Canyonlands Utah in the 1990’s was a beautiful getaway for me and my then-fiancée. Having heard of this wonderful mountain-bike mecca, we had come, bikes-on-top of my subcompact, met up with our tour group, a diverse crew of men and women of various ages.
It would be 100 miles in 4 days across rugged terrain on mountain bikes with a group of 12, a couple of guides and a required-escort (at that time) park ranger. Check it out for yourself, it is a quintessential southwest wonderland.
We begin with a 1000 foot descent into the canyon along a jeep trail. We had brought our old unsuspended bikes with hand brakes. Although the ride was hard on our bodies, we were pleasantly surprised that our equipment was up to the task.
Our ride was a blast: wildflowers, spectacular vistas, and good company, with mostly flat single track.
Our guides drive a 4×4 SAG wagon with our gear and food and set up not only our first lunch, but all our meals for the coming days. We have gallons of water that we don’t have to carry! Our camelback hydration backpacks are fantastic for on-the-bike refreshment. This is the life.
Glamping (glamour camping)
At about 25 miles into the trip, at the end of the first day, we get to camp: our guides have driven ahead, set up our site. Dinner is ready and all we have to do is pitch a tent, grab a plate and a folding chair, sit and eat. So awesome. And after dinner, a campfire (apparently forbidden in recent years in the park) and then the Milky Way. Canyonlands, and other national parks, are famous for the lack of light pollution and the spectacular view of the night sky.
At the end of our third day of riding, as we set up camp, our guide tells us: the Green River is about 4 miles away for anyone wanting an extra excursion. Only I take up the challenge, others choose to rest at our campsite. At the time, I was training to ride my first (and only) double century later that summer (200 miles in a day: the Davis Double, but that is a story for another day), and I was anxious to get in some additional miles.
The Zen of Sand
Solo, I head out. We had learned from our guides about long patches of deep sand on the trail, and the “zen” trick of sitting back, focusing on being “smooth and circular” on the pedals, having a fingertip light touch on the handlebars, and gazing far down the track to improve balance. If done just right, one could “float” over deep sand on the trail. Turns out, this guy agrees with me (youtube).
I actually had a few moments of success doing the sand-float in the shadow of the Airport Tower formation, entirely alone with the crags and formations of the Southwest landscape. Other times, I did the meditative sand-bike-walk.
Arriving at the river, I stash my bike in the shrubbery. I see a flat rock jutting out into the river and I determine that I’m going to skinny dip, be clean for the first time in days, and sun myself dry on the rock. Should be great.
To my parched, sand-and-sunscreen-caked, sun-blasted body, splashing in water is heaven. I soak in the cool, rub off the grime, submerge my head and hair and luxuriate.
Then I climb out into the rock, buck naked and unafraid. It has been days since I’ve seen more than our merry biker band, and they’re all kicking back at camp. I shall air-dry, sensually alive and glorious.
I am a glorious human form.
I am one with nature.
I am a Sun God.
In the back of my head, I begin to hear a buzzing. What is that? Do I have tinnitus? Odd.
It gets louder. Hmm. A washing machine? Absurd.
Yet louder. An airplane? I look overhead. No contrails. Nothing. Clear blue to the horizon.
Unmistakably the sound of machinery. Rrrr-rrrr-mmm-mmm.
… and around the bend of the river, a 20-seater tour boat, 20 feet away, a gawk-fest of tourists, with a couple kids pointing out the naked man with a bike-shorts-tan splayed out on a rock in the river.
I believe all parties were mortified.
What was there to do, but wave? And then =plop= back into the river.
I am a bottom-dwelling salamander. I am a shrinking violet. I am an overexposed slide.
This data dilettante (see previous posts: dilettante #1, dilettante #2) has enjoyed armchair theorizing with all of you, my best (online) friends. Today we explore how our super-smart team scrambled our way to improving sepsis care with a predictive algorithm we built.
The old saying goes: the success of any major project in a large organization follows the 80:20 rule. 20% of the work is getting the technology right, and 80% is the socio-political skill of the people doing the work.
We all underappreciate this fact.
