Turkeys

Had Thanksgiving at Team Crabtree's place last week. It was, mostly, delicious, and the time was, mostly, a good time. Wanted to share a few pictures. And hate on a dog.

First, the board. The central hub of organization and scheduling. Why Adam and Ashley have a gigantic white marker board I am not entirely sure, but it came in handy when we finally started preparing dinner at 1100. Plus how else would we have remembered to dress Spanky the Chihuahua?

Second, the fixins. After hours of labor -- Ashley's not mine -- we finally had ourselves some food. From top going clockwise we have the cooked parts of the turkey, the less cooked carcass of the turkey, "rolls", my attempt at some sort of candied yam thing, some tasty stuffing, mashed potatoes, green beans, creamed corn soup, and a ceramic bird full of gravy. All in all a good dinner aside from a continuous background chorus compliments of Sparky the Chihuahua.


And, lastly, the what the hell is this? If you guessed Nerf football cut in half and placed in a Pyrex baking dish you would be only partially correct. For reasons unknown squash was on the menu until a prolonged bake yielded this. A very comfortable bike seat. Due to unforeseen complications in preparation the squash was ditched in favor of eating Patsy the Chihuahua instead.

For more Thanksgiving photos including pictures of Cupcake the Corgi, Sushi the... some sort of dog, and Spunky the Chihuahua; check it out! The rest of the weekend was spent playing video games. Just as the Pilgrims did back in 1776.

My Nation Calls

Today I gave my yearly urine sample for the standard military drug screen. In light of past years difficulties I actively prehydrated. And then prehydrated some more. After an unreasonably long period of time I was finally able to give them what they wanted, and I've never stopped peeing since. I am not sure how much water I drank exactly, but I believe it would be measured in buckets. Or perhaps barrels if we were talking small barrels. I anticipate the urine flow to taper off sometime in early December assuming I don't slip into a hyponatremic coma first. Until next year.

In other news they built an IHOP underneath my apartment. Stay classy, San Antonio.

(And bring me a donut shop...)

Corn Activities

A few weeks ago we went to a corn maze -- excuse me, maize maze -- and it was... fun? What to say about a labyrinth of produce? Is corn truly a vegetable? Thanks to a handful of flashlights and an excess of clues it was not terribly difficult or very scary. The kettle corn was delicious, however, and they did have a corn cannon with which to shoot corns out of. All in all it took about 45 minutes to complete and after eating a little more corn we went home.

Here's a picture of this year's corntacular challenge!

Standing in Mud for a Song

Last week, complements of Ro, I went to Austin City Limits. Without exaggeration it was the hottest, sweatiest, and muddiest I have been in a good time. Which, coincidentally, makes for a pretty good time. The temptation to slip and slide about the muddy knolls was present but I remained dignified. Plus no one else was doing it.

Although the two bands I truly wanted to see, Dave Matthews and Flogging Molly, had played the day before, I still got to see a bunch of bands I had never heard of (David Garza, The Dead Weather, and Heartless Bastards) and two bands I had heard of but, really, never heard (The Toadies and Pearl Jam.) It turned out one of David Garza's band mates also apparently does hula hoop tricks? By the end of the evening when Pearl Jam finally came on for their two appointed hours we were shoulder to shoulder with countless thousands of other people in what was likely the greatest exchanging of germs the nation has seen in years. I may or may not have been standing on top of someone. I definitely got to first base with the back of the dude's head in front of me.

Despite knowing all of only three or four songs, Pearl Jam was still pretty great. There was not a whole lot in the way of pyrotechnics or special effects, just deafening music that gave me phantom vibrations and tinnitus for about three days afterward. Crowd surfing was attempted but resulted in the guy being thrown over a shoulder and promptly into the gack, and moshing was impossible due to the complete inability to shift one's body weight. Live music it seems is powerful stuff even if much of it is unintelligible. I suppose that's why any respectable nationalist uprising or religious revival always has a good chorus. Post concert we ate at Wendy's -- and I do believe even the food tasted better.

