep baritone of the trauma surgeon as he stands, quarterback-like in the middle of the maelstrom, barking orders to his team.

I'm at the far end of the room behind a red line on the floor with the words "DO NOT CROSS" painted onto the tile in bold, fuck-off letters. Standing next to me is one of the vascular surgeon fellows - a tall basketball player of a woman wearing scrubs, surgical clogs and a physician's coat so white that looks as though it just came back from the cleaners. She's explaining the finer points of trauma medicine to me - the different stages of hypovolemic shock (a result of blood loss), how to tell a contact wound from a shot at a longer range (look for a star-shaped powder burn) and countless other small tidbits of information that I file away for a future cocktail party. Then, during a lull in the madness, she asks a question that catches me entirely off-guard.

"Do you know how the mafia used to execute traitors?" she whispers into my ear.


A nine millimeter parabellum round weighs roughly 7.75 grams. For reference: the average male human weighs about 80 kilograms, meaning that a bullet is roughly one hundredth of one percent the mass of your garden variety bruiser. No one disputes the power of these tiny pieces of lead to bring down even the largest of foes, but the amount of damage even a single round can cause has fascinated - and challenged - trauma teams since the first gunshot victims were brought into hospitals.

They are unpredictable demons, sometimes entering and exiting quickly and without incident (a "through and through") but just as often becoming lodged somewhere in the body, playing hide-and-go-seek, or hitting bone, fragmenting into pieces and leaving bits of themselves in several far-flung locations. I once saw a case where a patient was shot in the chest, straight into the the nipple, and the emergency resident found an exit wound just below their left buttock, the bullet marking its path with a trail of shredded flesh.


Back in the emergency room a resident inserts a needle into the chest of the patient, releasing the pressure on their lung and allowing the organ to inflate. The fellow continues her lecture on execution styles of the Cosa Nostra.

"Over time," she murmurs, "they developed a tidy method. They put the victim on his knees - hands tied behind the back, head down and facing forward. They used a small-caliber bullet; a .22, for instance, something that'd enter the head without coming out the other side. The setup was designed to minimize the number of bullets it would take to kill - as it tore through the brain it would ricochet off the inside of the skull and scramble things around. It was pretty efficient as far as killing goes."
"Developed a method?"
"Yeah - all that stuff about 'two to the back of the head' is true I guess, but in the beginning they found that some people would actually survive - neurologically intact in a few cases - and I'm sure it was all sorts of fun when those people started talking to the FBI."

Bullets, apparently, sometimes provide equal frustration to both surgeons and hitmen.
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(no subject) [Dec. 31st, 2009|11:25 am]
Ruling the bends.
95% Confidence Intervals (1/3)

I'm half an hour early for my first date in almost a year and a half, time enough to walk around for a bit and calm my nerves.The lobby of the Cincinnati Art Museum is crowded and hot, and I make an immediate beeline for the coat check desk where an elegant black man in a smoking jacket takes a quick look behind him before waving me in.

"It's all right," he smiles impishly, "There's no one in there - go ahead and check 'em in yourself."

The coat check room looks like a very prodigal children's closet. There are hundreds of coats, scarves, gloves, and beanies all hung neatly on silver wire racks or folded and placed in cubbyholes above the hangers. A pair of windows faces south-east, overlooking Eden Park and its now empty fountain, and the afternoon light creates a warm glow throughout the entire room, making it seem much larger. I grab an empty hanger and unload my heavy coat onto the slim steel wire, then wrap my scarf around the stem and shove my gloves into an empty pocket.

I head back into the lobby and thread my way through the crowd, walking a straight path past the glass cases filled with ancient Egyptian statuettes and thorugh an interesting-looking exhibit on African masks, all the way to a second lobby where an impressive double-set of marble steps spiral up towards the second floor. It's a huge room, lined with pillars at intervals and tiled with black and tan eight-pointed stars set in a bronze lattice. Here the crowd's thinned out significantly - a few people are reading at tables in the corners of the room and an elderly woman chases a pudgy, giggling blonde child across the expansive floor.

When I'm nervous, straight lines and easily identifiable geometric shapes calm me down. One of my friends - a graduate student in clinical psychology  - told me that this is not uncommon, and that it's a small way of seeking order from visual chaos. I walk slowlyr, my eyes focused a few feet in front of me, tracing the lines in the floor and trying to pretend that the room is empty, silent, an oasis of calm that will pin me to the tiled floor under its shady embrace and leech the anxiety from me like the moisture form a snail that has been dusted with salt by a malicious child. When I reach the opposite side of the room my insides are still churning, so I head upstairs to the rotating galleries. I pace through the wood-paneled floors, not focusing on anything in particular, hoping that

My phone buzzes.

