"Onward! We Journey Forth!" (Honeymoon Edition, Pt. 2)

So, when we last we left our couple, they were enjoying relaxing days in the sunny streets of Prague. But the adventure was about to shift into high gear...

So, after the most pleasant puddle jump flight either of us have ever experienced, we landed in Hungary. Again, not much planning had been done up to this point, but shout out to P.A. and my other friends who have been to Budapest for their suggestions and ideas. The first night, after we got off the plane, we just sat in the hotel and laid our strategy. That is, after sampling the signature dish of Hungary, chicken paprikash. Believe me, if you like sour cream or paprika, Hungary is the place for you. Shout out to the Budapest City Break for creating a tourist map with splendid routes for self-guided walking tours of the city's sites - you da real MVP of this trip. 

Our well-used tourist map

Our first full day in Hungary, we realized we were on the Buda side and much of what we wanted to see was in Pest (Buda and Pest being the two sides of the city divided by the Danube River, and united by 6 bridges and a love for sour cream). Still, we took our first walk across the famous Chain Bridge and immediately were taken by the gorgeous buildings. Prague had a lot of great architecture, but Budapest celebrates its historic buildings and bridges and other infrastructure in a much more intense way. As Reptar put it, "Even their manhole covers are pretty!"






(Interesting fact about the Chain Bridge: According to legend, the architect who designed it proclaimed that if someone found a flaw with it, he would commit suicide. And of course, an intern - or whatever the 19th century equivalent of an architectural intern was - piped up and pointed out that the lions have no tongues. The architect didn't commit suicide...although he did die not long after. Also...apparently the lions do have tongues.) 

After crossing the bridge, we found the gorgeous Parliament building and its lovely gardens, and were introduced to the word lapidarium - "a place where stone monuments and fragments of archaeological interest are exhibited." It's actually way more interesting than it sounds, and some of the history was actually quite engrossing. Well, for me, at least. Reptar deigned not to spend quite as much time examining the pieces.
Later we would walk Vaci Street and its many boutiques, merchants, and all other matter of shopping. As you can imagine, there aren't a whole lot of Indians in Budapest at any given time, so Reptar and I got a few stares here and there, but more importantly, we were magnets for restaurateurs and store employees looking to sell their wares. One girl walked up and immediately asked, "India?" We simply nodded, unsure of what else to say. 
"Oh, India, great! So for you...Saabon? Saabon?" She offered us two small translucent rectangular prisms, one bright blue and one bright yellow. We each picked one up and stared at each other, and then I asked the question that was on both of our minds.
"Do we eat it?"

"No!" the girl replied, "It's saabon!" At our continued blank stares, she finally understood. "So...I speak more Hindi than you both do?"
Turns out, saabon is the Hindi word for soap. She was selling us Dead Sea soap. Reptar loved the soap. It made her skin feel smooth and tingly. 

I hated it. Stupid dead sea soap. We actually took a detour so I could find a bathroom and wash it off my hands.

But it was made up for by going to St. Stephen's Basilica and witnessing one of their weekly organ concerts. I mean, I know I talked about cathedral concerts in Part 1 of this post, but I had no idea. I thought I knew how beautiful music could sound in a huge church. But the organist at St. Stephen's Basilica took his throne and blew the doors off the place. I think his rendition of Bach's Toccata and Fugue in D minor actually punched me in the face. Or at least the ear drums. I was floored by the beauty of both the cathedral and the music.

Day 2 was...well, it was a pretty far walk. I've had to apologize and/or humorously confess to this a few times now, so I may as well state it here for the record: I kept telling Reptar (not falsely, as I was convinced of it myself), that we were walking about 2-3 miles a day, despite her protests. We later looked at it on Google Maps...we were walking close to 8-9 miles a day. So, as is bound to happen so many times in the near and far future, my wife was correct and I was not.
Of course, if she'd listened to my advice and worn sneakers instead of sandals, her feet, legs, and back would not have ached quite as much.

Anyway, we walked to the Balna, or "The Whale" - a uniquely-shaped shopping center with interesting restaurants and a delicious lamb burger in one of its restaurants. From there it was off to the Zwack Museum, where they distill the Hungarian answer to Jagermeister known as Unicum, as well as host the largest collection of mini-bottles of liquor (17,000!) in Central Europe. Fun fact: Peter Zwack once came to Buffalo as an ambassador - they have a letter of praise signed by Mayor Byron Brown, as well as Bills and Buffalo memorabilia in a display case. Pretty cool!

