Afghanistan in pictures

An interesting photo gallery of Afghanistan by Emilio Morenatti, who worked for a year as a photographer in Kabul for the Associated Press (AP).

http://www.emiliomorenatti.com/

The pictures offer small glimpses into daily life in Afghanistan and speak volumes about how land mines, weather, poverty and poor infrastructure are just a few of the problems the Afghani people face.

Amazing videos

People,

Check this link out, it's called "Tom Kills Oprah", just hilarious

And then I came across another one that's really amazing, a video of a giant octopus eating a shark at the Seattle Aquarium. It is legit, from PBS's Nature show. Unreal. Don't mess with the octopi...

All courtesy of Google Video, a highly addictive habit...

A crazy week

So, my time in the ICU has come to an end, just in time for Thanksgiving. A symbolic end to a month where I have seen some of the sickest patients I have ever encountered. This last weekend I had to work both days in the ICU and had quite an experience.

One patient came in because of problems with a "G tube", which is a tube put in through the skin into the stomach to allow a person to be fed. In this patient's case it was put in because he had two massive strokes and could no longer swallow. When we looked at the CT scan of his brain, it looked like a significant portion of the right side of his brain had been removed. And there were changes in other parts of his brain that looked like what an old stroke would look like.

One of the effects of the stroke is that he has "expressive aphasia." He can understand what we are saying to him, but, when he tries to speak, he is unable to think of the words he wants to say. It's like constantly having something "on the tip of your tongue" but not being able to say it. So the primary way he communicates with us is through gestures. We later found out from family that he had surgery to remove part of his brain because of complications from the first stroke. The G tube works fine now but he's still in the ICU because he developed an infection, though he's been started on the right antibiotics and God willing will do well.

I guess this guy's case was so striking to me because I would never have guessed that more than half of the right side of his brain was taken out...

Another patient was a trauma patient, who was developing a pneumothorax, which is basically air in the lung. The air "leaks in" and one lung starts overinflating, pushing your windpipe to the other side and smushing the other lung down. It can happen after trauma, such as the motor vehicle crash this patient was in. So surgery was in the process of putting chest tubes in him, and I was there helping to hold his legs down while they did so. After getting the tubes in, they started suctioning through his mouth to get rid of some secretions, when he suddenly vomited blood, much of which landed right on me. There are few things more revolting than having blood vomited onto you, but I just reminded myself that I was there to help someone whose situation was much worse than mine. Since there was more than enough help around, I went out, showered and had a quick change of clothes...the patient will probably never remember me (he wasn't totally conscious) but I doubt I'll forget him anytime soon...

If all that wasn't enough, there was a patient who coded (heart stops) but was successfully resuscitated with CPR and, last I heard is actually doing well. Usually people do not fare well after resuscitation, so I was glad to hear this patient made it through...

Still another patient who has an abdominal aortic aneurysm (AAA), which is when the walls of the aorta (the largest artery in your body) get weak and the artery dilates. This guy's AAA was 6cm and he was so skinny you could easily palpate it through the skin. It's something you read about in physical exam books, but rarely get to see or feel. On top of all this, he had air leaking into his body, but in his situation we couldn't find any source or reason for it. The air was tracking all the way from his brain, in his chest (but not in the lungs, so he was breathing fine), and down into his abdomen. We got a bunch of CT scans in which we inject contrast, to search for the leak, but could not find one. The surgical team was going to do exploratory surgery, but since his clinical condition was stable and he had a large AAA that could rupture, they elected not to. Last I heard he was sent to hospice because his overall prognosis was poor. He is still something of a mystery, as I don't think anyone ever figured out where all that air was coming from. I hope, at the very least, that he is comfortable wherever he is. He seemed like a very nice man, a World War II vet.

Today, I had a lady who had a hypertensive, hemorrhagic stroke. Essentially her blood pressure was so high, it caused a blood vessel in her brain to rupture and bleed, causing a stroke. It was on the right side of her brain and she has left sided weakness. She could understand everything we said, and responded appropriately, but had a lot of slurred speech because of the stroke. Prior to the stroke, she was being treated for high blood pressure with more than 5 different blood pressure lowering medications, but she has a resistant form of hypertension. So the blood vessel ruptured, despite all the medicines we were giving to try and prevent that from happening.

She apparently has had many "mini-strokes" in the past (the fancy medical term is transient ischemic attacks or TIAs) but none caused any major neurological deficit. The stroke she just had, however, has caused her not only to slur her speech, but also to become weak on the entire left side of her body. She can no longer move her left arm or foot. I can only hope and pray that she makes some sort of recovery from this stroke. Apparently her mother and grandmother both died of strokes as well. The strange thing is she never smoked but she is diabetic (although she controls it well through diet alone, which is pretty impressive). In addition, her kidneys are barely working and she was likely going to start dialysis in the near future, prior to the stroke. Poor kidney function could also be at the heart of her resistant high blood pressure (renovascular hypertension) or maybe something more exotic like an arteriovenous shunt...another mystery, waiting to be solved...

