Interviews Continue

In the process of making some of my last reservations for airfare and hotel, I cannot help but think about how fortunate in these ever-worsening economic times we senior medical students are to have a say in where we will work next year. It seems more of a pain than a privilege to have to jet across the US in search of the best-fit residency. But as each interview unfolds and as I'm toured the guts of America's hospitals, and as I observe how emergency departments operate on this coast or that, I feel tinges of conflict. Here I am with great opportunities - only one of which I will pursue - while the patients I'm chomping at the bit to meet, treat and advocate for face the converse: evaporating opportunity, escalating suffering and vanishing resources.

When framed this way, I ponder canceling the rest of my interviews. My pro&con lists from each program pick out relatively small differences between places. In the end, I know I must continue on for another few weeks. While the next month may consist of greenhouse gas guilt, travel fatigue and missed loved ones, the four years of residency will consist of lost sleep, steep learning curves, stresses of responsibility and the anguish of bearing witness to great pain and suffering. It will be important to live in a context of a supportive environment. Academic, social and even political and geographic context will play a part in my decision to rank programs. After then, it is up to the big computer in the sky to decide where is best.

We Escaped!

We flew on a different airline and to a different city than initially planned, but on Sunday night, my wife and I escaped the clutches of the winter storm currently incapacitating Seattle. I overheard one Southwest Airlines employee say we were the last plane to leave Seatac. I'm not sure if that was on Southwest, or in the whole airport. I wouldn't be surprised if it was the latter: we had to wait for more than 30 minutes just so the snow could be cleared on the tarmac between the plane and the runway. Our departure insured that our luggage did not make it into any "sorry, your flight was canceled, please collect your belongings in baggage claim" collections like this:


Susan was able to get to her interview at UCSF on Monday. I spent the day in the UCSF emergency departments for a 'second look.' Today, I interview across the bay at Oakland's Highland Hospital.

There are several reasons to be glad not to be in Seattle! It would be fun to play in the snow and all, but it turns out there's a reason why the city couldn't handle an inch of snow last week: Seattle refuses to use salt on its roads and the sand they do use is not enough to ensure safe motorist transit. The stated reason is the salt might impact Puget Sound's endangered salmon populations. Some biologists argue sand is actually worse because it fills the spaces between streambed pebbles such that insects and other fauna important to waterway health perish. Seattle is the only municipality (according to one article) that has a ban on salt. Sand is also 20% the cost of salt. My guess is that only the tincture of time and climate would benefit this picture:

With grades up to 20% in places, it's Mr. Sun who can restore normalcy to Seattle. Given this time of year's 8 hours of sunlight and perpetual winter clouds, I wish everyone there a hearty good luck! That packed ice takes a lot longer to melt than the fluffy stuff the kids are playing in. From a distance, Denny Way looks more like a ski slope than a road. In fact, there were intrepid young men snowboarding down Queen Anne Ave., NE 70th St., and I'm sure many others.

Snow Geese and Flying Home

On this Solstice Eve, the Pacific Northwest is getting slammed with a winter storm. And winter storms, we do not need! On Wednesday night Seattle received 1-2 inches (in most parts of the city), and look what happened:

Yes, that is a passenger bus that slid down a steep grade and plowed through a guard rail resulting in a cantilevered installation over I-5. Note the topography in the background. It's a good thing Seattle doesn't get winter weather very much. Susan and I are visiting our parents for the next two weeks, and hope to be able to leave Seattle tomorrow by plane. We also interview in the Bay Area on Monday and Tuesday! We'll be heading to the airport by bus extra early to account for difficulties from the the expected 4-8 inches of snow. If you want to see the view of the weather, here is a webcam view from the NOAA station across the street from where we live.

But we wanted to experience just a little bit of the current snow, so just as this evening's snow started to fall, we took a stroll around the golf course near our apartment. We were surprised to see a flock of about 30 large white birds circle and land on a nearby snow covered fairway. Upon closer inspection, I confirmed that it was a small gaggle of snow geese. I can only assume that they were in transit from the North Slope of Alaska to winter grounds in California or beyond.

At the time of writing, the snow has completely obstructed our view across Lake Washington. Unlike this Seattle-softened Midwesterner, I expect these birds to know what to do in the cold...

Science News

Among many other strong choices for science advisers, it appears an outspoken advocate for curbing greenhouse gasses has been selected to serve as chief science adviser for the Obama administration. John Holdren, a past president of American Association for the Advancement of Science, had to cancel a meeting at Harvard to fly to Chicago. According to journalists who are familiar with these escapades, this probably means he is meeting with Obama about a job. The AAAS blog reports this, as does a NYTimes blog. About climate change, he says,

I am one of those who believes that any reasonably comprehensive and up-to-date look at the evidence makes clear that civilization has already generated dangerous anthropogenic interference in the climate system…. What keeps me going is my belief that there is still a chance of avoiding catastrophe.

Sounds pretty okay to me. He also was involved with Pugwash and was part of the crew that accepted a Nobel Peace Prize in 1995 for nuclear non-proliferation work.

