Delightfully tacky

I know this probably won't endear me to the female readers, but I love Hooters. I would say that I really like the food, but I can hear the outcry already. The food is very good though, and it's hard to get spicy hot American food, but their wings and sauce are HOT.

But the best part about Hooters is that it revels in its tackiness. This is what drew me to Hooters on a beautiful day with a friend of mine, Macintosh. Mac had never been to Hooters before, so we had to go. Our server girl was nice. It's just a fun place to eat.

I actually go by myself sometimes because the Hooters near me has an outdoor patio where few people sit (because indoors are where all the girls are), so if I want to eat outside, there's always a table. It helps that I actually like the food.

My favorite Hooters memory was in med school. Me and Chocolate Thunder went on one of our man dates. We went to the local museum and soaked up the arts. Afterwards, we had to counterbalance all that culture, so we stopped at Hooters for dinner! The waitress thought that was hilarious. I mean, how many people at Hooters just spent a day at the museum?

The confusing thing to me was the table next to us was some guy with his 4 yr old girl and his 60's mother. Overhearing their conversation, he took his mother to Hooters for her birthday. WTF? That just doesn't make much sense. I mean, who takes his mother AND his daughter to Hooters?

If you've never been, I recommend it, because it's one of those places where you feel like they enjoy your presence, and sometimes when you live a solitary life, it's very nice to have someone talk to you for a minute and seem interested. ... I must really be starved for meaningful human contact.

Why I can never vote Republican ever again

I was watching Fox News this morning, and they were talking about racial profiling for terrorists. One of the interviewees was advocating profiling Muslims to improve the yield of security measures. For a while, it was a very reasonable discussion. Arguments about slippery slopes and non-Arabic Muslims, echoing of Manzanar and Japanese internment camps, versus efficiency and efficacy of our current national security model.

Then, one of the interviewees said by far the dumbest thing anyone has ever said in the history of the spoken word, since caveman first grunted to another caveman. I'm paraphrasing: Look at Israel. They are surrounded by Muslim nations, and they have used profiling very successfully to manage threats to their security. They should be our model for how to deal with terrorism.

So, here are as many problems with that statement as I can come up with in 10 minutes: (1) Israel still has terrorist attacks on a nearly daily basis. (2) Profiling is easy when you profile everyone. They are SURROUNDED by Muslims. It's not like they're picking a couple people out. (3) You can't profile the fastest growing religion in the world. Indonesia is the largest Muslim country in the world. There have been Filipino Islamic terrorists for decades. And what about Chechnya? They're fucking WHITE. How are you gonna profile WHITE? (4) Do we really want to use Israel as a model for Middle East relations? Really? Because they get along with their neighbors sooooo well. (5) Profiling will only enrage more people. Has profiling blacks done anything except piss off a lot of black people? I guess it also makes white people feel better. (6) Israel is a model for terrible security decisions. They continually aggravate and irritate, rather than try to address the root causes of terrorism.

Okay, that's all I can do in ten minutes. I really should learn to keep flipping past Fox News.

The Talk

I’ve given ‘the Talk’ more times than I can count. I’ve gotten quite good at it, and I’m very comfortable doing it. But whenever I have the chance to see someone else give the talk, I listen in to pick up things that I can use, or else see things that I would not use. On my last ICU rotation, I had the chance to sit in on a few talks, given by a variety of services.

One thing that I realized very quickly is that everyone has a bias when they give the talk. My bias is in favor of palliative care and hospice services. To me, a 5% chance of survival is a death sentence, but to a lot of people, that’s more than a fighting chance. We all take something different into the room with us when we talk to family.

Watching other attendings give the talk, there were a lot of things I wouldn’t do. None of this stuff is wrong per se, it’s just stuff that I wouldn’t do. My goal is to simplify a complicated situation. One of my attendings complimented me by saying, “You’ve got a remarkable ability to boil a complicated situation down into bite sized portions without losing sight of the person.” That was high praise in my book.

And so what I try to do is to make something complicated and fraught with emotional turmoil into something easy to digest. That doesn’t mean it’s palatable, but it can be grasped and understood.

I saw was one doc who tried to connect emotionally with the family. It was all hands-on and happy to meet you. He shook hands and hugged and patted shoulders and referred to everyone affectionately: mom and dad this, bro and sis that. He asked everyone their own opinion and encouraged everyone to talk.

The next day, the patient worsened, and I asked the family to meet again for an update, and they asked not to meet with that attending again. They saw through him like a window. They knew his concern wasn't genuine. Not that he was trying to be malicious or fake, but if you're going to play the sympathy card, you have to actually sympathize. This is why empathy is much more powerful. After you have practiced for a while, empathy is much easier. As a reminder: sympathy = I feel sorry for you. Empathy = I can see why you'd be sad. Sympathy is emotion. Empathy is thinking.

Another doc was very in tune with palliative care and hospice, but the way he presented it made it so unpalatable. He was a former collegiate athlete, so everything was a sports metaphor. It was all 'we're not going to win,' and 'do you want to throw in the towel?' Well, NO ONE wants to lose. It's like what Herm Edwards (the former NY Jets head coach) said: "You play to win the game. Hello? You play to win the game. You don't play it to just play it."

It's not fair to equate palliative care with losing, because truthfully, it's not. Palliative care is all about changing what it means to win. It's recognizing that winning isn't always about living long, but also about living well. And that choice isn't quitting and it isn't losing and it isn't giving up. A family shouldn't feel guilty for making a choice like this.