I did also interview in Milwaukee on Monday for a prelim spot. Great program up there, really resident focused. I've started noticing that smaller cities in the Midwest really do a better job in terms of taking care of their residents. Plus traffic in Milwaukee is way, way less than Chicago. From where I live to get to the Chicago Medical District is a 2 hour drive in rush hour, just ridiculous. In Milwaukee, one of the attendings told me he leaves his house at 7:15am in order to start his 7:30am rounds...I really don't think you can put a price on that...

Well, enough blabbering...happy Turkey Day everyone...

NYC Baby

Last Sunday, I left for New York City for an interview and, like every journey worth taking, I began my adventure by heading in the opposite direction. Yes, thanks to the friendly folks at Northwest Airlines, my odyssey would begin by going west, to the exotic confines of Minneapolis/St. Paul.

I was, actually, somewhat curious to see the great state of Minnesota, for I had no reason to ever go there before and a stopover on a flight to NYC seemed like as good a reason as any to visit the state of 10,000 lakes. I was particularly curious to see what it would look like from overhead, as I imagined the aerial view of thousands of lakes would simply catch my breath and thus entrance me never to leave Minnesota.

Of course, I slept all the way on the flight over. So I never saw the panoramas I envisioned, groggily arising to realize I had better get off the plane before they decided to go to Tulsa or something.

I will say, however, that Minneapolis/St. Paul has a rather impressive airport, MSP International, complete with tram and an expansive shopping center area. There were several boutique shops including ones called, appropriately enough, Minnesota. Seemed like an upscale souvenir shop, which usually means you end up paying $30 for a t-shirt that says something creative like, "Minnesota." I meant to get a shot of one of the stores with a big moose in front of it, but had to settle for this one that had two bears. But perhaps the best feature of the MSP Airport is the fact that it has a large replica of Snoopy, who I guess pays the bills these days by endorsing Mall of America and the MSP International Airport. It's always the sponsorships that pay the bills...you go Snoop...

From Minnesota, my next destination was New York City and I made it to LaGuardia Airport and hopped on the M60 bus to Manhattan and then the subway to Tareq's place, where I would be staying. Tareq is one of my homies from U of C and is in his second year of law school. It was great to see him and hang out like we used to do back in Chitown. He has a nice place right next to the subway, which I discovered is absolutely vital in NYC.

After settling in, we went out to grab a late lunch at Patsy's, a well-known pizza joint. We were met up by two other U of C alums and good friends, Murtaza and Yazen. Murtaza is working for a hedge fund company while Yazen is in his fourth-year of medical school, looking to go into med-peds.

When we were at Patsy's, and deciding on toppings, I confidently told the waiter that I wanted spinach and mushrooms, without even looking at the menu. The waiter replied, "where do you see spinach on the menu?". Of course, I then looked down at the menu and realized, with total shock, that they did not, in fact, offer spinach on their pizzas.

Let's stop for a moment here and ask ourselves an important question: what kind of self-respecting pizza joint doesn't offer spinach? I know you can't get it at Pizza Hut, Domino's or Little Caesar's but any classy sit-down pizzeria in Chicago will give you pizza. Giordano's, Gino's East, Pizzeria Uno, Edwardo's. I just didn't know what to say at this point, so I just left it to Murtaza to pick the other topping...Chicago pizza is undoubtedly the best...

Afterwards, Tareq and I did a little walking tour of his neighborhood and I got to see some of NYU's campus, which has a nice Parisian-style "Arc de Triomphe" at its entrance, and stopped off to eat at a small restaurant called Istanbul Cafe, which makes unbelievable kefta kebob sandwiches. I mean, home-made good. This place easily made my top-ten list of restaurants and the sandwich was quite filling. Not a bad deal...

Later that night, we decided to have dessert and meet up with my cousin Nadia and her fiancee Omar at a place called Cafeteria. We were also joined by another good friend of mine, Fares, who also went to U of C and is a lawyer practicing in NYC. I wasn't particularly impressed with the restaurant, but it was great to catch up with friends and family and have a non-medical discussion for once...

It was getting late, but late takes on a whole new meaning in New York, where I think the air is caffeinated. So Nadia graciously offered to take me down to see Times Square, since I had never been before and it was amazing to see it at night. The place was so lit up, it could have been the middle of an overcast afternoon. And the other thing that was amazing to me was that there was much heavier traffic than I would have expected for a Sunday night and street vendors out peddling their wares and stores open like it was 2 in the afternoon. I mean, really, this city never sleeps...