What I want to know is if he will get an office IN the White House. You may recall that GWBush kicked his science advisers out in favor of them occupying space down the street.

Random Musings

• 14 gauge needles are huge.
• Work hours debates continue.
• Teaching is fun.
• An electrified skeleton of a deer is feeding on the tundra that is our balcony.
• Did I mention how large 14 gauge needles are? I mean, an arm vein with a 14 gauge catheter seems to lose more blood (and faster too!) than a catheterized wrist artery... I've the bloody scrubs to prove it!
• Must... Get... Out... Into... Sun.... SOON!
• Thanks fto an anesthesia rotation, not only do I now check out people's veins when I meet them ("Could I get a 16 gauge into that antecubital?") but I inspect their chins. ("Start with the MacIntosh, or go straight to the Miller?")
• There are plenty of real people out there that think about more than, well... see above.
• Soon, I will be pulled in only one direction: the beach.

Note to Self:

Hey Robey!

When you have the time, write some blog entries about the latest Papal statement ("Dignitas Personae,") about in vitro fertilization and stem cell science and some of the responses to it.

Or maybe something about the scandal of free religious expression in the Washington State capitol building.

Or even about how the magi's part in the Christmas story provides a pretty good metaphor for a healthy interplay between science and religion.

I'd imagine each of these to be a good fit over at Clashing Culture, the blog I started about science and religion, which I have sorely neglected in the past few months. In the interim, get back to work!

Eagles

One thing I know about wherever we end up next year after the residency search is that I probably will not be able to sit in my living room and take pictures like this. (This bird was probably 20 meters from my window.)


Granted this is an out-of-focus shot with a point-and-shoot digital camera, but that I can see this on a regular basis from where I type away on my various projects is one of several reasons why my wife and I will miss Seattle. I just wish I could have gotten the snow covered mountains or Lake Washington in the background of this shot. But really: yesterday, I saw a bald eagle, a red tailed hawk and a Cooper's hawk in the span of a few hours.

Intubation

Today, I intubated my first (human) patient. I used a MacIntosh laryngoscope to displace the epiglottis so that I could insert a breathing tube down a patient's windpipe (trachea) so that she could be comfortably anesthetized during a surgery to remove her thyroid. The anesthesiologist had let me insert the plastic tube twice on other patients while he held the blade. He then let me do #3 from start to finish. #4, however, was not so successful. The patient's short chin and other factors made for a difficult process. At least I got one!


And let me say, my experience ventilating mice was not of much use as preparation. (I've probably intubated 750 rodents.) In the case of the mouse procedure, a cotton swab is the laryngoscope and a 10-100 piece of beveled tubing is the endotracheal tube. Evaluation of proper intubation (visualizing vocal cords, seeing fog on the inside of the tube and symmetric chest inflation) is however the same...

I can usually put patients at ease when I sew up their cuts if I say I've lots of practice stitching mice. Based on today, neither anesthsiologist nor patient will learn of my previous 'experience' with rodent intubation...

Delta Work Hours?

Last week the National Academies' Institute of Medicine released a report recommending that medical resident work hours be curtailed even more than they were five years ago. This is based on some pretty solid research, mostly from a sleep study group at Harvard. The report is the subject of my latest post at The Differential, which if you're in academic medicine, you should definitely read (if not my post, the report). Unfortunately for me, if the accreditation group makes any changes it will likely be AFTER my intern year when I'm expected to work 30 hour shifts...

Update 12/9/08: My post is getting a lot of comment activity, particularly from resident surgeons who are proudly defending the fact that they violate their 80 hour limits and love it! Check it out! By the way, Pauline Chen at the NYTimes wrote a biased "I didn't have work hours limits when I was a resident and I turned out just fine, thank you!" article about this issue. And there is lively discussion of the topic at the Times' Well Blog as well.

4th in 5 Days

I'm in NYC ready to interview at the NYU/Bellevue emergency medicine residency. It's my 3rd city in 4 days, and tomorrow will be my 4th interview in 5 days. On my day off, I observed for a few hours in the New Haven hospital before going by Amtrak to NYC. I'm not particularly tired, but I do miss being home. Some things that have made this trip easier include:

• Traveling by train in the northeast is easy: show up at the station, get on the train, work in peace and quiet for a few hours, get off the train & you're there.
• Staying with friends from med school is great. Since I took 4 years to do my PhD, my classmates are all 4th year residents and therefore very knowledgeable hosts. It saves lots of ca$h, too.
• Traveling light is a must. For me, that's a bike messenger bag and a shoulder garment bag.

Negatives include:

• Not seeing or talking to my wife much - The three hour time zone difference further complicates the fact that she is working a night shift and sleeping days, and "everything's in a fog" for her.
• Gum on transit seats. Bad form folks... If only we were in Singapore! My impromptu road extraction kit lacks a key solvent. Hopefully the friendly neighborhood dry cleaners will be able to help me next week. My evaluators will have to look REALLY CLOSE at my backside to notice the gum remnant!
• Answering the SAME QUESTION over and again. At least my response stays the same each time.

Well then! Enough from me...