The Pushiest Dog

Last week I house sat for some friends. After eight days of drinking all their Dr. Pepper I called it and went home, a resounding success. Aside from a brief visit from the police due to my inability to effectively turn off the alarm system the stay was uneventful. What was eventful, however, was their dog. Or rather, dang that's a pushy canine.

My friends are the proud owners of a Siberian Husky -- Sienna. How it survives in San Antonio I am not entirely sure, but I believe it hibernates in the freezer from the months of June to September. Although friendly and unassuming in appearance, she has the perseverance and single minded focus of... a Siberian Husky? Perhaps a very focused and relentless Siberian Husky. Regardless, when she wants her walks she will let you know, and she wants her walks all the time. My daily strolls proved insufficient, however, and so every afternoon upon returning from work I would sit on the couch only to be repeatedly, in 3-4 minute cycles, interrupted by a very eager Sienna. Typically she would bound up to the couch, get as close to me as possible, make a few mildly disconcerting-sounding dog noises, and then spin in circles a few times. If ineffective she would either then give me peace for a few moments or proceed to lick my legs. If I refused walks this loop would then proceed on for hours. And If I gave her walks then it was time she let me know she wanted to play, the whole process repeating itself. Unfortunately while her need for walks was satisfiable enough, her need for play was a little more difficult to meet. Considering she seemed happiest just jumping around the living room, though, perhaps she was demanding less play and more frolics.

Sienna aside, there were two bulimic cats to take care of as well. Thankfully they were relegated to the lower level of the house. Whenever I ventured to the kitchen, though, I would be welcomed by their incessant meowing to be fed no matter the time of day or time of most recent feeding. I would have happily fed them to their early obesity-related demises had I not been warned that overfeeding leads to throwing up behind the furniture so instead I agreed to ignore them and they agreed to keep meowing whenever I went downstairs.

The similarity in tactics shared amongst all the household's animals may not have been purely coincidental, though, as near nightly the dog would amble over to the top of the stair case where one of the cats would be waiting. After exchanging greetings or stares or telepathic cartoon thoughts, whatever, the cat would then carry on a 1-2 minute lecture during which, presumably, Sienna would take careful mental notes for the following day. I broke up one of these pow-wows one evening more out of curiosity than anything else, and the next day I returned from work to a 30 gallon bag of down feathers torn up and strewn about the living room.* A word of warning I dutifully heeded. No way I'm going out like a strange plastic bag of feathers.

I will admit though. As much as I at times wanted to, and sometimes did, yell at the dog to leave me alone, and as many times as I teased her with the leash when it was walky time, I miss her a bit. Dogs are one of the few animals that seem to make us love them more even as they drive us further crazy. She's a good dog, that Sienna. Her friendliness; her pushiness; her beady, red eyes and all.

* The destruction of the bag of fluff may or may not have happened after my pet conference interruption.

Internal Medicine: After Dark

I just finished Night Float. It was crap. It turns out taking care of people with the lights out -- though much like taking care of people with the lights on -- is much less rewarding. I should have seen this coming considering the omens. Within the first five minutes of the first shift my intern lost an eye to the tarp covering the scrub stacks. He was only briefly incapacitated and was left only with a small bruise on his eyeball, but for a short moment I was torn between resuscitation and calling to find his back up.

Anyways, Night Float. Six times the number of supervisors with none of the actual supervision. Plus medicine consults, plus 72-hour consults, plus out of hospital transfers, plus morning report, plus an endless cycle of freetriplescore.com commercials on late night TV. Add to all those new responsibilities a generous supply of next day second guessing and general orneriness from the primary teams, and myeh. Truthfully, I would of rather been kicked in the junk. Now we'd have to haggle over the details, but nevertheless, do it again, kick me in the junk.

The hours themselves weren't that bad mind you; I actually slept rather well. Similarly not knowing what meal to eat at any particular time of day was disorienting but three breakfasts in a row never hurt anyone. My interns were both by and large good, solid citizens, and work load wise we truthfully got off relatively light. It was just the nature of the job, of being subject to a multitude of divergent interests leading to an inability to sufficiently satisfy any which made Night Float a lonely, thankless task. I suppose it developed character, but only if paranoia is a character trait.

