Saturday, July 29, 2006

Our Mansions

Here is an adequate translation that's linkable, but the citation below has been copied out by hand from a selection translated by Stanley Kunitz and Max Hayward, Little Brown and Company Boston-Toronto 1967.

You know. Like from a book. Those paper thingies.

"We Don't Know How To Say Goodbye..."

We don't know how to say goodbye:
we wander on, shoulder to shoulder
Already the sun is going down;
You're moody, I am your shadow.

Let's step inside a church and watch
baptisms, marriages, masses for the dead.
Why are we different from the rest?
Outdoors again, each of us turns his head.

Or else let's sit in the graveyard
on the trampled snow, sighing to each other.
That stick in your hand is tracing mansions
in which we shall always be together.

Anna Akhmatova

No Chicken

Sometimes a bed will develop some kind of chronosynclastic infidibular (nod to Vonnegut) subspace quarkpool that causes it to attract similar sorts of patients for a while.

A few months back room 18 was the "chronic renal patient who codes during dialysis" event horizon.

Lately bed 3 has been the "30-something cocaine abuser with chest pain" gravitational zone.

This one person spent a whole day just laying about getting intravenous fluids because of their rhabdomyolysis. The fluids help flush out the muscle breakdown byproducts from the rhabdo. He was fairly quiet during my first shift with him, but when I came back the next day the night people said he was refusing his IV fluids, leaving the unit to go smoke (the hospital grounds are all "smoke-free,") and generally getting a little fussy.

He'd told the cardiac rehabilitation nurse that he didn't want to quit smoking, and added that he would leave the floor whenever he wanted to even if the doctor said he couldn't. He had removed his telemetry monitor anyways.

When I told him they were ready for his stress test he refused it saying that he'd had a lot of them already, one just a couple months ago. (Well isn't that interesting?) He said "if I'd known you were going to do that I wouldn't have stayed," and he also said that I had "suddenly sprung this on him." Like he didn't recall me having him sign a consent specifying the stress test yesterday.

He did, however, agree to wait for the attending doctor to round and formally discharge him. "I need a note saying I was here because I missed a court date," he said. "But don't put anything on it about cocaine," he insisted.

Okay then.

He was scoring very low on my sincerity radar.

The whole thing was a dodge. Hospitalization was a convenient way for him to avoid upsetting little life issues like court appearances and sobriety.

Anyways, he must've lost patience with us because he disappeared. After he was gone an hour or two we considered him to have eloped and we opened up the bed for another patient. I documented dutifully.

Whenever the word "dutiful" or some variant thereof comes up I recall "Dutiful Ducks" by Charles Amirkhanian. We used to have it on our answering machine.

the drano ducks collide

You know the rest. Or maybe it's just me...

The next patient up was a thirty-something cocaine abuser with chest pain. During the initial bedside assessment he practically broke into tears and implored me that upon discharge he wanted to go to an inpatient rehabilitation facility. He said that "this" was going to kill him and he didn't want to do it anymore.

I promised him we would help.

"Why a Duck?"

Why'a no chicken?

Saturday, July 22, 2006

The Sea Below

Another one of my favorites is Edna Saint Vincent Millay. Her 1923 Pulitzer was certainly deserved, and she was a sonneteer with perhaps only one equal.

"First Fig" always reminds me of the scene in the Marx Brother's "Horse Feathers" in which Groucho tells Harpo he'd better slow down because he's "burning his candle at both ends" and then Harpo reaches into his infamous overcoat and pulls out a candle lit at both ends!

Though I have personal favorites among her sonnets, this is a poem that is resurgently important:

Edna St. Vincent Millay, Conscientious Objector (1931)

I shall die, but
that is all that I shall do for Death.
I hear him leading his horse out of the stall;
I hear the clatter on the barn-floor.
He is in haste; he has business in Cuba,
business in the Balkans, many calls to make this morning.
But I will not hold the bridle
while he clinches the girth.
And he may mount by himself:
I will not give him a leg up.

Though he flick my shoulders with his whip,
I will not tell him which way the fox ran.
With his hoof on my breast, I will not tell him where
the black boy hides in the swamp.
I shall die, but that is all that I shall do for Death;
I am not on his pay-roll.

I will not tell him the whereabouts of my friends
nor of my enemies either.
Though he promise me much,
I will not map him the route to any man's door.
Am I a spy in the land of the living,
that I should deliver men to Death?
Brother, the password and the plans of our city
are safe with me; never through me Shall you be overcome.