Later that night we went on a beautiful evening dinner cruise along the Danube. The food was delicious, the wine was lovely, the view was gorgeous. The one thing I would change is that we should have taken the 10 PM cruise - it's even prettier at night.
That's the single biggest difference between Prague and Budapest. Budapest has a significant nightlife. In Prague, there were a few restaurants and bars open late, including that jazz club we enjoyed on our last night there. And I'm sure there was more, too, but it seemed like by 10:00 PM or so, things were wrapping up. In Budapest, on the other hand, it seemed more like the lights were still up, people were still out in droves, and more was happening. Even the street musicians and buskers were out later (which is why I also own a CD from a Hungarian group...although it's mostly instrumental smooth rock covers of American songs, it's not bad).
On Day 3, we decided to stay on the Buda side of Budapest. The Castle District is truly beautiful, with its gorgeous scenery views and intensely beautiful architecture. The history seemed to flow out of each building and mountain. The biggest treat for two fledgling physicians was getting to see the Hospital in the Rock, an underground medical facility that served both as hospital and neutral sanctuary for victims of the war-ravaged and under-siege Budapest during WWII. Later we enjoyed the Museum of Military History (well, we raced through the exhibit because it seemed like they were basically closing each wing for the night right after we finished seeing it). We finished off the day by finding out that jazz clubs in Budapest fill to capacity much faster than clubs in Prague, but we enjoyed some amateur blues musicians instead and Reptar re-discovered that she is a major fan of tiramisu. Finally, again on P.A.'s advice, we headed to the Ruin Pub Szimplakert - unsure of what to expect on a Wednesday night, but instead finding a cool vibe, good beer, and some really intricate graffiti. 
On our last full day, we checked out the artsy district of Andrassy Avenue, finding the opera House and several rehearsal spaces that brought back pleasant memories of college when I played drums for modern dancers in similar rooms. The House of Terror Museum brought home (and brought it hard) the devastation the Nazi Party and the Soviet Regime caused to Hungarians. Heroes Square, City Park Lake, and Vajdahunyad Castle rounded out the trip, and then it was time to pack and collapse.

Notes on the trip home: Budapest airport was ridiculous. I have never seen a more disorganized check-in area. Rope lines are useful for a reason, Budapest Airport. Other than that, it was quite pleasant.
And how did we finish off our incredible honeymoon adventure?

We got home and, for our first meal in the USA, had Chipotle. It was delicious. NOM NOM.

10 Days Off the Island (a.k.a Honeymoon Edition, Part 1)

"So...I'm married now. That's pretty cool." -Me, Tweeting 5/28/2016

I know it's lame to quote yourself, and ordinarily I would never do it...but that's still a pretty amazing thought to me. Fiancée Reptar has evolved into Wife Reptar, and if anything she looks more beautiful than before. Things are roughly the same as before...but something feels different.
But anyway, enough of the sentimental stuff. Or "senti", as my cousin (and Deacon at my wedding) Josh puts it. We took off for our honeymoon, a much-needed 10-day vacation to end my intern year and start Reptar's. After an 8-hour flight, Wife Reptar and I landed in Prague with the typical "Um...what do we do now?" expression on our faces. So...

We took a nap.

From the Charles Bridge

Later we explored some of the surrounding areas, and to show you how little research we had done prior to the trip, at one point we crossed a bridge with a ton of statues depicting various scenes of religious strife and major figures. It was crowded, nearly choked with tourists gawking at the statues, peddlers hawking their wares, and caricature artists creating hilarious art, all the way across. At the end of the walkway, Reptar turned and asked, "Joe, was that the Charles Bridge? The big tourist landmark everyone told us to check out?" As it turned out, it was. Almost missed the significance, there. 

We also immediately discovered the Czech Republic's rich artistic culture. Obviously the architecture is immediately breathtaking, as visible in any photo or painting of Prague. But beyond that, in nearly every cathedral or church or other other venue, almost nightly they have classical music performances. Have you ever heard Vivaldi or Dvorak as performed by string quartet+organ combo? Toss a rock in Prague and you can hit a performance. It's beautiful. More on music later.

We also realized that we had timed our trip perfectly with the Prague Fringe Festival! Amazing performers from all over Europe had arrived to show off their talents. The first night itself we caught a one-woman show of Richard III, one of my favorite Shakespearean plays. Soon to become one of Reptar's(?). Later in the week we would catch the hilarious improv group Men with Coconuts, as well as the Who Dares Twins, a musical stand-up act featuring two twin brothers, and at the end of the week we would be taken along on an acid trip in story form, simply titled "Tiger," and be read (disappointingly) by the Singing Psychic, an act which should really just be called "A British Woman Puts on an Eastern European Accent and Shows Off Her Singing Talent by Looking Up (In a Book) and Then Singing Top 40 Hits from the Week You Were Born."

The peeing statues

Our second day of the trip was probably the most memorable, as it started off with us setting an alarm for 8:30 and not actually waking up until...1:00 PM. Whoops. Still, we wasted no time in getting lunch and then headed to the KGB Museum. If you're ever in Prague, I highly suggest this (thank you Foursquare app for suggesting it to us!). The owner is clearly waiting for Putin to call him and initiate a new Soviet Union by taking the Czech Republic back into Russian hands. He also may have a bit of a cocaine habit fueling his Russian pride. But he will give you an excellent and animated tour of his little museum, pointing out and demonstrating the function of various Russian weaponry, communications, and spy equipment and using it to provide historical context as he takes you through the history of the KGB from pre-WWI up to the end of WWII and beyond. The whole thing was really intriguing and educational (if biased)...but he was weird. 

The other great museum is that of Franz Kafka. If you have even a passing familiarity with his work, or any interest in a man whose writing shapes our interpretation both of life and of history, you should definitely go here. The creepy yet enticing exhibit takes you through his life and thinking process, and you really get a sense of knowing the man a tiny bit better (if only a tiny bit).

