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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project
Tuesday
Mar142006

Democracy in New Orleans?

Of all the stories coming out of New Orleans lately, this one irritates me the most: The NAACP is trying to block mayor and city council elections scheduled for April 22, arguing that too many displaced individuals will not be able to vote. Since the displaced people are mostly black, this means the election, if held, will discriminate against them.

There is some merit to this argument, but it is wrong on so many other levels that the NAACP is insane to pursue it. The NAACP is petitioning a federal court, arguing that the election is illegal because it will leave too many voters out. Now, I have lived in a democratic society my entire life, and I have never before heard anyone argue that it is against the law for a city to hold a general election, especially one mandated in the city charter. Since when is it illegal to hold an election in America? The election has already been postponed once!

Imagine two athletes are about to compete in a sprint. Then, suppose one of the referees in the race says the race is unfair because it is too short a distance and favors one runner over the other. The referee argues that the race should be lengthened to make it fairer. So far so good. But here’s the catch: the referee declines to say exactly how long the race should be. Instead, he intends to end the race when his favorite racer is in the lead, no matter when that happens.

This is exactly what the NAACP is doing. It wants to delay the elections, not to a specific date, but to some time in the future when there are enough black people back in New Orleans to make the electorate 50% African-American.

This strategy is very close to fixing an election. How else to describe a legal effort to block an election until the ethnic balance of the electorate suits your druthers? One of the glorious things about an American election is that, come election day, no one really knows who is going to show up. This and the many other unknowns keep elections out of the reach of schemers who try to manipulate the democratic process. In New Orleans, more than in any big city election in recent history, no one knows who will vote. That is the beauty of the thing, and the reason the elections should happen, rain or shine, as soon as possible.

What could be more fair than an election with an outcome totally up for grabs? The mayor’s race has 23 candidates. That is the most dramatic evidence of a fair election you will ever see in America. The fact that 22 people think they can beat an incumbent mayor tells me that there are a lot of people around who feel that this is the one time they have a fair chance to make their mark in what ordinarily is an insider’s game.

Clearly the evacuees need to be heard from in the election. This is not prohibitively difficult. The first time I ever voted in an election, I voted absentee from my college in Virginia. Absentee voting works in every other election. It works for all the troops in the military stationed throughout the world. It can work for New Orleans.

New Orleans is suffering from a terrible absence of leadership, and the last thing it needs is a lame duck mayor and city council wandering aimlessly, awaiting an election. New Orleans needs an election immediately, if for no other reason than to shake things up and get some people in place with a voter mandate for change. Without change, this city could stumble and fall.

Looked at that way, the NAACP is the worst enemy the African-Americans of New Orleans have.

Sunday
Mar122006

Off the Cuff Remarks

I was just covering for the weekend. "Just covering" means doing a lot of dancing on thin ice. I round on dozens of patients, none of whom I have ever seen before or will ever see again. All I know about them is what I read in the chart in the previous 5 minutes before I go into the hospital room. Though I know the medicine concerning every patient -- pneumonia, pulmonary embolism, or squamous cell carcinoma of the lung -- what I lack is knowledge of the specifics of the case. I know the science, but I don't know the patient. When I go into the hospital room and start talking, I immediately start my ice dancing routine, telling them everything I know about the science of their illness, and nothing about their personal situation. It may not be fair, but it gets me through most of the time.

Room 441 looked easy. DNR was written loudly on the chart, telling me that the patient and family recognized that the end was near and were requesting that no resuscitation measures be taken. The most recent progress note from the primary care physician was even more assuring. The patient, who had had advanced lung cancer, suffered cardiopulmonary arrest at home when a blood clot from her leg flaked off and lodged in her lung. The heart stopped for 15 minutes, and she now had severe brain injury. The last remark on the note was a nice, clean skating line: "Comfort care measures only." A simple, straightforward case of a patient waiting for death. All I had to do was play the babysitter, as easy a gliding path as I could hope for.

I went in, and found myself surrounded by anxious family members. My stomach told me this would not be as easy as I had hoped. Yes, the family had consented to abandon all medical intervention except comfort measures, but they were not entirely comfortable with their decision.

The patient's middle-aged daughter was at the bedside, and I could tell that the eye of this storm of anxiety quietly spun around her. She had many questions.

She was probing me. Every doctor has this experience from time to time. A patient or family member is not entirely satisfied with another doctor's opinion, so she probes another doctor to see if he agrees. Each question and statement she made seemed a test to see if I would answer the same way my partner did. Did I agree with the diagnosis? The prognosis?