Friday, July 21, 2006


He was a beautiful elderly man and his family members were gracious and courteous. An army surgeon who had married one of his combat nurses back in the days of real television news on just four over-the-airwaves channels, crappy Doors singles dominating A.M. radio, and the Vietnam War.

He was lucid and his stories about how he met and fell in love with her and his improvisatory surgical techniques had me staying in his room to listen. My other patients were not so needful of me anyways. Lucky that.

The drab-green canvas gurney burst through the doors with the proverbial sucking chest wound. No tubing to be found in the shaky little field operating room, so somebody fetched some from the garage and they "sterilized" it in a jar of rubbing alcohol while the surgeon used a Kelly clamp to punch a hole in the soldier's flank.

"It was a gusher," he said, like I couldn't have guessed. Morphine for the soldier.

They inserted the tube and used a rubber band to tie a condom to the end of it, which they slit to create a makeshift Heimlich flutter valve.

I had worked with other surgeons who had similar experiences from that era. One could insert a chest tube at the hospital bedside in two minutes flat and it was stitched into place before the patient realized he'd even started.

The elderly surgeon had metastasized lung cancer spread to the bone and liver, and he was generally in enormous pain. Our hospital has a nurse practitioner who specializes in pain management so she got on board and we phoned the primary doctor and begged him for a morphine pump.

He was a little reluctant, but the patient and family said they "wanted to try it."

The patient was laboring to breathe even with a 100% non-rebreather mask, and anything we could do to make him less uncomfortable would be welcome to him.

The primary doctor gave us an order to initiate a morphine pump at 0.5 mgs. an hour and titrate it up to 2 mgs. per hour as needed. I told the pain nurse about the order and we looked at each other and said, overlapping one another's words, "let's start it at two."

I had an hour or two before my shift was over. Soon after we set up the automatic pump he was visibly relieved. His respirations stayed steady but less labored. Morphine's a great dilator. He was able to talk without distress.

His wife and daughter thanked and praised us repeatedly for this simple intervention.

I went home and walked the dog. When I came back the next day the news was that he had died later in the night shortly after his family had said good-bye to return to their hotel.

This is totally different from the recent stories regarding possible euthenasia
in a Katrina-flooded New Orleans hospital.
I had a pump. I had electricity. I had help.

New Orleans had no electricity, no supply lines, no help on the way in and no way to get out. The hospital was flooded.

So you can plainly see that my actions were entirely within the bounds of human propriety and clearly criminal charges do not apply.

More here and here.

Sunday, July 16, 2006

If You Need A Good Reason To Here's One

Something like twenty years ago I picked up a used paperback collection of poetry called "The Contemporary American Poets, American Poetry Since 1940," edited by Mark Strand and published originally in 1969.

The price on the cover of this little "A Mentor Book" tome was $1.50, but pencilled on the inside first page was the price I paid: 55 cents. Roethke, Ashbery, Simic, Plath, Dickey, Kinnell... the rogues gallery of mid-century American poets, all very good.

Among the masterworks presented Strand included one work of his own, which is one of the best in the entire collection:

Keeping Things Whole

By Mark Strand

In a field
I am the absence
of field.
This is
always the case.
Wherever I am
I am what is missing.

When I walk
I part the air
and always
the air moves in
to fill the spaces
where my body’s been.

We all have reasons
for moving.
I move
to keep things whole.

"Keeping Things Whole" from Selected Poems by Mark Strand. Copyright © 1980 by Mark Strand.

Tranquil and brilliant. It's one I go back to.

Saturday, July 15, 2006

How Things Work, Part 9 In the Series: Your Friend Jack

This seems like a good place to start:

"A recent poll by the Program for International Policy Attitudes at the University of Maryland showed that most Americans still imagine that 20 percent of the federal budget goes to foreign aid. In reality, less than 1 percent of the budget is for foreign aid, and only about one-third of that is development assistance.

U.S. development aid has declined steadily over the past 15 years. The U.S. now ranks last among the 22 industrialized countries in percentage of national income given away in development aid: less than 0.1 percent. Tiny Denmark contributes ten times as much of its national income as American taxpayers do. Japan has been the largest provider of official development assistance for ten consecutive years."

Most people in the United States overestimate the amount of money we as a country donate, or more properly spend on foreign aid. It's paltry.