St. Vitus Cathedral

Reptar and I prided ourselves on not using the tour group thing and just discovering the city and its history on our own. But one tourist trap you absolutely should fall into is Prague Castle. The basic ticket package consists of the four main attractions - St. Vitus Cathedral, St. George's Basilica, Old Royal Palace, Golden Lane. I have never seen Reptar display as much wonderment as when we walked through the awe-inspiring St. Vitus Cathedral, with its brilliantly detailed stained-glass windows and its incredible architecture, and the sheer ethereal quality to the air that made you feel like you were truly in God's presence. Later, we would encounter the camaraderie of our profession in a cafe after the Castle. Reptar's American Medical Student Association sweatshirt prompted a pathologist and her reproductive endocrinologist husband to introduce themselves, wish us congratulations, and pass on both career and marital advice, as well as suggestions for leg 2 of our trip, Budapest. 

And they had Starbucks

Of course, no travel post would be complete without food. Czech food is heavy on the meats and carbs. Reptar and I quickly found our favorite dish to be goulash, a far cry from the pasta-and-ground beef combo of American goulash, but rather delicious chunks of spiced beef in a sauce reminiscent of (but not as flavorful or spicy as) an Indian curry, with bread dumplings that would have been tasty enough on their own. This can be found in any Czech restaurant, but our clear favorite was a quaint little mom-and-pop eatery in Old Town named U Modrého Hroznu. We might go back to Prague sometime just to eat at that place again.

The amazing hot chocolate

I drank a beer with every non-breakfast meal, which was pretty standard (the Pilsener was first brewed in the Czech Republic, so that's what is found pretty much everywhere - it would take some doing to find a good dark beer to suit my tastes). They appear to drink more beer than water (which comes only in bottles and costs extra) in Prague, much to Reptar's beer-aversive chagrin.
In the cafe with the two physicians we would encounter the terrific combination of Schnitzel+strudel, as well as Prague's infamous delicious spoon-required hot chocolate. Later we wandered through a wine festival with some of the best chocolate cheesecake I have ever encountered. But no trip to Prague is complete without the cinnamon sugar-coated dough spiral known as Trdelnik, now sometimes paired with flavored gelato for a truly delicious cold treat.
And, of course, it wouldn't be me without some music. In addition to the aforementioned classical music, the wine festival featured an impressive jazz quartet of guitar, accordion, banjo, and double bass, putting a delightful Eastern Europe spin on classics like "The Girl From Ipanema" and "On Green Dolphin Street." And on our last night we descended into one of the established jazz clubs in the area and took in the mighty Jan Kofenik and the GrooveKeepers, of whom I've never heard, but they were a tight little organ jazz quintet that brought the house down for their CD release party. That's right, I own a CD of a Czech jazz group now.

Overall, an amazing trip. And it's the only the first half! Now we're off to Budapest for the second leg. Maybe I'll let Reptar talk in the next post. Or at least talk about her a little more.

Yay, Trdelnik!

Music Heard on the Island, 2015 Edition

So my last couple of posts got pretty heavy, so let's change it up to something a bit more lighthearted.
2015 was a cool year in music. I liked a lot of what happened last year. Of course, there was some crap, but it seemed like I saw less of it then I did in 2014. Heck, 2015 was the year Justin Bieber finally became somewhat acceptable listening material. That in and of itself was enough to sit up and take notice of the musical year.

2015 saw a lot of great music, and sadly I missed a lot of it. I heard snatches here and there - Chris Stapleton's appearance on SNL left me wanting more, and the Chris Cornell and Sara Bareilles features on Zac Brown Band's new Jekyll+Hyde intrigued me. I still have yet to get to those albums.
2015 was also the year of the comeback. Shania Twain released a live album? Natalie Imbruglia finally stopped feeling "Torn"and released new music? Howie Day still exists and is making music? I didn't listen to any of them, but it's interesting that they came back (see below for more).
And there were a bunch of albums that I listened to in 2015 that, on looking them, actually came out in 2014, or even 2013. Son Little is an excellent modern blues album that caught my attention with the return of Spotify's "Discover Weekly" feature. Vance Joy's "Riptide" pulled me in (get it?), but that album came out last year, too. Whoops.

Anyway, onto albums that actually came out in 2015 and that I did listen to:

1. Kendrick Lamar - To Pimp A Butterfly: In March, the Billboard charts were swimming in the sludge that was Meghan Trainor's "Title", struggling to stay afloat with Fall Out Boy, Ne-Yo, and the remaining singles from Mark Ronson's "Uptown Special", none of which were making us dance in the street (RIP David Bowie) the way Uptown Funk did. Meanwhile, people who know more about rap than I do were abuzz with discussion of an impending new album from Kendrick Lamar. Then near the Ides of March, "King Kunta" threw open the pop-culture doors and drop-kicked Meghan Trainor across the room. I think Australian comedian Felicity Ward put it best when she Tweeted:

Aaarrrrgghghgh @kendricklamar 's King Kunta makes me want to scream out loud on this bus. I won't. But I love it. REPEAT.

— Felicity Ward (@felicityward) March 31, 2015

The rest of the album is amazing, but very differently so. It gets heavy. It's an intense 78 minutes that delves deep into racism in our country, and it takes a couple of listens before it can fully sink in. But it is a beautiful album. One of the coolest parts is that most of the album features live musicians creating the musical canvas on which Kendrick paints his words.  My friend Jon Lehning, a working jazz saxophonist, points out that TPAB is as much jazz as it is rap in some places. I fell in love with it instantly. Check out this video of a live performance.