I strapped on my skates. Carefully I spiraled around every question, throwing in triple loops and double axels of knowledge to keep my answers sounding credible. This lady was very sick, and she would not last long. I tried to assure the daughter that the decision to limit treatment to comfort care was indeed the right one, even though ten minutes ago I did not even know this patient existed.

Everything kept coming back to a single concern. In the intensive care unit, her mother continually ran a low blood pressure. As soon as she got to the floor, her pressure jumped up fifty points higher and has remained there ever since. How could it be that her pressure suddenly rose?

I tried the typical dance moves. Maybe the equipment was different. Maybe a medication had been changed that raised the pressure. Patients often have variations in blood pressure from day to day. Anyway, I said, it was nothing to worry about. High pressure or low pressure, I assured the nervous family, her prognosis was the same.

Still the daughter pursued the issue. I couldn't figure out the concern, but it was obvious that the blood pressure discrepancy was important to her. During her queries, my eyes wandered, and I spotted a blood pressure cuff (technically, a sphygmomanometer) mounted on the wall. I sighed impatiently. I was busy. I was running way behind. It had been a long day, and I didn't want to do it. But she was not going to stop, so I did something I haven't done in a long time.

I took a blood pressure measurement myself. With my own, pristine, doctor's hands. As every eye in the room focussed on me, I velcroed the cuff around the woman's flaccid arm and adjusted and readjusted its position. I pumped up the bladder, and slowly bled the air. Then I did it again, just to be sure.

"Ninety over fifty-eight," I said. It was the same measurement the ICU nurses had been getting. I had just proved the floor nursing aides wrong.

Trouble. That was my first thought. The daughter would use this information to argue that the floor aides were incompetent.  Now I would hear it: the floor nurses don't know what they are doing, they have given up on my mother because she is dying. I braced myself.

The daughter surprised me. Her face relaxed as if a great hand had passed over it, delivering the blessing of peace. I had made her happy.

Then I realized what had happened. The daughter had been fearful that the higher pressure meant her mother's heart was getting stronger. She was having doubts about her decision. When I demonstrated that the low pressure was real, she relaxed in the knowledge that indeed her mother's heart was as weak as ever. It reassured her she was right in continuing with comfort care.

She was wrong to doubt herself. Her mother's brain was gone, no matter what the blood pressure was. Strong heart, weak heart, no matter. She was still a vegetable. The daughter logically knew this, but she needed proof.

When the daughter expressed her relief I was able to excuse myself at last and left the room. I closed the door and walked down the hall thinking, I just did nothing. Absolutely nothing. Yet the nothing I did mattered very much to that patient's daughter.

The patient died that night.

It was a typical day's work for me. I am often at my best when doing the least,

Author's Note: Some of the identifying facts in this story were changed after the first posting to keep the identity of the patient in confidence. 

Thursday
Mar092006

And the Envelope Please . . . .

In the spirit of the recent award season, I am unveiling an award of my own, the O.K. Allen Award for Extremely Lazy Thinking. The award is named in honor of Oscar K. Allen, governor of Louisiana from 1932-36. Allen was widely known as a puppet of Senator Huey P. Long, who ran the state from his office in Washington, DC. He was nicknamed “O.K.” because he approved every piece of legislation Long backed, without question or argument. Rumor had it that Allen was in his office one day, signing bills for Long, when a leaf blew in through the window. Allen signed the leaf.

The first recipient of the award is Tim Harford of Slate Magazine, for his egregiously lazy essay “Why New Orleans Won’t Recover.”

His argument starts off with a cheap shot at the band Dire Straits and then makes an assertion that New Orleans is like his stolen CD collection. Huh?

Not taxing a single brain cell, Harford bumbles into his real argument – New Orleans will fail not because it was flooded in a storm but because it was not economically viable before the storm. This could make the foundation of a real argument, if he offered any proof. He weakly proclaims, “Cities have their own trajectories, governed most by the dynamism of their inhabitants and surprisingly little by their physical infrastructure.” I read this and think he is saying a city will survive if its inhabitants have the will to bring it back. Wouldn't’t that be New Orleans? But no. Harford thinks New Orleans will fail because unlike New York, it does not have $1 million apartments. (I’m not kidding; check the article!) By that reasoning, only about a dozen cities in the world can be expected to survive the next decade. Where do you live? You better move to NYC!