After getting back to Tareq's place, (Nadia was nice enough to call to make sure I didn't get lost on the way), Tareq and I spent most of the night catching up on things, and what our futures might hold. Luckily, he didn't have class until midmorning and my interview was scheduled for after lunch.

The rest of the trip, and interview, almost seem anti-climactic compared to my Sunday/early Monday. The interview went well, thank God, and afterwards I was taking the subway to go to the airport. I realized that I had left my coat at Tareq's place and, after calling him, he left his place right away and took the subway all the way to where I was, to make sure I had it before I left. It was quite kind of him, especially since, when I got to Chicago, it was freezing and I wouldn't have had a coat unless he did that...

A great whirlwind of a trip, I was thoroughly exhausted afterwards (I reached home near midnight--had a layover in Detroit--on Monday and had to get up bright and early for another day at the ICU) but had a great time.

Thanks to all my family and friends for making it so much fun!

Is it time to unplug...

A couple days ago, one of the ICU nurses was telling me that she has seen a lot of patients come into the ICU, often in such bad shape, she was sure they would never leave. Yet, more often than she expected, these patients who had death cloaking their very breaths would leave the ICU alive. At the same time, she has seen patients who were sitting in their beds, eating dinner and then dying within a half hour, their lives lost to a paroxysmal death. She told me that these experiences convinced her it is God who determines the outcome.

I really enjoyed that insight from her, for God is rarely mentioned or considered in the ICU. You are too busy calculating corrected calciums, interpreting ABGs, or figuring out vent settings to remember that a little prayer for the patient could only help in the midst of placing central lines, G tubes or peering into the patient's body with CTs or xrays...

The remembrance of God also seems surprisingly absent when it is time to make decisions about the final disposition of patients in the ICU. Today, the daughter of one of my patient's decided it was time to transition her mother to hospice and withdraw the ventilator.

I feel sad for the patient. She cannot talk, she cannot move herself, her heart beats too fast and in an irregular rhythm, her lungs don't work well enough to allow her to breathe on her own, her kidneys are failing, her body is swollen with fluids, and she has a huge ulcer on her back that goes down almost to the bone. That's only a few of the things wrong with her...

Despite all this, she still opens her eyes and looks around the room. She will still wince when in pain. To me, she is very much alive. Although she does not seem to gaze in a particular pattern, and will not track your movements, her eyes do open and move about. The nurses, and I, feel that sometimes she understands what we're saying or doing, though we have no objective evidence of that at all.

I feel like we should still fight for this patient, that there is still hope for her. Yet all the physicians, nurses, residents, clergy and, now, even the daughter, feel like she has gone beyond hope. That she is in some sort of living death and that it is time to remove the ventilator and see if she will complete the journey or, miraculously, remain.

As we were discussing the case, prior to meeting the daughter, a priest working for the hospital said he felt it was a moral sin to keep such people going when there was no benefit, no real chance for survival, that we were only prolonging their suffering.

I found that comment strange coming from a Catholic priest, as I always thought the Catholic Church thought highly of those who endure suffering, in line with the Christian belief that Jesus (peace be upon him) suffered on the cross so humankind would be forgiven for their sins. So I would have expected some other line of reasoning to support withdrawing care, one not based on notions of suffering, but rather on notions of beneficence, mercy, etc.

Of course, Muslims do not believe Jesus (peace be upon him) suffered on the cross, rather he was miraculously lifted to Heaven and thus never crucified. For us, forgiveness is not dependent on anyone's suffering, but rather on our repentance and God's Grace and His Love of Forgiving...

Yet it seems the entire question of whether or not to continue my patient's treatment hinges on the notion of suffering, or quality of life. The argument is made that withdrawing care will benefit her more because it will relieve her of suffering and because further treatment is futile, that no meaningful recovery is likely.

I don't think any of us really know how much my patient is suffering. The only real objective sign of suffering we get are the winces, and changes in respiration and heart rate, when we insert a central line. Many studies, in fact, have revealed that physicians are remarkably bad at assessing a patient's suffering. Surveys that asked patients with disabling conditions about their quality of life, almost always rate it higher than the physicians or nurses who treat them...if we make that mistake with people who have their cognition intact, than why should we be any better with people who do not?

I think we need to remember God in such situations and ask whether or not He has given us any guidance on this issue. Rather than focusing exclusively on the patient's quality of life, or suffering, we should also consider the inherent sanctity of life, and the tremendous virtue associated with protecting and preserving life placed by all Abrahamic faiths. I am sure we would find the guidance if we devoted more of our efforts to pursuing it...