2. Gavin Harrison - Cheating the Polygraph. I have been a longtime fan of the band Porcupine Tree. It started with, as many of my musical discoveries start, with an interview in Modern Drummer that introduced me to this master of making intricate drumming chops blend into the music so you barely notice. Harrison creates beats at times that I can often only begin to guess at, much less try to imitate. Here he takes Porcupine Tree songs and filters them through big band arrangements, molding them from progressive hard rock into a beautiful bop jazz, while maintaining their progressive sensibilities. The result is a mix of guess-the-PT-song as you enjoy the awesome layers of horns and woodwinds breathing new life into the tunes. The album goes by pretty quickly, but it's a fun ride for jazz fans and PT lovers alike. A Sampler Montage.

3. Chris Cornell - Higher Truth: Chris Cornell's new album pre-order emerged right as I was starting to get the itch for new music in October of last year. Soundgarden had put out a new album and tour the previous year, and Cornell had announced he was doing another solo project this year. His previous solo albums have seen mild success, with the melodic alt-rock of Euphoria Morning and Carry On, contrasted with the Timbaland-produced Scream, an album that fused Cornell's voice with hip-hop beats and made Cornell fans everywhere seriously question one of the greatest voices in rock. Higher Truth takes a more stripped-down approach and lays it all on the songwriting. And it absolutely does not disappoint. It balances an acoustic folk aesthetic with heartfelt rock-out moments (lead single Nearly Forgot My Broken Heart displays this perfectly). The songs on this album let Cornell's voice shine, as the pain, sorrow, or hope of the forlorn lyrics cuts into your soul. Definitely one of my favorites. Arguable best moment: "Murderer of Blue Skies" which starts as a quietly intense folk+electronica rhythm and suddenly bursts forth with an electric guitar and crashing drum beat, one of the album's best cathartic moments. 

4. Zella Day - Kicker: I actually forgot about this album until I went to make this list. Spotify brought back its "Discover Weekly" feature (I guess it used to be called something else, my sister was telling me - she was over the moon when it came back). One of my playlists featured the song "Ace of Hearts." I was immediately floored as Zella Day's forlorn voice cut into my soul over the slick slow 6/8 beat. I went to check the rest of the album out and Mustang Kids immediately had me dancing, having fun with the same theme that Halsey's "New Americana" tried to use later in the year (and not nearly as well). The album features a lot of emotion, but it's channeled through some beautiful lyrical imagery and fantastic layered beats and soundscapes.


The next one is not one I actually heard in 2015, but I was strapped for another selection that really captured my heart. On review of albums that came out last year in anticipation of this playlist, I came across this and was pretty much immediately sold:

5. The Corrs - White Light: I know what you're thinking. The most beloved Irish family band of the late '90s and early 2000s has returned? Okay, maybe you're not thinking that, because if you're like most of the population of the United States, the last (and possibly only) time you ever heard The Corrs was 2000's "Breathless," and that's only if you saw The Corrs Live in Dublin DVD, or heard it in that Debra Messing movie "The Wedding Date." Well, they made 2 albums after that, the last one in 2004, and then lead vocalist Andrea Corr struck out on her own for a bit. Apparently in recent years, drummer Caroline got the band back together, and they went into the studio under the radar. The result is an album that seems to pick up right where they left off in 2004. The first single, "Bring On The Night," features the same dance-pop vibe  that kept "Breathless" in your head for days, with a resilient hope that makes you want to sing along and then go fight a dragon. The rest of the album continues the Corrs' tradition of balancing pop sensibilities with traditional Irish songwriting and instrumentation - the tin whistle, bodhran, and violin blend so well with guitar, keyboards, and drums. They didn't necessarily break much new ground, but after 11 years, this is exactly what Corrs fans want. 


Honorable Mentions:
Kamasi Washington - The Epic. If you like the instruments and stylings you heard in TPAB above, check this out. Washington provides the saxophone flavor on the album. My closest musicophilic compadre Eric suggested it to me, and similar to TPAB, I was instantly hooked.
Brian Wilson - No Pier Pressure. I've been expecting this album since this video came out. And it does not disappoint. Wilson hearkens back to Pet Sounds with the same Beach Boy-style harmonies and sonic textures that we've loved for years.
Def Leppard - Def Leppard. Another comeback album, DL releases an album of new material that manages to cull together all the best parts of their music over the years. "Wings of an Angel" is one of my new belt-out-in-the-car anthems.

Toto - Toto XIV. This was a great album, but, while Joseph Williams may be a technically better singer, and the years have been good to him and his voice, I miss Bobby Kimball's over-the-top vocals, the desperate wails and angry growls of his mighty choruses.  On the whole, a good album...I just wasn't satisfied on a visceral level.

Happy New Year! Let's Talk About Death

I've been thinking a lot about death lately.

Admittedly, I do work in hospitals. Plenty of sick patients, and, as they say in Scrubs, sometimes it seems like Death is just another coworker. A coworker we fight against and do our best to foil every day, at every turn.

Recently on the floors, they called a rapid response when a patient displayed seizure activity. I arrived at the scene and heard the story from the witnesses, and got ready to turn the patient on his side in case he vomited. AK, one of my residents, arrived right on my heels, looked at the patient and asked me if the patient had a pulse.

He did not.