Harford breezily dismisses New Orleans as “a charming place for tourists but a desperate clump of poverty and poor schooling.” Oh, slam dunk. So the only two reasons he bothers to offer for New Orleans’ imminent collapse are correctable problems? If poverty and poor schooling are going to render the Crescent City an empty ruin, America has serious problems. New Orleans has never come within a bayou mile of cornering the U.S. market on either, so if New Orleans is going down, apoptosis is coming to a town near you.

In medicine, we have something called a post-mortem. This is an analysis of a dead patient designed to uncover the cause of death, and to help involved individuals learn from the case. But we consider it bad form to carry out an autopsy when the patient is still alive. With a population of 1 million, New Orleans would be the largest ghost town in world history. And none of those million have jobs. Nah.

I think a city that is trying to dig itself out from under a terrible natural disaster deserves better than sloppy journalism. Even if New Orleans is moribund  (which I contest), there is no excuse for such shoddiness. Again borrowing a page from medicine, a doctor is not excused from caring for a patient when the patient is dying. In fact, dying is an important stage of life, and it is a serious breach of professional conduct for any health care professional to abandon a patient just because the end is near.

Rooting against a city that is struggling to survive?  Buddy, here's an O.K. for you.

A second O.K. Allen Award goes to the lazy sportswriters who gave Olympian Zach Lund a free pass for getting kicked out of the Olympic games. This story is over 6 weeks old, so I will recap: Zach Lund is a skeleton athlete who was told to withdraw from the Olympics because he tested positive for Propecia, an anti-baldness medication.

This award has to be shared among the many shallow-witted sportswriters and sportscasters who echoed the same sentiment: What? Kick somebody out of the Games because he is trying to grow hair? It was mostly a joke in the press, or proof of bureaucratic idiocy, all of which was aided and abetted by Lund’s sheepish grin as he packed his bags and walked out of Turin.

The media did get something right. Most recognized that Propecia (generic name: finesteride) is not used as a steroid itself but as a masking agent that prevents real steroids from showing up on screening tests. Then, the O.K. Allen effect kicked in, and there was thinking no more. Har, har, they said, kicked out of the Olympics for being bald. How stupid can the World Anti-Doping Agency (the organization that suspended him) be?

Actually, not that dumb. The Anti-Doping agency added finesteride to its list of banned substances over a year ago, and hardly made a secret of it. The agency publicly publishes its list, and even maintains a 24-hour hotline to answer any questions about banned drugs. If I am an Olympic athlete, training 40 hours a week in an obscure sport that only sees the light of day every 4 years when the Games come around, I would consider it part of my job to make sure I was eligible to compete. If I were Mr. Lund, every pill, lotion, herbal remedy, and poppy seed would be in the trash can in front of my house 2 months before the Olympics. With so much at stake, why would anyone take any risk at all?

Unless, of course, he was not stupid, but using steroids. Only Zach Lund knows the answer to that question, but it is a mistake to just dismiss Lund as a good ol’ American boy with a little hair loss. Steroid use causes hair loss. I can’t help but feel a little incredulous that a doctor would prescribe Propecia to an Olympic athlete with out at least saying, “You understand that this medication is chemically similar to steroids and might show up on a drug screen.” I know I would.

I learned the hard way in my clinical practice how readily patients lie when it comes to drug abuse. I have seen over 10,000 patients in my 4 year career and can count on one hand the number of people who have said to me, “Doc, I drink too much.” Over 90% of my patients say they do not drink at all, which is simply not possible.

When it comes to illegal drugs, the fibs get more and more fabulous. One patient caught red-handed told me he was at a party and somebody must have put something in his drink. (The same guy died 2 months later from a methadone overdose.) Another said he was with some friends who were smoking “something,” and he wondered if crack particles could waft through the air and preferentially deposit in his poor, innocent lung. (A family member called a few days later and told me this man was selling drugs out of his house.)

The reality is that the caught abuser has no reason to tell the truth, and every incentive to lie until his dying day.  

The stereotypical drug abuser is the bum under the bridge, or the crack-addicted prostitute. I have been fooled by many clean-cut, upstanding citizens who just seem too nice to do something so dirty. That is their cover. No one suspects them because, gosh darn it, they are such nice people. In giving them this pass, we grease the path to their destruction.

