Tuesday, July 31, 2012

Pickles and other reasons the summer is lovely

The ICU has been sucking away my time, so this will be somewhat brief. In fact, the title is now blatantly misleading, as I’m really only going to talk about radish pickles.
These pickles were amazing. I try to cook seasonally, and in Michigan, that means eating a LOT of vegetables in the summer, and preserving some for the winter. These were my first attempt at a recipe from the canning book I got for Christmas, although I will note that they were not actually canned. I will also note that they were so delicious that they did not need to be canned. They probably didn’t even need to be refrigerated, given how quickly I ate them (as evidenced in part by the fact that I couldn't even snap a picture before the jar was half empty). Also they were pink.

Radish Pickles
adapted liberally from the Ball Complete Book of Home Preserving

2-3 cups sliced radishes
2 cups white vinegar
2/3 cup granulated sugar
1 tsp mustard seeds
2 tsp whole black peppercorns
sprinkle of red pepper flakes

Place the sliced radishes in a large glass or stainless steel bowl and set them aside. Combine everything else in a saucepan, and bring it to a boil over medium-high heat. Reduce the heat and let the liquid boil gently for a few minutes. Pour the liquid over the radishes, and then let it stand for about 30 minutes, or until it’s cooled to room temperature. Pack the radishes into jars, and ladle the pickling liquid over them to cover. Put the lids on the jars and refrigerate. The recipe recommends that they marinate at least two weeks and up to three months. I think I made it about 5 days, and they were all eating with two weeks. Yum.

Sunday, July 29, 2012


Cross-posted on Dose of Reality

I don’t often think about my life in terms of percentages, particularly as a way of judging success, but there are times when it is hard to avoid. For example, as sub-interns (the fancy word for fourth year medical students on more intensive rotations, such as in the ICU), we are expected to have off one day in every seven, or a total of four for the rotation. If a normal workweek, one in which the weekend is free, is 5/7, or 71.4%, then my workweek is 6/7, or 85.7%. This leaves only 14.3% of my time as free, which is small. Smaller even than the proportion of arterial lines that I have successfully placed, which is what prompted the writing of this post. An arterial line, or art line, or a-line as you may hear, dear readers, is a special IV that goes into an artery, most often the radial artery in the wrist. It allows for the easy drawing of arterial blood for labs, for continuous blood pressure monitoring, and for the humiliation of every medical student who ever did an ICU rotation. I have attempted the placement of five arterial lines, six if you count the one that I missed the first time but then got later after the one my resident placed failed, and that I subsequently got, as two separate lines. I have successfully placed two. That’s right, two. That gives me a resounding 33% or 40% success rate, depending on the counting I mentioned above. This is not reassuring. It is, however, profoundly humbling, which is probably not a bad thing. Maybe humility is what the ICU teaches most effectively of all?

Monday, July 23, 2012

Negative Margins!

I don’t have much time for a good post, but wanted to update you all about Walter’s exciting medical drama (background here and here). I got the call from the vet letting me know that Walter’s margins were negative, which is basically the most positive possible outcome. It means that it is unlikely that any cancer was left in his mouth when they cut out the side portion of his jaw. It also means, since the path came back as a sarcoma, that he doesn’t need any further treatment. Walter is a survivor! (I apologize if that term is offensive to anyone who is a human cancer survivor… I don’t mean to demean your experience at all.)

He is basically back to being himself, as you can see below. The primary side effect from the surgery is that he can’t eat things as efficiently as previously, which is great. Those of you who have ever seen him eat anything know that he used to inhale food and other random semi-edible objects. Now it takes a minute, which gives me a fighting chance…

You can hardly see where the teeth are missing...

Unchanged love of sleeping in clean laundry. Only now he sticks his tongue out as if to spite me...

Climbing rocks and having fun, just like pre-op.

Ever the snuggler...

Wednesday, July 18, 2012

Medical decision-making

Cross posted at Dose of Reality

I know the title sounds approximately as riveting as not at all, but I’ve been thinking a lot about it since I’ve started my ICU month. While I’ve been reflecting on the medical decisions I’m making, in the time I take to process everything I’ve seen, I’ve been focused more on those we expect the patients and families we care for to make. We call on them during their most dire hours and ask them to consider options they don’t necessarily understand, to weigh risks and benefits that are hard to put into context, and to make calls that no one ever wants to have to make. And they do it. Not always with the calm and rational process that would be easiest for the physicians working for them, but more often than not with an incredible degree of grace and reflection mixed into the grief and frustration.