I turned him on to his back. She told me to start compressions, which I promptly did. My other resident arrived and he and AK ran the code. I did what I was told, helping to perform chest compressions while another team member breathed for him and another team member drew up medications. We performed CPR until the Zoll monitor told us it was time to shock him. After two shocks, we were able to successfully resuscitate the patient, took him straight to the ER, and from there he went to the cardiac catheterization lab. A couple of days later I saw him in a hospital room, recovering.
He looked awesome. He was relaxed, breathing easily, and did not look at all like the choking, gasping, swollen man I saw on the floor that day.
That's one of those times when it seems amazing, what we can do. We brought a man back to life. And he walked out of the hospital and will go on to live his life. Take that, Death. Checkmate (for this round).

On the other hand, I remember all too well the first time I watched someone die. It was in the emergency room. I was working a night shift during my last month as a third-year medical student. I had just done my tenth rectal exam that week, and was settling in for what I was hoping would be an interesting shift. Well, I got that and then some. She was 93 years old, African American, with several comorbidities. She came in with shortness of breath, and the rest was a blur. She could not maintain her oxygen saturations, but her pre-written advanced directive orders did not allow for transfer to higher level of care. We could not intubate her to give her more oxygen, and more importantly, she did not want us to do that. I don't remember what nursing home she came from, or even what her name was. I remember being told to take her blood pressure, and asking her how she felt. All she did was smile at me. A wan, accepting smile that was weighed down by pain, an inability to oxygenate, and 93 years of life experience. A wry, humble smile that was matched by the dim light in her eyes - a smile that will remain with me for a long, long time. She gave me that smile, and I had no idea what to say to her. All I could do was smile weakly back, and give my best reassuring grip of her hand. That grip of mine, while not the strongest or the largest of hands, usually serves to reassure patients that I'm doing my best for them and that I'm working hard to get them better. But in her hand...to be honest, I am not sure who was reassuring whom: The medical student who was doing his best to feign calm, or the elderly lady who was ready to face the next world. Soon her breathing became more labored, and the nurse came to tell us. My attending beckoned me along and we ordered a narcotic pain medication to ease her work of breathing. She got drowsier, and then we just stood there as she breathed her last. Her breathing stopped, her heart soon joined it, and that dim light in her eyes finally dimmed to nothing.
The hardest part was then, we had to just move on. There were other patients that required more immediate assistance, and we couldn't afford to dwell on it at the time.

I recently started listening to The House of God on audiobook. It's my second time with the book, the first time being a read-through in my third year of medical school (shortly before that ER shift), not to mention my repeated viewings of Scrubs, which is loosely based on some of the book's satirical concepts. An OB/GYN attending I once worked with told me I should read the book three times - as a medical student, again as an intern, and again after completing residency. In the first chapter of the book, the chief of medicine illustrates the hospital's mission statement of "doing everything always for everyone forever to keep the patient alive." A lot has changed since 1978, and that policy is not the end-all, be-all it used to be. Now, a part of nearly every History & Physical we interns write is a conversation about what the patient's end-of-life wishes are. Well, it's supposed to be a part of that H&P. Such conversations are uncomfortable for both the physician and the patient, and we often do not like having them. Or, as a palliative care attending I know will tell you, "too many doctors are afraid to have that conversation, or even say the word 'die.'"
Every palliative care specialist will tell you that having that conversation is not, as The House of God states so flippantly, "Getting the DNR." It's about knowing the patient and what they want. How they feel about the end of their life, whether it's coming soon or decades away. It's like getting consent for any other procedure - it's explaining the risks and benefits of cardiopulmonary resuscitation and intubation. And it's about respecting the patient's wishes once they make their informed decision. That doesn't make it any easier to talk about, though.

You know what I remember most about that code? The dull, sickening crunch of the patient's ribs breaking with that first compression. It's a sound I have heard multiple times in codes and, to break any illusion of eloquence, it freaking sucks. We may joke about it, but it's a terrible sound. And granted, sometimes it's a small sacrifice to make to restart the patient's heart. And in this case, he was a young enough guy that he recovered quickly. But sometimes...that's not the case. Sometimes those broken ribs just compound the fact that the patient's heart was only barely resuscitated, and he/she/they cannot be weaned off the ventilator. Sometimes it's that they required CPR and multiple shocks for so long that they suffered anoxic brain injury because we could not get the blood pumped to the brain in time, and for the rest of their lives, they will be unable to tell us anything about their thoughts or wishes.

When someone decides to become a physician, he/she usually does not consider this part. We become doctors "because we want to help people" but in our heads that is often synonymous with saving lives. With performing "heroic measures" to bring patients back from the dead, and watching them walk out of the hospital. Never once do we think about the other side of it. About what to do when people don't want those measures. About how to talk to a family about letting their relative go because he/she just cannot fight anymore, or how to accept that a patient wants to die with dignity and on their own terms rather than facing the possible adverse consequences of our so-called "heroic measures." Because we don't always want to think about that. We imagine the oft-used, "if it was my mother or father" scenario to help us counsel the patients...but in this case, that thought often terrifies us. We can bring ourselves to deal with patient deaths, and shrug those off, but when it comes to our own family, we often feel powerless. All of our medical insight and education becomes clouded as we find ourselves on the patient side. Even in our imaginations.

And that's when we question ourselves. We can't help but wonder if it is worth it (in these particular cases). Are our "heroic measures" there to protect the patient from death, or to protect us, the physicians, from having to deal with death?

The one-line answer is that there's a balance between the two sides of that sentence. 

But there is no easy way to find that balance, nor is there a universal way. But if we as doctors truly want to be the best physicians we can be (and, if that aforementioned palliative care attending has her druthers) - for the sake of the patients - we will never stop trying to find that balance.