One other factor one must not ignore is the economic incentive that exists to withdraw care. It is "cheaper" for society to unplug, and it consumes far less resources if you decide it is time to let the patient die a "natural" death. Sometimes patients have to make the horrendous decision of how to pay for expenses for such care, and some may feel forced by economic circumstance to pull the plug. Economics muddy up the waters, and many family members feel great guilt in such situations.

In the end, I still find myself at something of an impasse. Rationally, I can understand the arguments in favor of withdrawing care. Emotionally, I refuse to pull the plug, to cut loose the one tether they have to this world and, along with it, all hope of them ever coming back.

Once my patient is transferred to a hospice, she will be made as comfortable as possible and the ventilator will be withdrawn. The outcome, as it has been all along, is God's decision. I only hope we all made the right one in bringing her up for judgment...

Too Little Yardage...

Rented the remake of "The Longest Yard", with Adam Sandler, over the weekend and I wasn't particularly impressed with the movie. Sandler's character wasn't really that compelling, or funny, and the comic relief of Chris Rock relied too heavily on tired stereotypes of black people in a way that wasn't particularly inventive or fresh (though one line was funny, "I was so bad at sports that when I was in school they would usually pick me after the white kids."). The most amusing character was Bob Sapp's Switowski, the giant of a guy who turned out to be as gentle as a kid. Basically, if it's on TV and you've got nothing else to do, you could watch this flick, but not worth a rental...

Also saw "In Good Company", featuring Dennis Quaid and Topher Grace. It started out real good, could've been an interesting commentary on big corporations and office politics, especially dealing with a young hotshot boss who is half your age. Instead, it wanders off course exploring a romance that really wasn't compelling and tries to find its way back by the end, but it is too late by that point. A disappointing flick, since it started out well enough...

Man, had a long day at the ICU today. I'm exhausted...you get to see some really interesting cases in the ICU but the hours are draining. I think there should be mandatory afternoon naptime anytime you have to come to the hospital before 7am...

Bulls lost tonight in overtime. Luol Deng, however, had an amazing game for the Bulls, had some really nice moves. Caught about 10 minutes of the game...

Eid Mubarak!

Ramadan has come to an end and I would like to wish everyone Eid Mubarak! May Allah accept our fasting and worship during Ramadan and give us its full reward, a blessing only He can give. It is always a joy to celebrate Eid, a great time to be with friends and family. It is also customary to give gifts, so if any of you like to give rather than receive, you can hook me up...

I won't be able to take a day off for Eid this year, such is life in the ICU, but I will be celebrating on the inside while looking up lab values, talking to attendings and sitting in lecture...you can keep me away from the party, but you can't keep the party out of me, if you know what I'm sayin...

Eid Mubarak

The Arabic phrase for Blessed Holiday

is rendered in Kufi by Mamoun Sakkal (c) 2002

I see you...

I just started my Intensive Care Unit (ICU) rotation and it's been quite the adjustment, getting to the hospital at 6am. My last rotation was infectious disease and it was a great experience because the attending is brilliant and loves to teach. In addition to that, he usually started rounds around noon, so we usually started our day around 10am...man, that was nice...

ICU is interesting because you have patients that have nearly everything wrong with them and need it all managed. There is a lot of opportunity to learn and solidify concepts you've been exposed to in med school.

As we were doing rounds, walking from bed to bed and discussing the patients with the resident and interns, another med student pointed out to me that it was almost like we were at a zoo, the patients in their rooms with their exotic illnesses, as we walked by, gawking and remarking on how amazingly bad someone's ABG was or how severe someone's urosepsis had gotten...

It made me realize that in our earnestness to learn, you can't forget these are people grappling with very serious illnesses. I think part of the reason it is easy to forget is that more than one person in the unit has diminished mental status, so it's easier to think of them as just some "problem list" that you need to work on "solving". And yet these people are the ones who are most in need of our extra efforts and compassion. Their illnesses have overwhelmed them to the extent that they have lost awareness of themselves; and yet their eyes remain open, with vacant stares that chill you...

Many people that see such scenes, whether it is physicians, nurses or the patient's family, often say they would never want to end up in such a state, that life is not worth living under such conditions.

I'm not sure where I stand on the issue.

I do think we should do our utmost to preserve and extend life. I'm not sure what role quality of life has in that equation, that is, at what point can quality of life override the imperative to preserve life? If we say that quality of life can override efforts to preserve life, then where do you draw that line? Doesn't that open up a slipperly slope?

Too much for me to delve into right now...gotta get up at 4:30 so I can get to work by 6...