"Hey." I whisper into the receiver, "Are you in the museum?"
"Yeah," she replies, "I just got here - I'm in the lobby, under a hanging blue sculpture that looks like a ball of worms."
"All right, I'll be right down. I won't take more than a couple of minutes. See you in a few."

Maybe it's my own anxiety, but I swear I can hear a nervous staccato in her voice - and in a complete "duh" moment I realize that we're both probably equally eager to create a good first impression. This does more for me than any of my previous attempts to relax, and as I descend the marble steps in the column room a slow change comes over my frenetic motions. Somewhere in the middle of my walk back to the lobby everything slows down. Like in a John-Woo action sequence, except with Oscar Peterson in the background. Consciously but unconsciously my back straightens, my pace slows - I am suddenly acutely aware of the rolling heel-to-toe motion of my boat shoes against the museum floor - my chin tilts slightly upward and a warm tingling feeling spreads itself across the back of my skull and works its way forward to my temples.

And gradually, I start to have fun.
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(no subject) [Dec. 1st, 2009|11:19 pm]
Ruling the bends.
So that I can remember today: Sun (Acoustic)
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(no subject) [Oct. 15th, 2009|11:05 pm]
Ruling the bends.

"That's my roommate shivering" says J. into the phone, "he's wearing a merino wool sweater, a jacket, jeans and wool socks. And we still don't really have heat yet. They're putting in the furnace some time next week."

I pause in the middle of the living room to stare at him, then sit down at my desk and devour the rest of my mac n' cheese.

"No mom, it's okay - it's not that cold - oh c'mon really it's nothing..." his voice trails off as I close my door. Then comes the audible 'click' of the phone being closed before he yells through my door:
"Jewish mothers! They worry about everything!"


I went for a run through Northside on Sunday. It reminds me a lot of San Francisco - grungy, multiracial, a huge LGBT community, coffeeshops where the waiters are also the same people that lead your tri-weekly bike ride. It's also got a lot of dark haired, skinny-jeans wearing, tattooed cyclist chicks; as if the fact that the neighborhood is chillingly beautiful in the Fall isn't reason enough for tromping through the place.

My normal morning run takes me to a park about a half quarter mile east of Northside to a hill that overlooks the west side of Cincinnati. It's become such a ritual that random co-workers have stopped me to tell me that they've seen me.

"Hey N." said my boss.
"I think I saw you running this morning."
"Are you sure it was me?"
"Were you running down Ludlow this morning at 9am?"
"I knew it was you!"

Honestly? It's nice to be noticed. But I'd prefer it were by a younger, more hip crowd.
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(no subject) [Sep. 7th, 2009|11:22 pm]
Ruling the bends.
The Minor Leagues1,2

I'm coming off of a 14 hour shift in the emergency room; half a day of enrolling patients in trials, HIV counseling and being on my feet. There's a faint line on the back of my lab coat that wasn't there this morning, the off-white bisected by a brown streak of dirt and sweat. My handlers are still ambivalent on how to properly train me: half want me to go through a structured, three week program in which I learn all of the clinical studies we're running and shadow more experienced researchers until I get the hang of things. The other half want me to, in their words, "jump in headfirst" and direct my own progress. Lately the second group has been winning out on my treatment, and I'm slowly understanding that I learn more quickly when I have minimal hand-holding. So far it's been a rough beginning but I know I've got a long way to go.

I thought that interviewing would be easy - or at least easier than the first year of medical coursework. The truth is that it's not so much difficult as it is different; studying cofactors for ten hours each day requires a completely divergent skillset than is required to properly diagnose an illness or tell someone that they're now paralyzed from the waist down. There's also a huge difference between watching a physician convince a patient to join a trial and trying to do it yourself. The first time I tried to get consent from someone to enroll in our HIV study I failed spectacularly:

"Hello. I'm, um, a researcher in the, uh, ED and westudyHIVrisksandprevention and, um, isitokayifIaskyousomequestions?"

You could have heard a cricket fart in the room after I finished that sentence, it was so quiet.


On my first day I got an almost 80% refusal rate. It did wonders for my ego.

The truth: I wish I could do this almost every day.

1: Put your headphones on and crank up the volume before you hit |>
2: Pharrell Williams and Chad Hugo are, right now, my favorite contemporary hip-hop production team. This beat is solid.
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