It's done and over now, though. May we never do it again.

Exit 25

This past month I earned my Geriatrician Merit Badge. In order to do so I had to start five campfires, diagnose ten cases of dementia, and administer twenty-five Exit 25 interviews. Thankfully the second and third tasks are related as it turns out there is no better way to diagnose dementia then to disorient the elderly and there is no better way to disorient the elderly than the Exit 25 exam.

Although the most recognized and often feared aspects of dementia tend to circle around the increasingly noticeable memory loss that slowly penetrates the minds of the afflicted, this is not the truly incapacitating aspect of dementia and the scare is only superficial. Memory loss makes life inconvenient and tends to sap away from us much of what makes us unique individuals, but it by itself does not lead to the helplessness commonly seen in demented patients. If you or I are forgetful we simplify tasks, standardize routines, write down lists and so on. There are a variety of ways to compensate and people are adaptive animals if nothing else. What truly makes dementia a terrible disease is its effects on executive function: our ability to plan and act. Without this there is no ability to adapt and, as the disease progresses, there is no ability to lead a normal life. Young children often have wonderful memories, it's the poorly developed frontal lobes which make them act as young, dependent children. And so that's why the Exit 25 interview was developed.

The Exit 25 is a series of twenty-five questions designed in a variety of ways to primarily test a patient's executive function and cognition. And it does this -- it seems -- primarily by disorienting and making as uncomfortable as possible the target of the interview. Although some parts are fairly standard consisting of the "remember these 3 objects" and "repeat these phrases," many are not. They range from tests of primitive reflexes and learned behavior by pushing and prodding on the patients' hands and arms in a variety of manners (and also tapping on their lips) while continuously telling them to "just relax", to asking them to stick out their tongue and say "ahh" for an uncomfortably long period of time, to a series of complex hand maneuvers that I still have not quite completely mastered myself. The best parts, however, are the ones I can rarely do without laughing.

The first is simple enough. Complete part 19 and then suddenly and without warning clap closely and loudly by the patient. If they do nothing but eye you curiously then they're in the clear. If they look about or motion uncertainly that's one point on the dementia scale. And if they clap back at you, a phenomenon called echopraxia, then it may be time to take the credit cards and car keys.

In a similar vein, the best portion of the test also consists of an abrupt, awkward transition from regular questioning. Part 10 is followed by a three second silent stare into the eyes of the interviewee followed by a polite and matter of fact "thank you." If the patient responds with a questions like, for example, "what the hell are you doing?" then they're good. If they again get anxious and flustered that's one point against them. And if they say, "you're welcome," well it may be time for a death panel consultation. My favorite response to date has been a panicked, "is this part of the test?! Is this part of the test?!" with simultaneous darting of the eyes to every part of the room.

In all seriousness the Exit 25 interview seems to be a consistently effective tool for screening and monitoring dementia, and will likely be an increasingly important one as it is more extensively used. Unfortunately I always feel bad doing it on my patients. It also takes a good twenty minutes to complete the whole bloody thing. Considering the main measure seems to be confusion and disorder, I almost feel as if yelling and shaking a gnarled stick at the elderly for a minute could have much the same sensitivity and specificity at a fraction of the cost in time. It's a shame I won't be going into geriatrics; I could have revolutionized the practice.

The best part of geriatrics was not terrorizing the elderly; however, it was the absence of call and two day weekends. Beautiful. And the worst part, conversely, wasn't trying to then persuade demented people that they were in fact demented, but rather the senior citizen two handed handshake I now find habitual. For whatever reason I found myself clasping with both hands the single hand of patient and/or accompanying family member in a gratuitous gesture of friendship. They seemed to appreciate it well enough, but some of my colleagues not so much. Men weren't meant to double hand clasp the hands of other men, and many a muffled look of befuddlement has been exchanged between myself and another as a result. It is either a sign of my great empathy or my folie à deux that I have become more like the elderly in treating them. Or perhaps it's just two more points on the dementia scale.