The conversations are almost always accompanied by a great deal of sighing, sobbing, and shouting, which can be disconcerting to those of us working to provide medical care. I think what made me most frustrated back when President Obama’s plans to encourage the discussion of advanced directives turned into a death panel debacle, was the callousness of it with regard to the families of critically ill patients. How many of the individuals who were most loudly heard during that national discussion had been in the position of trying to determine the appropriate goals of care for a loved one at the end of life? I’d hazard a guess that there were very few. Anyone who has had to weigh these questions, particularly without the benefit of a signed document crafted by the patient him/herself charging the course ahead, would think twice about protesting a more considered approach.

With or without a mandate from the government, however, I increasingly believe that physicians and other healthcare providers have a serious obligation to discuss end of life care with all of their patients. A few questions about code status when a person is hospitalized (i.e., whether or not an individual would want chest compressions, shocks to the heart, or other measures to bring back a patient whose heart has stopped while in the hospital) are simply not enough. Although I have been impressed with the way many of my teachers and mentors have navigated these challenging situations with hospitalized patients and their loved ones, I can’t help but wish that as a nation we could pause, reflect on what we want from our last weeks, days, and hours, and take a moment to write it down.

Looking for more resources on Advanced Directives and Living Wills? Check here for the UMHS Publication.

Friday, July 13, 2012

100 miles… done.

Sorry for the pause in the posting... I started my ICU month on Monday, and it's set things a bit behind in all other aspects of life...

I did it! In the process of training I rode over 1,000 miles, over 500 of which were in June alone. It paid off though, in that most of the 100 mile ride was very comfortable. The last few miles up some very steep hills (really, ride organizers, really?) were rather painful, but I don’t think anything I could have done would have prepared me more for those. As was decided by you all in this post, we rode the Covered Bridge Tour, and I couldn’t recommend it more!


We started out in the historic village of Fallasburg, which is about 30 minutes by car outside of Grand Rapids. After registering and eating a very quick breakfast, we hopped on the bikes. Our first stop was in Ida, a mere 14 miles down the road. They had delicious snacks, and a beautiful covered bridge:

It was beautiful and shady for the next portion of our ride, and when we stopped again in Coldwater (past another bridge, see below) I hardly wanted to slow down.

We were about 25 or so miles into the ride, which is where I tend to really hit my stride. I’m properly warmed up, but not tired, and really enjoying myself. After that we went straight north back into Fallasburg for lunch. They served delicious pasta, garlic bread, strawberry shortcake, root beer, and chocolate milk (from the local dairy farmers, no less). Have I mentioned before that I primarily enjoy biking for the food? It was fantastic, and a good prep for our next 50 miles.

The second half of the route was much less shady and included a few more busier roads. The rest stop, however, was at a beautiful historic home in Ionia, MI. They were so gracious as to let me use the bathroom – probably the nicest one on any bike ride anywhere…

After that we cycled past the prison (seems you can’t bike more than 50 miles in this state without hitting a prison), the State Recreation Area (which looks surprisingly similar from the perimeter), the city (town? village?) of Lowell, and some of the most gigantic hills I’ve ridden ever on my bike.
And then it was done!

Friday, July 06, 2012

Polka-dot jersey kind of ride…

Last weekend Alicia and I did another long ride – this one 71 miles round trip. It felt a lot longer, however, because of the hills. Part of the route was similar to the preceding week’s ride, but the part that looped a bit farther north was also quite a bit steeper. We agreed that we should go around perpetuating the kind of graffiti we appreciate so much on Huron River Drive:

You see, the polka-dot jersey is awarded to the Tour de France cyclist who is the best at climbing hills. They get points for big climbs that are separate from the overall race, and throughout the race, the rider with the most points gets to wear the jersey. There are a number of different classifications, and each of them comes with a special jersey. The yellow jersey is worn by the rider with the best overall time, the green jersey by the rider with the most points, the polka-dot jersey for climbing, and the white jersey for the best young rider. Some enterprising individual painted a tiny polka-dot jersey on the road at the top of the largest hill on Huron River Drive, and it is a delightfully motivating little symbol.

Only a few days left until the big ride, so I’m taking it pretty easy. It’s also 101.8F today, so I’m trying not to die as well.