Snowy or Extra Snowy?

Portland gave me the finger.

Actually they were much more polite than that. No one gave anyone the bird. I just got an apologetic phone call and a formal letter a few days later. And that was that. I was not going to Oregon Health Science University (OHSU).

By then I had also visited the Medical College of Wisconsin (MCoW) in Milwaukee which, I learned, is not spelled with an "a" after the "l", and received word from Dartmouth-Hitchcock Medical Center (DHMC) that they too would like to invite me out for a quick chance to turn me down. The Milwaukee interview was standard as far as interviews go, and the program was myeh. In short: it was snowy, the people were nice, I flew home. I was going to say I finally saw the Great Lakes, but then I remembered that I had seen them the year before in Toronto. Truly a remarkable experience.

Milwaukee from a snowy pasture somewhere.

Dartmouth, on the other hand, was something a little different. The obvious name recognition aside, the program had an explicit global health focus in addition to a sound foundation in the infectious disease basics: HIV, wound infections, and beaver bites. They additionally made no apologies for the snow instead boasting of the numerous winter activities you could partake in virtually year round. The staff were similarly friendly, the hospital remarkably modern, and the city was charming in the sense that it was roughly the size of a small truck stop assuming it was a small truck stop run by affluent, well dressed white people. And, to top things off, their anticipated call rotation the next year was once six weekly. Truly a magical place. Both institutions offered me a job.

Hanover from... well... anywhere.

The next week I signed the dotted line over the phone and began the process of separation from the Air Force culminating in much paper work and even more merrymaking. Of all my three options, OHSU included, I believe I lucked out with Dartmouth as I was only informed of their availability literally a day or two before I was to sign a million dollar, multiseason contract with MCoW. It is the best combination and balance of education, interest, and free time. A place I look forward to going to. Shortly thereafter I got an email from the University of Utah in Salt Lake City -- an institution that had arguably been my number one choice earlier in my search -- stating that they too had spot and were wondering if I wanted to visit for an interview....

God sure gets His jollies in weird ways sometimes.

I just hope that when they dig my body out of the New Hampshire snow hundreds of years from now they find some interesting things in my pockets.

Down From the Land Where the Sun Don't Shine

I am told Portland is a town of tree huggers. From my recent visit I can truthfully say this appears to be correct. The town has many trees and some of them appeared to have actively been in the process of being hugged. Parks and rivers run through it, bicycle lanes riddle the streets, and it is reportedly a crime to run over pedestrians. Because of all this mother nature loving, squirrel kissing, crystal rubbing hippiness there is also an active land management program by the city which aggressively manages how land is used and which limits suburban sprawl. As a result of this, then, and combined with a well-developed street car and light rail system, Portland has what seems to be one of the most livable downtowns in the nation. Unfortunately this means I need to drive a ways to find a good strip mall, but I think I may finally be strong enough to get by without massively discounted bath soap and bath soap accessories.

Portland’s urban thriftiness is never more visible than in its main medical center, the Oregon Health Science University. Perched atop a rocky and tree strewn hilltop near the city center the medical complex has been forced to work with limited land and limited not-cliff space by building less in the horizontal and more in the vertical, diagonal, and all over the place. Stand near a window in the main adult hospital and you can see a sky bridge leading to the pediatric hospital adjacent, a parking garage stationed immediately off the precipace below, and the veteran’s hospital sitting oddly at an angle sitting somewhere in the clouds. It is an unusual and striking site to see as building is built almost upon building to make it all work. So unusual in fact, that I did not take a single picture of it.

I did, however, take a picture of this:

I think it’s a sign warning bicyclists of booby traps. There was another one a few blocks down which I believe depicted bamboo spikes and an improvised of foot snare.

All in all Portland seems like a pretty great city. Mostly because I enjoy squirrel kissing, but also because the Infectious Disease program at OHSU seems quite amazing. The staff were cordial, the program rigorous, and the facilities impeccable. I am admittedly likely under qualified. Thankfully, however, just like me the suckers got limited options. Here’s to making the best of what you got. Hopefully that means I’ll soon be Oregon bound.

Code Sepsis

Hospitals got secrets. Where we buy our kidneys, where we hide our bodies, what that drug that starts with an "x" and sounds like "manex" is. It's what all the locked doors and privacy's about. Not personal protection, but cover for a massive, secret effort by the health insurance industry and World Health Organization to put thimerosal in all the tap water and autism in all your children. We're up to something, and let me tell you: it's gonna be big.