Overnight Shift Introspection

Welcome to month 4!

At the end of my first month of residency, I wrote this entry about the daily thoughts of a new intern. #5 of the points I made in that post talked about how medicine is invading my subconscious, and how I kept dreaming about the hospital every night. I hoped that would be a temporary thing. In month #2, I went to the proving ground that is the intensive care unit, where I continued to have nightmares for the first week...but by week 2 or so, they had stopped. I thought I was free, that I had passed that stage. But then I went back to the regular floor medicine for month 3 and the nightmares started up again. I shouldn't say nightmares...not all of them were scary. But I hear nurses' voices and bed alarms in my sleep, and sometimes I dream about patients having certain conditions or illnesses and then when I wake up in the morning, I find myself trying to form a treatment plan in the shower to address a problem that doesn't actually exist. 

I know I'm not alone in this. I've talked to multiple other interns that are in similar situations. One has suffered weekly (if not nightly) insomnia from the pressures of medicine compounding her own (self-admitted) neurotic personality. Another intern finds himself facing a bitter slow-burning rage every time he feels unprepared for something or something goes wrong with a patient (even if it's not his fault). And I myself had to learn how to become less tightly wound - from overreacting to every little thing (and swearing like a sailor while I did it) to responding more often with, "Okay, here's what we can do." I'm still learning that - balancing knee-jerk reactions with careful thought and consideration of the patient's overall condition.

Every year there are new articles around this time about intern depression. Suicide rates are high among new physicians, frustrations with work schedules and work-hour restrictions are consistently present, and burnout seems to come frequently no matter what countermeasures are taken. It's only month 4, so we aren't quite there yet, but it's something we've been seriously warned about. Especially the fact that doctors make the worst patients, and we're terrible about speaking up about or going to see someone for our mental health symptoms. And recently I noticed that some of my fellow residents were having a gripe session (just venting because we needed to) and I noticed some of the medical students looking on, and I could read their expressions. "This sounds terrible. Are we going into the right field?" And I told them this:

Sure, there are times when we get frustrated or look longingly at people with normal jobs. There are days when I would love to wake up and suddenly realize I would rather work a 9-5 job, in some office doing equally important but less demanding work, where I get to clock out and go to a happy hour and have weekends off. But I can't do that.

I freaking love this job. I may not always want to get out of bed, but by the time I get to work, I'm excited to see what my patients are doing and if they are okay, and if not, what I can do for them...even as it frustrates me when they don't get better. I am fascinated, as my fellow interns and residents all are, by the disease processes we see in our patients, and how complicated it sometimes is to find the right treatment regimen. And I know that part is not just a phase, because I see third-years who are getting ready to graduate and have seen quite a bit during their residencies, but when I tell them about an interesting case I saw, their ears perk up and they're just as excited and interested as I am.

I mean, don't get me wrong. We all treasure our days off. We love the days when we get to go out and enjoy the sunlight (or see the sun at all), and go drinking with our friends or apple-picking with our spouses/significant others. I spent a recent Saturday doing utterly mundane things with Fiancee Reptar and it was awesome. And we love the nights where we DON'T dream about the hospital (seriously, one night I had a dream where I saw the face of one of the nurses, and then it melted into the face of one of the patients, and then it did the Raiders of the Lost Ark and turned into the skeleton ghost face thing...that was a wake-up-in-a-cold-sweat night).

Medicine is currently in a time of incredible discovery, even as it faces an unprecedented level of skepticism. We are now being made much more aware of the costliness of our myriad tests and medicines, and forced to really think about if or why we need any particular blood work or imaging. The days of unequivocal respect and obedience to doctors are long over, but now we work hard to form bonds and team up with our patients for their health. And while some patients are better team players than others, it's this way of thinking that helps us to find a balance between patient care and physician-heal-thyself care. I've written before (as have many other more experienced and more entertaining physician writers) about how the acknowledgement over the past decade or two that doctors make mistakes has led to two things: 1) Patient skepticism, and the appropriate but sometimes frustrating questioning of medical decisions, and 2) The urge on all levels of healthcare for doctors to look at ourselves and acknowledge our own health. To do things like take at least one day off a week to catch up on life (laundry day!) amid all the studying; or go play sports, or go out with friends, or write a blog post trying to sort out your subconscious in the hopes that you finally stop having hospital dreams.

So why do we love this field, even as it takes away our peace of mind, our sleep, our eating time, our time in relationships...why? I don't have a good answer. All I know is...I wouldn't have it any other way.

But seriously, no more patients turning into skull ghosts. That was freaky.

Ten Random Thoughts Every New Medical Intern Has

As I near the end of my first month of residency, as a newly-minted intern (and bask in the glory of my first real paychecks after four years of living on loans), I once again get the itch to read, write, and reflect. So rather than opinions, I give you ten random thoughts.

1. I feel like I'm hitting my 10,000 steps daily, and then some. Now that the iPhone measures your steps (with at least some degree of accuracy) I occasionally look at that app. The amount of steps I take daily has actually diminished significantly since summer time...though I certainly wouldn't know it. I know I spend a lot of time in front of a computer typing up progress notes and making phone calls, but with the amount of time I spend walking the floors on rounds and checking on patients...I certainly feel a lot less lazy than I did while on vacation.