It turns out that we spent months building a sepsis alert predictive tool, based on various deterioration metrics, and a deep analysis of years of our EHR data across multiple hospitals. We designed it to alert providers and nurses up to 12 hours BEFORE clinicians would spot deterioration.
We patted ourselves on the back, deployed the predictive score in a flowsheet row, and in the patient lists and monitoring boards, with color coding and filters, and stepped back to revel in our glory.
Turns out that our doctors and nurses were ALREADY FULLY BUSY (even before the pandemic) taking are of critically ill patients. Adding YET ANOTHER alert, even with fancy colors, did NOT result in a major behavior shift to ordering IV fluids, blood cultures, or life-saving antibiotics any quicker.
See the fancy patient-wearable tech on the left (Visi from Sotera, in this case), and one of our hardworking nurses, with ALL of our current technology hanging off her jacket and stethoscope. She should be the visual encyclopedia entry for “alert fatigue.” 😦
Back to the drawing board
As result of our failure, we huddled to think about transforming the way we provided care. It was time to disrupt ourselves. We decided to implement a Virtual Health Center, mimicking what we had seen in a couple places around the country: we deployed 2 critical care physicians and about a half-dozen critical care nurses on rotation, off-site at an innovative, award-winning Virtual Health Center.
This second time around, we created a cockpit of EHR data and predictive alerts to the VHC clinicians, who were dedicated to watching for deterioration across ALL our hospitals, and responding quickly. This does several things:
Takes the load off busy front line clinicians
Creates a calm environment for focused, rapid response
Dramatically improves the signal-to-noise ratio coming from predictive alerts
This way, the VHC nurses view all the alerts, investigate the chart, and contact the bedside nurse when the suspicion is high for sepsis, and start the sepsis bundle immediately.
Soon, by tweaking the ways our teams worked together, we were able to reduce the burden on bedside nurses and physicians and simplify handoffs.
See chart above: Before the VHC, bedside nurses were responsible for detecting sepsis (infrequent, subtle signals during a busy shift with lots of loud alarms for other things), with many ‘grey box’ tasks, as well as ‘magenta box’ delays.
After implementing the VHC, the VHC nurses took over the majority of ‘green box’ tasks, reducing the bedside ‘grey box’ work and completely eliminating ‘magenta box’ delays.
As a result, we have dropped our “time to fluids” by over an hour, and “time to antibiotics” by 20 minutes, which we estimate has saved 77 more lives from sepsis each year.
CMIO’s take? Predictive analytics, data science, machine learning, call it what you like. This is a paradigm shift in thinking that requires disrupting “business as usual” and is hard, but rewarding work. I can’t wait to see what we all can achieve with these new tools.
This was a good week. Like many of my medical colleagues who are plowing through our next surge of Covid patients, we have feelings of exhaustion, angst and sadness, or as one of my Twitter colleagues on #medtwitter calls it, a new emotion called ‘emptysad.’ So apt.
So it was great to get out of the house, and learn to occasionally ‘put my own oxygen mask on before assisting others’, as our airline colleagues would say. Today, I’d go for a 35 mile loop around Denver. Come along on my visual travelogue!
There’s lots of construction on the Highline canal, the Sand Creek trail, and the Cherry Creek path. I can’t wait to see what turns out. Meantime, we have detours upon detours. Here’s one near Northfield, an expanse of wild sunflowers illuminating the margins of I-70.
This is a 3.5 hour loop for me. The great thing is: very little bike or foot traffic even on a holiday weekend. The smoke is less noticeable today, the sky is blue, the Colorado zephyr winds still cool through the day.
Then, the Confluence of Sand Creek and Platte River, both the wild fowl that frequent the area, and also the industrial ‘aromas’ of Commerce City and the Purina Puppy Chow plant. Such a juxtaposition.
Then it’s a quick dash upstream along the Platte, to Confluence Park, where Cherry Creek meets the Platte. Here, see the crowds for REI and the splashy mess of shore that is kid and dog and kayak friendly.
On the quieter parts of the trail, I listen to my current audio book: Vacationland, by John Hodgman, read by the author. I have loved his previous stories on The Daily Show and on public radio. He doesn’t disappoint in this autobiography.
I hope you’re finding ways to have a restorative summer. Go out and do something you love.