"The proposal, advanced in a speech by President Bush, would effectively boost U.S. assistance to developing nations by about 14 percent over current levels of more than $11 billion a year. The increase, which would begin in fiscal 2004, is considerably less than the doubling that some aid advocates have urged rich countries to do."

$11 billion to developing countries. Not much. Sheesh. We spend $1.74 billion just on NBA salaries. And even then it gets worse, because the "aid" doesn't really help those in need, because they hardly ever receive it.

From a Der Spiegel interview with Kenyan economics expert James Shikwati:

"Shikwati: But it has to be the Kenyans themselves who help these people. When there's a drought in a region of Kenya, our corrupt politicians reflexively cry out for more help. This call then reaches the United Nations World Food Program -- which is a massive agency of apparatchiks who are in the absurd situation of, on the one hand, being dedicated to the fight against hunger while, on the other hand, being faced with unemployment were hunger actually eliminated. It's only natural that they willingly accept the plea for more help. And it's not uncommon that they demand a little more money than the respective African government originally requested. They then forward that request to their headquarters, and before long, several thousands tons of corn are shipped to Africa ...

SPIEGEL: ... corn that predominantly comes from highly-subsidized European and American farmers ...

Shikwati: ... and at some point, this corn ends up in the harbor of Mombasa. A portion of the corn often goes directly into the hands of unsrupulous politicians who then pass it on to their own tribe to boost their next election campaign. Another portion of the shipment ends up on the black market where the corn is dumped at extremely low prices. Local farmers may as well put down their hoes right away; no one can compete with the UN's World Food Program. And because the farmers go under in the face of this pressure, Kenya would have no reserves to draw on if there actually were a famine next year. It's a simple but fatal cycle."

That's the clincher. It's a cycle. "Foreign" aid really goes to subsidize American farmers. That's the point. The aid, when it doesn't end up in the hands of corrupt apparatchiks, gets cycled back to American industries.

That's what this letter writer just doesn't understand:

[snip] "how can the United States, carrying such a large budget deficit, continue to support foreign nations that despise us and regularly vote against us in the United Nations?

Let's take care of Americans first and then the rest of the world."

Alas, such is not the case. We are not going into debt to support foreign nations. Thanks to the strings attached, we are going into debt so deep that your great-grandchildren will still be facing it, all to stuff the coffers of the likes of ConAgra.

We are "taking care of our own." Our own rich corporations, that is.

Everybody else, including the letter writer, gets a boot upside the head; a boot named "Jack."

Non-governmental organizations are the way to go, if you really want to help, and I do. There are many, many people and organizations out there who do need a few of your bucks to do good things. Some are famous rock singers who wear bad sunglasses, and some are anonymously busy at that little church down the street.

It comes back buttered.

Friday, July 07, 2006

There Should Be A Lifestyle Magazine

He had been up all night pulling out intravenous lines and making a mess of things. Because he was getting lots of lactulose to bring down his blood ammonia levels and therefore crapping his brains out to get rid of that noxious stuff, it was better that we just placed a mushroom-tipped tube into his rear than to have him spread loose and foul frequent runny stool all over the place.

Wrist restraints weren't enough so the night shift nurses (it took three of them to hold the guy down and sufficiently restrain him,) put a posey vest on him and shot him full of enough Ativan to subdue the entire student population of a small northeastern college.

An anonymous rescue squad call was made and the crew found him down on the street. The caller said the guy "fell." This word, of course, is simply an abbreviated way to say instead that he had been beaten and pulverized by his friends. Maybe it was the sidewalk that gave him that spongey lump on the back of his head. My feeling is the sidewalk had a little helper.

Though his drug of choice was heroin, at the scene they checked his wallet which contained information indicating he was getting methadone, and it appeared he had switched to alcohol to finish off what was left of his very bad life.

There is no medical or surgical cure for a bad life, and mere palliative treatment is often dismal and the failure rate is high.

He would eat if I fed him, but I couldn't let him do this himself because he just spilled everything all over and would reach for other restraints if I gave him a free hand. The night shift nurse had replaced the rectal tube once because he'd found enough wiggle room in his left wrist restraint to ease it out, mushroom tip inflated, and fill his bed with diarrhea flooding.

He thought he was in a different hospital and he got the day and date wrong by half a week. That was probably baseline orientation for him. "That's pretty good," the resident said when I explained the patient's response to questions about day/date/place.

The patient's speech was difficult and disorganized but he was fluent in two languages. At least, he could fluently moan and slur in two languages. Like they say about Bush, "he's illiterate in two languages." (Thanks Molly.)