2. The value of a good poop. I know Scrubs sang about it. Older residents told me about it. I thought I was prepared for it. But I can't believe how obsessed I've become with making sure other people poop. Relief of constipation is a beautiful thing and sometimes has a dramatic impact on a patient's progress. I love it when people poop.

3. I am constantly fighting dehydration. I've never been one to carry a water bottle to work or in general. I just go get some water when I feel thirsty. But now I have these 13-to-16-hour days (at most...legally speaking) where all I have to drink is a thermos of coffee in the morning with my Clif Bar...and then sometimes I forget to eat lunch entirely. Don't tell my senior residents, they'll scold me (as will my mother if/when she reads this). So I find myself with dry mouth, dry skin, overusing Chapstick, and feeling generally sluggish. You know, the things that I see in my patients who are mildly dehydrated. So I'm working on that.

4. Medicine is invading my subconscious.  My first weekend, I sat bolt up right at 3:00 AM Saturday morning and immediately texted my co-intern (who was working the night shift) that I had forgotten to order labs on a patient. He told me to go back to sleep. And then in my third week I had an all-too-vivid dream about a patient who pooped too much (see #2) and then I came into the hospital the following day and discovered one of my patients had, in a fit of delirium, had stool incontinence and was trying to rub it on things until the nurses calmed him down. Dreams come true in the worst way sometimes (that guy is better now, by the way).

5. Weekends at a hospital sometimes demand the most patience for patient care. Doctors and nurses (and several other staffers) work any of 7 days a week, but when the weekend rolls around, everything slows down. Non-emergent procedures, diagnostic tests, anything that can wait until Monday, does so. I'm not arguing the point, necessarily, because frankly, that's the point of weekends. But it gets frustrating in the moment. Sometimes I wish weekends didn't matter unless they happened to be your scheduled day off (a notion that will vanish the first time I get a weekend to myself again).

6. I am exhausted. I've never been good at sticking to a hard bedtime. I know when-abouts I should sleep so I can get 5-6 hours before I have to be up, and I try to get to bed within an hour of that. Aside from that, between running around seeing patients and the fact that I am suddenly at the mercy of the office phone and the med team pager, and that I am constantly racking my brain for how best to treat a patient - at the end of the day it's all I can do not to fall into bed right away. And even there I can't escape the hospital (see #5).

7. Everything else has fallen by the wayside. I told my mother that I was gonna take charge of planning my wedding. I had seen other interns do it (mostly female, which is neither here nor there), and Reptar is studying for her upcoming Step 2 exam, so she'll be busy. So I would do it. I get one day off every week! Of course I can get a bunch of wedding stuff done on that one day. Except I forgot that I have no idea what goes into planning a wedding, and even though I eventually did get an idea, I still don't know how to execute it, how to pick vendors, what information I need. So by week 3 I had surrendered and delegated a lot of work to my mother (read: gladly accepted when she offered to help).

8. Well, everything WOULD fall by the wayside, except...my incredibly understanding family and friends keep me based in reality. Reptar is, as always, a blessing. The other day I managed to be late to dinner...by AN HOUR. Whoops. Thankfully she wasn't alone at the restaurant for that occasion, but I'm sure that will happen, too. But she understands, and doesn't hold it against me. My parents and sisters, too - they're really coming to my rescue with wedding planning, groceries, general fun stuff to take my mind off the workload...gotta love them for that. And my non-medical friends remind me that there's a world outside the hospital and fight to help me join them in it. For which I can't thank them enough, because I couldn't do it on my own. My best friends, especially - Ketan keeps me grounded and lets me know that even though I have this new job and crazy hours, I can't stop making an effort, while Eric reminds me of the sillier things in life while maintaining a higher level of discussion...this while they study and do extensive research and tell me how awesome I am. In addition...

9. Residency (at least mine) is like a family. We look out for each other. When someone is staying too long past their shift, we offer to help. When lunchtime hits, the senior resident always checks and makes sure the interns and students are eating, and vice versa. When an attending yells at an intern, the residents will later talk the intern through it. It's truly a camaraderie. And it makes me excited to come to work. Which leads into #10.

10. I am so pumped for this job. The hours are long, the days wear on us all, I don't see Fiancée Reptar much. But I am so excited to go to work every day, take care of patients, and do my best not to screw up. Ask me in 6 months, maybe I won't feel the same way. But for now, I've waited for this job for 21 years. So far...it's worth it.

A (Sort of) Farewell to Kings/Channeling Neil Peart, Part II

In Part I of this post, I talked about the first set of the June 10th Rush concert I recently attended (really just because I was "In the Mood"), and let the songs guide my reminiscence of my ten years as a Rush fan ("Making Memories" if you will). Here we have part II. 

1. Tom Sawyer: I don't even need to say anything about this song. Rush's most popular song. This is no deep cut, but it still gives me chills every time it starts. My drum teacher Jim had introduced me first to "Closer to the Heart" (mentioned later), which I liked. He tried to have me play "Tom Sawyer" but I was intimidated by the amount of notes on the page, and held off for a while. When I asked him to bring it back out again, I was instantly hooked. This was drumming on a level I'd never experienced before (at that age, having listened only to pop, country, and some classic rock for most of my life). I proceeded to pursue Rush's discography (using mostly FYE stores because I had no idea where to shop for music when I was 15) and devoured every album. On June 10th, I didn't quite catch the opening moment because we were running to our new seats, but it was still a command performance. And the South Park "Li'l Rush" parody gets funnier every time.