I was a nervous first year intern on the internal medicine hospital service. Our team had come down to the Emergency Department to accept the patients being admitted to our service. My resident turned to me: “Room 3 is your next patient. Pneumothorax. We need to care for this patient for a few days and stabilize his lungs until we can remove the chest tube vacuum. Obtain a quick history and exam and place his admission orders.”
I went in to chat briefly with the patient. Since we were busy meeting a host of new patients, I just had the briefest of conversations with him; he had gotten very out of breath, driven himself to the ER, was found to have a collapsed lung (pneumothorax), and had a chest tube vaccuum inserted to re-inflate the lung. Got it. I wondered how it happened, but that mystery would have to wait.
Later that evening, I went back in the room to chat with my patient with pneumothorax. The chest tube was working, he was feeling less short of breath and more comfortable speaking. He had a long history of injecting cocaine, and as a result of frequent use of needles, had scarred all the accessible veins in his arms and legs. During one of his previous hospital stays, he noticed nurses putting IV’s in other patients’ necks, and found out that he, also, could use a neck vein to inject. This worked well for a time, but THIS time he had inserted the needle too far and punctured his lung. He felt the “pop” and then began feeling short of breath, and immediately drove himself to the hospital, where he passed out in the parking lot at the ER entrance. Fortunately, someone saw him, and the ER team brought him in and resuscitated him.
I thought: “this is a cool case. Self-injection into a neck vein leading to pneumothorax.”
My resident agreed. “Why don’t you present this at Dawn Patrol tomorrow morning?”
There it was. It was finally my turn to present to the dreaded Chair of Medicine at Dawn Patrol, the infamous rounds where the post call team would assemble at 6:30am and one unlucky intern would present a selected case history and have a thoughtful ad-hoc pathophysiology discussion.
At 6:30 am precisely, the looming presence of Dr. Silva arrived in the white-scrubbed hallway. “G’ mornin’ everybody! How’re we doin’? Who has a case?”
“Good morning Dr. Silva, I do.”
“Oh good! Okay CJ, go ahead.”
I was so flustered I didn’t even correct his mis-remembering of my name “CT”, and I just plunged ahead. “This is a 31 year-old prisoner, who presents with sudden onset shortness of breath and is admitted with pneumothorax. His history began earlier yesterday when …
“Pneumothorax. Interesting. What is his educational background?”
“… Um, he is a prisoner. I did not ask.”
“So, he could be a medical student, and you would not know?”
“Hmm. So you might be speaking disrespectfully to a medical professional and you didn’t find this out. Okay. Is he a rose gardener? You know, sporotrichosis thrives in rose bushes and can cause spontaneous pneumothorax.”
“Um. I don’t know.” (Head hanging lower)
“Or, maybe has he recently purchased or cleaned out a pickup truck he bought from the Forest Service? You know that coccidiomycosis is endemic in the Central Valley nearby, so called “Valley Fever” that can commonly cause spontaneous pneumothorax.”
“I don’t know sir.” (Staring at the ground, hoping it would swallow me up)
“You know what? We need to change this. I have been disappointed this year with Dawn Patrol presentations where we have gathered inadequate Social History. This is going to change today. Starting now, Dawn Patrol presentations shall BEGIN with a FOCUS on SOCIAL HISTORY.”
“Yes, sir.” I mumbled my way through the rest of my desultory presentation, the amazing external-jugular self-inflicted needle-puncture of the apex of the lung forgotten in the shame of inadequate “social history” skills I demonstrated that day.
After rounds, my fellow interns came up, punched me (hard) in the shoulder “Thanks ‘CJ’. Good job. As if we weren’t working hard enough already, now we have Social History to worry about too.”
For the rest of that year, every University of California Davis intern gathered a world-class, comprehensive social history. We knew every patient’s educational background, what schools they went to, what they studied and enjoyed, what occupations they held (every one of them since the beginning of time), what hobbies they had, what their families were like, how active they were, what groups they belonged to, every place they had ever lived or visited.
As for me, for a long time the Social History was my albatross. I wanted to avoid ever getting caught with my pants down again. For the remainder of my residency, my fellow residents never let “CJ” forget what he brought down on all of us.