A lot of docs recommend being 'in touch' with the family, crying with them, holding hands and dabbing at tears, mourning with the family, blah blah blah. This is a mistake. It has its role, for sure, but when you are treating a patient, families are looking for authority. Like when you meet a police detective, you want him to say, "Hey, we're going to do our best to catch this guy. You let me worry about it." You don't want him to say, "I can feel your pain. Let's have a good cry, and you can tell me some stories about how he liked to fish." You want your doctor to be confident.

And it's not all about confidence in prognosis, but confident is about attitude. I may not know how things will turn out, but I am prepared for the outcome. I want families to go home at night thinking, "Well, I don't know how this will turn out, but my loved one is in good hands. I can sleep tonight and worry tomorrow."

A first death

Closing in on the end of the residency year, most of the interns have earned their first death. Some took their time. Some didn’t have to wait too long at all. All in all, I find that the reactions that they have to death are quite different and sometimes offer a unique insight.

The experience of death is a little different for each of them. Getting called by the nurse at 4 AM and being told that Mrs. R expired is quite different from being the person pumping on Mrs. R’s chest, and even this is more insulated than being the person having to tell Mrs. R’s family that there’s nothing more that we can do. And all of this is easy compared to being the person who forgot to write for an antibiotic for Mrs. R’s positive blood culture.

When a patient dies, some of the interns are relieved. The patient is no longer going to torture the intern with really hard decisions and clinical questions, many of which are life or death types of choices. It’s all over now. No more stress. Maybe the intern can get some sleep now.

Some are utterly devastated. There was so much emotional involvement, and now, no outlet. It feels like gas in your stomach, and you can’t belch it out. And it hurts in a deep way that can’t be easily resolved. You can’t talk yourself out of it. Some people drink themselves out of it.

And sometimes, every now and then, you’ll meet someone who just doesn’t care. They take the news of their patient’s death with the same attitude that someone from Nebraska would have about the Mets losing the NLCS.

I thought for sure that I would be the destroyed person when I had my first death. I thought it would empty me out and hurt me in ways that I couldn’t even comprehend. But surprisingly, I found myself in the ‘don’t care’ column. A nurse called me to pronounce on a patient that was DNR. I went to bedside, pronounced the patient, and then went back to bed.

Since then, I’ve had a lot of other death experiences, and they’ve run the gamut of relief to devastation. But I’ve always felt a little guilty about Mrs. R. Not that I did anything wrong per se but her death was so forgettable to me, and that my reaction was not one of sadness, but of relief.

I’ve since had some surprisingly hard deaths, deaths where I was so angry and so disappointed with myself that I threw things and slammed doors. I punched a door so hard that I thought I broke my hand. And I remember one death where I went balls to the wall in treatment, I talked the family out of a DNR, and after 8 hours of very aggressive treatment, the patient had a systolic pressure of 50/20. I talked to the family and we went to comfort care, and I threw things and cursed and was so angry. I did everything right, and even then, I failed.

Each death is a little different, and in the end, I find that it helps to insulate yourself a little. Each death hurts, and rather than pouring yourself out each time, it helps to ration out your compassion a bit. I know it sounds cold, but the human soul can only bear so much suffering.

Your e-mail box is full

When I went to college, I was a technocrati. I was a cyber Jedi. And while other people were tiptoeing around the world of e-mail, I was an e-mail king. And e-mail wasn’t enough eventually. I learned how to maximally abuse my shell account, and I used ytalk and zwrite and IRC as comfortably as most people breathe. I was a little too early for AIM (I was back in the day of ICQ anyway). But my point here is that internet communication was fun and exciting.

Now, I’m afraid to open my e-mail. My inbox is flooded with 10-12 e-mails a day of stuff that is NOT SPAM! It’s actually meant for me! I have to go through 50+ e-mails a week! Two weeks of vacation, I can fully expect 200 e-mails waiting for me! It’s ruined all the fun of e-mail.

So I’ve given up hope on e-mail, and I’ve gone back to writing letters on pen and paper, and hopefully, I can reclaim the joy of snail mail. I’ve given up hope on e-mail. At least with written correspondence, there is still the visceral pleasure of holding a letter in your hands.

Alternately, I may move ahead to text messaging…


So, sometimes, I get terrible insomnia. And now it's 3AM and I can't sleep. I'm smoking cigarettes, thinking about a beer, wondering if I can get someone to write me some Ambien tomorrow. But it's not noise or pain or anything obvious causing my insomnia. It's that I can't stop thinking.

I'm thinking about this patient in his 90's who I intubated, and I was literally begging his son not to make me do this. Or the little old lady who I was doing CPR on, and I could hear each rib snapping under my hands. I was thinking about the 40 something mother of two who I've admitted for the fourth time for complications from chemotherapy. I'm thinking about a potassium of 2.7, and how I only gave 40mEq orally and added 20 mEq in the IV fluids, but maybe I needed to give more.

I can't let it go sometimes. I leave the hospital, and thinking about my own life is so unattractive that I'd rather think about whether I should've added a second antibiotic to cover anaerobes.

Beautiful things

I responded to a cardiac arrest code on this young girl in her twenties. Most of my patients are old. Seeing this young, beautiful girl clinging onto life was jarring. Her wavy, blond hair was slipping across the pillow, shimmering with each chest compression. Her breasts bare to the world, their sexual power removed by a sea of telemetry wires, EKG stickers, defibrillator pads.

As I barked out orders, I was fixated on how I have this beautiful thing in my care, and I have destroyed it, like pulling the petals off a flower or rubbing the wings of a butterfly. And it's hard not to think about all the beauty I have destroyed: sisters and mothers, daughters, grandfathers, uncles, postmasters, waitresses, policemen, nurses, all kinds of beauty, ruined in my hands.

And I decided that she wouldn't die. I couldn't afford it.