2. The Camera Eye: A deep cut that resurfaced during 2011's Time Machine Tour, celebrating the 30th anniversary of Moving Pictures. It is one of the longer songs at almost 11 minutes, describing the hustle and bustle of big cities, switching back and forth between sharply focused verses and a deeply satisfying mid-tempo rock riff. It was also here (during the show) that I could not help but admire Neil Peart and Rush's control - if I was playing these songs, I'd be excitedly speeding the tempos up every song, or at least trying desperately not to. But these guys make it look easy (even if they are playing to a click track).

3. The Spirit of Radio: This can be best summed up by Mike's reaction as he sat next to me. The song's opening riff poured out of Alex Lifeson's amps and all I heard from my left was, "Aw, yes!" It's the great listener's anthem whose message about music and artists vs. advertisers and corporate executives still rings true today. I love "begin[ning] my day with a friendly voice, a companion unobtrusive." And when the lights go from rainbows over the crowd to small intimate Jamaica colored spots for the reggae-ish part? That's just gravy.

4. Jacob's Ladder: Another deep cut from 1980 - an epic grooving jam featuring a brief but epic lyric that, if you close your eyes, really makes you feel like the heavens' fury is coming down in a storm (which is appropriate for this week's Buffalo weather).

5. Cygnus X-1, Book II: Hemispheres, Part 1: Prelude: This track (leading into its own part I) is the only one I couldn't identify in the first five seconds...but as soon as I heard the signature riff I knew it. This is another one where reading the backdrop of the song is quite helpful. For one, in the studio track, even I have to admit that Geddy's high vocals are sometimes hard to follow. For another, it's also a pretty cool tale - again heavy on the sci-fi, though this one features a spacefaring protagonist.

6. Cygnus X-1, Book I: Parts 1 and 3 (with drum solo): The gift that keeps on giving.

7. Closer to the Heart: "This is a great song from 'A Farewell to Kings'...it's got a pretty little acoustic intro." As soon as Geddy said it, the entire audience quaked with anticipation and then broke into raucous cheers. This was the first Rush song I learned to play on the drums, and, as my friend Mick stated leading up to the concert, it proved that radio-friendly songs could have loftier lyrics and more complex themes. I defy anyone not to sing along with Geddy when he tells us we can be the captain and he will draw the chart. I DEFY YOU. 

8. Xanadu: No, this is not that Olivia Newton-John movie. But it is based on the same Coleridge poem. Man, people got a lot of mileage out of his work - that movie, Citizen Kane, and a Rush epic that, in 1978, had the works - gong hits, chimes, woodblock and cowbell hits, as well as thundering rolling-down-the-stairs drum fills. They brought a little bit of that magic back for this, and Peart could be seen rising from his throne to hammer the chime notes of the song's introduction - which was pretty cool.

9. 2112: Parts I, II, IV, VII: A retrospective wouldn't be complete without the 20-minute, 37-second song that put Rush on the map. Admittedly, they did a shortened version for this concert. But as the opening ARP Odyssey Synthesizer tones hit my ears and the overture burst into existence, I was immediately transported to yet another dystopian tale, a concept revived in 2012's Clockwork Angels. As Geddy alternately channels the protagonist (with his discovery of the guitar and music) and the Temple Priests (who shut the former down), it's easy to see why this song brought them back from the brink of musical failure and thrust them into a spotlight that carries on to this day.

Encore: TH-TH-TH-THROWBACK!

1. Lakeside Park: This encore went all the way back to 1974-5. The first two songs haven't been played by them live in decades, since the vocals go pretty high and Geddy says his head threatens to explode. But a true retrospective necessitated bringing them back. So they tuned down a key or two, but these songs haven't lost a step. I love "Lakeside Park" in particular because it epitomizes Geddy and Alex's ability to write music that completely captures the mood of Neil's lyrics. It even takes me back to playing in parks when I was a boy, although "Beaty Park" doesn't have quite the same magic to it. Maybe Mulberry Park.

2. Anthem: The song that introduced 1975 to the new lineup of Rush, and introduced me to Ayn Rand's philosophies. Sort of. I didn't quite look that deeply into it at the time, I was just enraptured by the sheer prog mastery of the song. I put on this one and the guitar riff started and immediately went into creative drum fills that blasted out of my headphones and I knew I had found my new drum hero.

3. What You're Doing: A great song off their 1974 debut album (before Neil joined the band) - just classic bluesy rebellious rock that needs no explanation. Just turn up your volume and let it blast. Oh, and definitely check out this video someone made of the Peanuts gang singing it:  

4. Working Man (W/Garden Road outro): Ending on a classic, this song is the one track from the 1970s that has always been a staple. I'd like to think even the guys in Rush never get tired of this one, that they still have fun with the guitar solo section. Everyone can relate to this song in some way. Even if you don't understand any other Rush song...you get this one. And the fact that they teased Garden Road (a fun track whose lyrics are almost unintelligible, only released on two live albums recorded back in 1974, shortly after Neil joined the band) at the end is icing on the retrospective cake.

So that was long and self-indulgent. But I hope I made it easy to see how awesome this show was, and how much of a presence this band has been in my life for the past ten years. And how, even if you're not a Rush fan, or if you stopped listening when they introduced synths in the '80s, they still deserve a great deal of merit. Here's hoping for a lot more music, and even a few more shows from the best damn trio period.