One secret I can share without fear of a propofol coma, however, is the color code system which keeps hospital staff informed of impending disasters while simultaneously allowing all our naive and overly trusting patients to continue wandering about the hospital premises. Maybe they'll wander into a fire, maybe an armed assailant, maybe a chemical spill, or maybe all of the above. It's for us to know and everyone else to eventually find out. In this system each conceived of disaster is assigned a color which is then relayed over the hospital intercom. The most common code is the "code blue" for cardiac arrest -- or as it often is at our facility, old man down in the parking lot. Additionally, however, there are "code pinks" for child abduction, "code oranges" for chemical spills, "code greens" for aggressive, angry person, and, most recently added, "code whites" for aggressive, angry person who is now shooting a gun. Many of these codes are adopted across the country with some variation, but there is one that is relatively unique to San Antonio: code sepsis.

"Code sepsis" is the call for the medical intensive care unit (MICU) team to come and evaluate a septic (severe infection) patient for immediate admission to the MICU. Practically speaking, however, it's the call for everyone in the ER to don their crazy hats and go completely out of their minds. Twenty people surround what need only be a 3 or 4 man intervention while central lines and endotracheal tubes fly about in a mad effort to place the patient on minimal ventilator settings and a random dose of dopamine vasopressor. Sometimes the patient will get antibiotics during this time, sometimes a nurse ends up with a femoral catheter in groin. Once this is concluded, typically shortly after the MICU team has arrived, the crowds disperse in a flurry of triumph and indifference while the staff begin the hard work of incessantly pressuring the MICU team to admit the patient to the unit as quickly as possible lest the chupacabra get them. Eventually the orders get in and the insanity returns to normal levels, but not before there is one last self-congratulatory high five.

So it is with my career currently. Somewhere in mid-December the Air Force yelled, "code sepsis!" and all sorts of rip up your bed sheets, fling your poo craziness has ensued. In the course of completing my residency and determining my future station in life I've worked at three different hospitals, flown to two separate fellowship interviews after sending out dozens of separate emails and making dozens of different phone calls, underwent ATLS certification and a week of military field training, had some vacation, had my computer die, got a shot, got an HIV test, got some lunch, filled out an unholy amount of paperwork only to be rewarded with even more illogical sums of paperwork, created and given a lecture, attended a mid-year evaluation meeting, had my already completed research project randomly chosen for quality control review and then had that review canceled, planned for an upcoming medical readiness training exercise (MEDRETE) in the Dominican Republic, and been booted from a base reassignment process entirely without my knowledge. I have not at any given moment been entirely sure of where I am or what time of day it is, nor do I even really know where this all is heading, but I am confident that, in the end, the Air Force will totally be throwing the high fives all around. They'll have done their job of sticking me somewhere, and I will have been successfully stuck somewhere. Good job guys, the chupacabra didn't get me.

One Million Tiny Fireworks

Developmentally it's been said we doctors are a little slow. Life's milestones are delayed. We marry later, start families later, buy houses later, and start wearing our pants above our belly buttons all a little bit later. The continuous cycling of school and training, long work hours, and general social isolation all serve to make us a little retarded maturationally* speaking. Thus whereas most thirty year olds are living upstanding lives as industrious citizens by generally shirking all responsibility we are avoiding responsibility altogether by garnering ever greater levels of debt and inflated senses of self-worth. I have just gotten through my teenage years myself, thank you very much, and am confident that hanging out late all night in college is totally going to rule.**

Physically, however, the opposite is true. We old. Nothing brings about an early bed time better than incessant call. Our backs are stooped, we have no idea what day it is, and sometimes I find myself gumming my food even though I know I still have a full complement of teeth. This is never more evident than on New Year's Eve every December. Last year we spent a subdued evening watching the ball drop in New York at 11:00 followed by bed, and this year we spent a subdued evening watching the ball drop in New York at 11:00 followed by bed. We even had a mashed desert (banana custard and Nilla wafers) and a lively game of Bananagrams. Paul fell asleep on the couch at like 09:30 and the Yorkies refused to wear their party hats. Sometimes I don't know what to make of all this medicine business. Thankfully in a few years all I will remember is how young Ryan Seacrest used to look. Unfortunately I'll probably also forget my complete domination of Bananagrams.