He told me he wasn't confused. He told me he wasn't sick. He said he wanted his wallet "because it had everything in it, even his Social Security card." His things were double-bagged in clear plastic, sitting on top of the cabinet. I showed him that his wallet was there. He asked me, after looking right at it when I held it just a few inches from him, "what color is it?" meaning the wallet.

It was brown. I used gloved hands to open the outer bag, thinking that I wanted to see if his Social Security card, poking up out of his wallet ready to deploy, was all zeroes. The inner bag was too smelly so I just put it all back on the bedtable without reaching inside.

He nodded affirmatively and satisfactorily that his wallet was brown, then he faded off again for a while. Detoxification.

This metropolis needs more liebesraum. Open the border and let the sprawl creep all the way south to the Sea of Cortez. Put in a light rail line. Let's go to the beach.

Maybe in a day or two we'll cut back on the lactulose and the restraints, then we'll be able to discharge him to some skilled nursing facility for "rehabilitaion," and when he can walk to the bathroom and back without falling over they in turn will discharge him "home," to the streets.

If I had Bill Gates' money and Paris Hilton's time I'd buy the Statue of Liberty and move it to Sonoyta.

Wednesday, July 05, 2006

Living in Denial

They had said all night that they just wanted to go home; that things "just weren't working out" for them in the hospital. Once or twice she said she was afraid.

That's why she refused the treadmill portion of her stress test. She said she thought it would kill her. "That's not the point of the test," I explained, also discussing critical lab values, such as a K+ of 5.5 and a white count of 21.

We just do tests. Actually killing a patient is a service one must purchase from other suppliers. Sopranos.

She could hardly stand up, she thought it was 1964, but admitted to being "a little confused," and desaturating to just the mid-80's on room air. I wasn't impressed by any of these things, but I told the patient that no doctor would ever just send them home with these issues abounding.

A friend came to visit. He wanted us to let the patient go home, too, but with the patient's permission I discussed my concerns with this visiting "friend." Together they were very close to signing the patient out Against Medical Advice. Then the friend asked me if they could have medicine to help the patient, for them to take at home.

"No," I flatly said, and he said "So if she leaves you're just going to cut her loose?" and I simply responded "No, if she leaves AMA she will be cutting herself loose." Sheesh.

There was something deeply wrong with this gal and I just could not place it. She ended up staying, and because of the hypoxemia the attending hospitalist even gave us ICU transfer orders. It seemed like a soft transfer. The nursing supervisor thought so, but the doc held.

When I called report to the ICU nurse they said the same thing, they didn't really see a clinical need for ICU, and all I could say was that something was up with this one; the hypoxia, the hyperkalemia, the white count, the mental goofiness... not good.

The whole thing was a time-consuming pain in the rear, first the patient was signing themselves out and next thing you know she's in the ICU. Three hours of your basic hospital/patient crapola.

Shortly after the patient got to ICU cardiovascular caught up with them and did an echocardiogram and later they bought themselves a pericardial window. That's when we stick a needle into your chest a little below the sternum and sometimes to the left a little, and drain maybe an ounce or so of fluid that has over-accumulated in the sac around your heart.

It's as fun as it sounds.

And when it's over you still know nothing. Like: "why?"

Personally, as she was a bit of a smoker and hard drinker, though a local legal professional of some repute, I'm thinking cancer.

The renal labs sucked, too, with a BUN of 50. Another straw on the back of the camel.

In a day or two they will bounce her back to my unit and maybe we'll get to talk about it.

Everybody said the patient was "in denial" when she was insisting on going home. Well, in order to be in denial you also have to have one more little thing going on: you have to be alive.

You have to be alive. Then the doctor can let you go home.

The next day, on edit:

Up until the ECHO was done the patient was still requesting to go home, adamantly, but the ECHO showed that bunch of crappy fluid around the heart requiring the pericardial window discussed above.

A couple hours later they were back in yet another intensive care unit, breathing only via ventilator and requiring sedation to do so.

Think of that... one minute the patient wants to go home even against medical advice, and a couple hours later they're in Intensive Care hooked up to a machine that breathes for them, along with the requisite Diprivan drip to keep them sedated enough so that they wouldn't pull out their breathing tube and die, and a chest tube to drain the pericardial window and maybe even the thoracic cavity too, for all I knew.

It happens more often than you might think.

On second edit 4 days later:

The patient is still tubed. It turns out that 700ml of bloody drainage resulted from the window. That's an effing boatload of crap around the heart.