Steroid abuse is a serious problem in sports, as the latest story about Barry Bonds again illustrates. Lund’s story is proof that the media does not look beneath the surface when it comes to drug use in sports. Such lazy thinking will hurt a lot of people.

Tuesday
Mar072006

When Azaleas Last In the Backyard Bloom'd

DSCN1457.JPGBy disposition, I am a stiff upper lip kind of a guy. My personal philosophy, borrowed in equal parts from the ancient Stoics and Buddhism, is that life is best lived with a certain reasoned detachment. Unhappiness is the difference between expectation and reality. That is, if we expect too much out of life, we suffer because life, with its imperfections, almost always fails to meet our ideal.

Sometimes, though, emotion has a way of touching reason on the sleeve and saying, "Sorry, I'm taking over here." These moments can be subtle or dramatic, but no amount of mental discipline can make them go away completely.

I am having one of those subtle moments now. March is with us, and in the Gulf South March means Spring. People in the North think we have no seasons down here, but this is not true. We may not ice over, but from December to February the trees are bare and the grass is brown. There will be a few frosts a month, and a light jacket is the constant companion of the wise. Shorts and T-shirts migrate to the back of the closet. Not that our winters are harsh by any stretch, but there is a definite change.

In my childhood, I always marked March 1 as the beginning of Spring. There could be a few chilly mornings still pending, but the frost was over. When these first truly warm days came around, I always felt my spirits rise. It was emotion, not reason, that marked the change. Often I would not even notice the grass darkening with green or the fresh shade cast by new leaves until my lighter mood tugged my shirtsleeve and told me so. Even in the days before the term seasonal affective disorder was coined, my heart knew the difference between winter and spring.

Not this year. The azaleas in my yard have been blushing pink for almost two weeks and I have barely noticed. There is no change in my winter mood, as if I have been frozen on the inside this time, and the natural warmth of Spring offers me nothing. I feel that Stoic sadness, the difference in expectation between what I feel and what I think I should feel.

Of course I know why. When your home town is wrecked by a hurricane it tends to rob you of something. Some have compared the damage of a natural disaster like Hurricane Katrina to a rape, but I don't see that. For me, it is more like losing a brother.

A brother is someone who shares your history and upbringing. There is a deep emotional bond, but not necessarily a financial one. When your brother dies, you march on in your life and career, sometimes more successfully than ever before, but to a rhythm that has a lesser meaning. There is a part of your past, a person who can bear witness to what you are and how you got there in a way that no one else can, that is gone.

That is how I feel about New Orleans. I was very lucky; I lost very little financially, but my emotional loss is very close to a loss of identity.

All people who are from New Orleans share in a brotherhood. There are so many things unique to that city, things that only a person who has called the place home would understand. Some people love New Orleans, some hate it. Brothers do not always get along either. But there are so many things shared, so many things that cannot be duplicated elsewhere, that there is no replacing that loss, no matter how hard you try. You cannot replace a brother.

As I walk in my garden, newly mine since last fall, I admire flowers I did not plant and wonder if they will always be mine, or if storm winds will eventually blow me somewhere else. McComb is a delightful place, relentlessly green, peaceful, and full of kind people. It is good enough that I could stay here forever. But I cannot help but remember that I am not from here, and the place I am from has become a wasteland.

I can start over, but there is no replanting a personal history. My main hope for recovering my history is that New Orleans will rise again, and will become something resembling what I remember it to be.

The beauty of a flower, like an azalea in my yard, comes not only from the perfection of the object itself but also from the memories of all the flowers we have seen before. The present and the past meld, and in the moment we experience the past and the present together. This is the value of place. We see the same events and the same faces year in and year out, and each year they acquire new meaning. Perhaps this is why I see little meaning in the flowers in my own yard. They would look more beautiful to me if they were growing in New Orleans.

As time goes on, I expect my present will find ways to resolve itself with my past, so that once again the things I experience will find roots in similar experiences in the past. For now, I can only pray enough of my hometown will be rebuilt that I will one day be able to say, I am from New Orleans, and it will mean something again.

Saturday
Mar042006

Katrina Photos

I have added a photo gallery to my website. At the moment it only includes pictures I took on September 30, 2005 on my first visit back to by home after Hurricane Katrina hit.

From time to time, I hope to add to it, so please check back.

Tip: I left these pictures in high res, so you can click on them and see them in a separate window, full size. Try it on a few. The details in the pictures really bring out the sense of total destruction that the thumbnails simply don't.