Over the years, my focus on Social History influenced my interview style. My history-taking skills improved. I did not even notice that I was getting to know my patients better. I saw my patients more as humans and less as diseases.
I learned that one of my patients used to practice-box with Joe Louis, the heavyweight champ.
One of my patients flew with the Flying Tigers who challenged Japanese invaders over communist China at the beginning of WWII.
It turns out, the entire history of the world walked in and out of our exam rooms and hospital beds, if we were just aware enough to ask.
Dr. Silva was brilliant. The surface lesson was: take a good history. Get to know your patients. They’re trying to tell you the answer to the questions you have about their illness.
The second lesson that I only came to understand years later: getting to know your patients, whether through social history, or just being generally curious about another human being, was the gateway to enduring, therapeutic relationships, for everyone involved.
My son and I were out for a bike ride. It was a beautiful Saturday afternoon, and we were learning to pace line and having a good time. Having recently watched the Tour de France, we had enjoyed how the US Postal team cyclists were less than a foot apart on the road, benefitting from the wind shadow of riders ahead. I told my son:
“Son, did you know that trailing cyclists in a pace line can save up to 1% of energy for every mile per hour they’re traveling? In the Tour, cyclist pace lining at 30 mph could save nearly a third of their energy doing that.”
My son, either breathless on the bike, or couldn’t care less: “Huh.”
We were zipping down the bike path along the Highline Canal in Denver, the wind in our hair, having a pretty good father-son afternoon. We were traveling about 15 mph on long clear stretches of smoothly paved, tree-shaded asphalt. We were alternating the lead. For now, I was leading, and he had developed enough consistency and confidence to be within a foot of my back tire.
“Do feel the difference? Are you in the wind shadow?”
“Yeah! Actually, this is pretty cool!”
What could be better, an outing with my son, a beautiful day, imparting an occasional word of wisdom, spending time together. I was being a good parent.
Ahead was the dip in the path towards the tunnel underpass at Iliff Avenue, where the path narrows and pedestrians share the right-of-way. As we approached, I suddenly spotted a pair of elderly walkers heading down into the tunnel, and we were already nearly upon them. Worse, there were bikes emerging from the tunnel from the other direction. I had no place to dodge. I signaled to slow, and immediately hit my brakes. My 16 year old son, immediately behind and slightly to my right, slammed on his brakes as well, squealing to a stop. I stopped just short of the pair. My son, squeezing the brakes for all he was worth, with no escape direction, struck one of the women, who shouted “Oh!”, and went down.
We were horrified.
We leapt off our bikes and apologized profusely.
Fortunately, the woman was able to stand after a bit, limping.
After glaring at us, she and her partner let us know exactly what they thought of our speeding down the path at unreasonable speeds and striking pedestrians.
We walked them to a nearby bench and sat with them for awhile, before we rode on, much more sedately, having lost the joy of the day. After a brief period, we decided to abandon the rest of our ride, turn around and head home.
We passed them again on the path home, and heard them say as we passed “those were the guys.” We felt terrible.
It took my son 2 months to get back on a bike again, and we have never pace lined since that day. We both take it slower now, particularly around ANY pedestrians or any blind corners or tunnels. The speed and the workout can always wait, right? Why did it ever need to be another way? I see others on bikes flying by, narrowly missing pedestrians, and wonder how we ever survived as a community, as a species.
Fortunately, my son and I still go cycling together. Thank goodness.
We approach the spot. Incredibly, it has been 5 years, and the skid marks are still there, indelibly marked into the concrete despite many seasons of sun and rain. He looks at it and sees his shameful past.
“There it is Dad, that spot where I almost killed someone.”
I’m surprised. I had hoped he had let that go, but he had not. I told him that I understood why he felt bad, but I also helped him see that you ought to be able to trust your parent’s judgement, but that =I= had let him down, and worse, I had literally pulled him into a situation where he could not avoid hurting someone. I told him:
“Those skid marks are not symbol of an error on your part. They’re a symbol of my Bad Parenting.” It was my shame, and not his.
In the years since, this moment has lost none of its painfulness. Somehow, excruciating emotions are the yellow highlighters of our lives. This memory is as indelible as those skid marks that I see every time I ride by.