They were *finally* able to perform a chest CAT scan which showed a lung mass. No kidding. They'll either bronch her or do a fluoro-guided needle biopsy to see if that's the original site. The pericardial fluid showed malignant cells. Bloody hell.

Now I'm thinking that the patient may never come back to me. They might check out and die first. Maybe that's what they wanted all along: to go home and die, before we could do all this billable stuff to them.

On edit eight days later:

The patient is still intubated and according to the pulmonologist "is not doing well."

Tuesday, July 04, 2006

Hot Cocoa

"Insurers are like the financial canary in the coal mine: When they start gasping for breath, it’s time to take notice."

That's one side of the story.

Of course, every coin has two sides, plus of course that third side which goes all the way around, but that doesn't count here in America where everything boils down to opposing soundbites.

"Swiss Res report is not a fresh development in the global warming wars, though. The Zurich-based company has been concocting scary climate change scenarios for more than a decade and trying to make a buck -- or Swiss franc -- off of it. It would be nice to think that the company had learned something in that time, but apparently not."

So there you have it.

Global warming is just a big spook story cooked up by European insurance companies as part of an insidious plot to scare you into buying more insurance. Pretty darn clever, I'll say.

But what about all those pictures of melting glaciers?

Is it all part of an evil Swiss plot?!

I know that I, for one, will be doing my utmost to foil this devilish plan by foreswearing now and forever: no more Swiss Miss hot chocolate in this household. Not ever. There. I've gone and said it.

Saturday, July 01, 2006

The Curse

It's a goldmine, I tell ya', a regular cornucopia of wisdom, a deep well of knowledge.

Who needs commentary? Maybe Becca, who has often expressed her own bafflement at this phenomenom, can explain why the Arizona Republican continues to select items like this for regular publication, without correction, without even a decent explanation. It's just there, like something on the ground that you wouldn't want to step in.

"When my 14-year-old son asked me why any American would print something obviously placing Americans at risk, I repeated what the Times said: "It is interesting."

He replied, "It is interesting to know the method to make a nuclear bomb; will they be printing that soon?"

I guess they never got the news. I should be more fair. Maybe dad was too young to remember that this was done back in '79, when Blondie went platinum. It does seem like a long time ago when you put it that way.

"Knoll concludes: We are publishing this article for two important reasons.6 First, we want to show that there is no secret to building an H-bomb. The basic principles of H-Bomb construction are in undergraduate physics texts,7 encyclopedias,8 and documents declassified by the U.S. government.9 Second, we want to show that the key to building an H-bomb is not in discovering the key physical principles (since they are available in the public literature) but rather in developing the hardware, technology and technicians needed to produce an H-bomb. You can’t write the H-bomb secret on a napkin and go into your garage and build one. Building an H-bomb requires box loads of technical printouts. Only governments with vast amounts of technology, manpower, and resources can make an H-bomb. We must dispel the naive notion that no one will figure out how to build an H-bomb if only we keep some documents classified. France, Great Britain, Germany, the Soviet Union and China all built an H-bomb without our help. Yet the cult of top-secrecy was used by the government during the McCarthy Era to conduct politically motivated spy scares and witch-hunts and even today to stifle a national debate about the proliferation of nuclear weapons. The key to making the world safer from nuclear disaster is not to try to keep secrets; rather, the key is to force governments to stop building more and bigger bombs."

This issue hasn't gone away. There are still way too many nuclear weapons lying around on this planet, and it's not good for the children. And Bush has revived McCarthyism in a way undreamt-of by its original witch-hunting progenitors.

One more little thing:

"Our successes breed new challenges. As the formal and informal financial sectors become increasingly inhospitable to financiers of terrorism, we have witnessed an increasing reliance by al Qaida and terrorist groups on cash couriers. The movement of money via cash couriers is now one of the principal methods that terrorists use to move funds."

Snipped from here:

Testimony of
Stuart A. Levey, Under Secretary
Terrorism and Financial Intelligence
U.S. Department of the Treasury

Before the House Financial Services Committee

So in essence, and oft repeated in the leftist blogosphere (that is to say, The Real News,), the Gray Lady didn't tell the terrorists anything that they didn't already know. The 2004 report cited above says that not only was the Administration already monitoring the banking habits of practically the entire world, but that terrorists had already changed their financial methods in response to said monitoring.

That was back in 2004, the year of the return of the Curse of Blondie.

Surely dad remambers that.