Rapidly advancing senility aside, the real reason I want to write? Fireworks. Given the opportunity to return to my apartment at 11:30 I was once again able to witness the cities fireworks from the comfort of my dorm room. Although the video is unfortunately not entirely clear -- or steady, damn you Parkinson's -- there was exploding color and fire from horizon to horizon. Near 180 degrees of my own personal fireworks sampler.

Happy New Years to all my family and friends at the VFW!

*Yes, this is a word. No, don't look it up.

**Totally.

There's A Zoo in Austin? With Real Animals?

This week I went to the Austin Zoo with Winks the one-eyed cat and Rohini the one-eyed pediatric neurologist. I am not sure Winks's story, but I hear Ro lost her eye in an ugly bar fight in Long Beach.

The zoo, for those of you who have never been or even heard of the Austin Zoo, is a little out in the middle of nowhere and I am not sure it still qualifies as being in Austin, but it is nevertheless a pleasant place to visit. Between the one-eyed cats, three hundred free ranging peacocks, and a variety of legitimate zoo-type animals it was a relatively respectable establishment. I do use the term "zoo" loosely, however, as it was composed almost entirely of animals hillbillies and rednecks throughout the South and Midwest had acquired for themselves until they got "too big to manage" which I can only imagine to mean they "got eaten" or had their arm or arms torn off by "play bites." As a result it was mostly big cats, monkeys, and traditional farm animals. This unfortunately meant no meerkats, but it did mean there was a good number of very friendly-looking foxes and one slightly less friendly-looking and constantly pacing, brooding fox. With the intent of his stare I'd stay away from the opposite side of the zoo for a while. He's got plans.

So go to the Austin Zoo, see some cats, feed some goats, wade through peacocks, and prize goes to the first to find which animal's only got three legs!

A Christmas Gift of Errant Boxes

Merry Christmas! You'll get your presents when you get 'em.

The merry holiday has now come and past, and although the majority of it was spent sitting in a chair in the cardiac care unit (CCU) it was quite nice. Not because I had a great time with my nieces and nephews -- I haven't seen them in some time and am not sure they even still exist -- but because for once, for whatever reason, I felt a little grateful. Now I have always known I am blessed beyond merit, but infrequently have I felt it. I am not sure what to attribute it to but my suspicions are Wilford Hall's ghetto rooftop Christmas tree or BAMC's military issue eggnog. In either case I did not terribly mind working or being alone for the navidad. Plus how can you complain when your friends give you Lyme Disease?

Season sentiments aside, let's get to the point of Christmas and to the point of this post: presents. Man were they a disaster. Although Amazon and its various retailers did their jobs well, I, in my job as distribution center ring leader, did not. I barely got everything wrapped and boxed by the evening of the 20th, but did not make it to Fedex in time for the evening shipment thanks in part to the incredible complexity of stuffing a Mini Cooper with enormous boxes and partly because I may or may not have run someone over on my blind side. I'm pretty sure it was a roll of carpet. The boxes were shipped out successfully the next morning of course, but successfully to the wrong addresses. Adam and Ashlee got a Christmas surprise of other people's presents and my sister's family in Hawaii will be delighted to find out the box they receive sometime in February in fact needs to be immediately repackaged and reshipped. I am sure in every case, however, that their real present was hearing my voice over the phone on Christmas day. Mine, of course, was giving Lucca 11 lbs of candy legos. And possibly diabetes.

To The DR With You

This past year I have tried in vein to leave the country. First I was to go research in Thailand but Thailand exploded. Then I was to go research somewhere else, but our program leader exploded. Scheduling conflicts boxed me out of the USAF humanitarian relief mission to Haiti and the scourge of residency scheduling somehow excluded me from the ICU rotation in Landstuhl, Germany. I was going nowhere and nowhere fast. Which, as far as residency goes, isn't that bad. I'd rather spend my days in San Antonio quickly than the other way around.

But a bright new day has dawned! A late breaking opportunity for a second USAF humanitarian mission in the spring arose recently and I said, "Hey, USAF medical mission, take me fool!" To which the USAF medical mission graciously obliged. I will now be going to the Dominican Republic in April to do... well I am not entirely sure what. Relieve things. Humanitarian things. Medical things. You know, heady stuff. The details are scarce in that I know no details, but it will undoubtedly be an experience. Opportunities like this are a major reason why I joined the military and I look forward to my first trip. Hopefully this time no one brings the cholera.*

*Bonus DR pesos to whoever guesses the current events reference!