Grand Canyon: optimism, knees and fatherhood

In November of 2020, my son and I set out on a cross-country adventure to check on my parents in Los Angeles. Here are some life lessons (for me).

The CANYON

In November of 2020, my son and I set out on a cross-country adventure. We stopped and hiked the Grand Canyon, on our 2000-mile round trip.

The Buick

By Arthur Hu (Wiarthurhu at en.wikipedia) – Transferred from en.wikipedia to Commons by Kobac using CommonsHelper on Labs., Public Domain, https://commons.wikimedia.org/w/index.php?curid=18438206

About 30 years ago, my parents drove me out in our Buick Station Wagon with faux wood paneling to attend medical school in California. On the way, we stopped by the Grand Canyon, goggled at the enormity of seeing a canyon 17 miles wide. On that day, with the smog, the North Rim looked more like a dingy painting rather than an impressive canyon. We read about adventurous souls who would hike down into the canyon either by mule or on foot, but it would never be us.

I have always dreamed about coming back and doing that hike, down to the river, and back. 

The Road Trip

Fast forward to 2020. My 18-year old son agrees on a 2-week road trip with Dad during his pandemic-infested gap year, so off we go. Finding my parents healthy, we spent a few days together in Los Angeles, and then headed back homeward.

On our return leg, we stay at the Grand Canyon Lodge. We take out our maps of trails to plan the next day. I reveal to him my long-forgotten, yet deep-seated hope of the massive Rim to River to Rim hike in one day. “Hey, it’ll be fun! What an adventure!”

The Lecture

To my amazement, my son starts lecturing me about knowing my limits.

Son: “Dad, you know this is 10,000 feet of elevation and 17 miles IN ONE DAY.”

Dad: “Yeah, I know. I can do it.”

“No, Dad, you haven’t trained for this. This is like climbing a 14-er. Remember how hard that was for you? Also like the ski-up to the 10th Mountain Hut trip. Remember how you said you would NEVER do that again? This is like that.”

“Oh. Right.”

“Wow, I sound a lot like Mom.”

“Yup, your mom always says that Dad has too much unwarranted optimism for his own good.”

“Um-hmm.”

“Well, it has been a dream of mine to hike down to the Colorado River at the bottom of the Canyon someday, and I think tomorrow is my chance to do it.”

“Sigh. Ok, sounds like your heart is set on it. We will have to make sure we give ourselves enough time. The ascent will be the hardest. Lets see…”

And so, my son the planner, set it all up. 

The Plan

  1. We get up at 4 am
  2. We arrive at the shuttle bus stop by 5 am (first bus), since no one is permitted to park AT the South Kaibab trailhead.
  3. We set off with flashlights on the trail at 5:15am. We allocate 4 hours for the descent, 7.7 miles, 5000 feet from 7500 to 2500. 
  4. We plan on 30 minutes for a meal at the river
  5. And then upwards, estimating 1 mile per hour for old Dad. Nearly 8 miles, nearly 8 hours. 
  6. We hope to reach the Rim again before dusk at 5pm. 

Whoa

Our first surprise: switchbacks. My son is in the lead, and he suddenly shouts “WHOA.”

Turns out our flashlights only see about 6 feet in front, and the switchback came up quickly, and his next step would have been…(shines flashlight), into the abyss. On our return trip, we look down, about 300 feet to the first rock outcroppings.

Whew.

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A bit chagrined, we continue. About 20 minutes later, we pause. Look up at the stars. The Milky Way about as bright as we’ve ever seen it. No sound. No birds. No wind. No hum. When it is THAT quiet, your ears sometimes make up a faint ringing just to fill the silence…

A minute later another traveler, jogging along. 

Son: “Hi there! How far you going?”

Traveler: “Rim to Rim to Rim. Have a good one!”

Wow. There is always someone crazier. 

The Glow

About an hour later, an orange glow on the horizon. Second hour, the crests of the North Rim start to glow bright orange. 

We take a water break, a potty break, small snack, then back on the trail. Fortunately, very cool still, 50 degrees, no wind, sunrise is spectacular in phases. I forgot my hiking poles! D’oh! but my knees were still doing remarkably well. 

The Mule Train

Third hour, sun is definitely up, and we get passed by the mule train.

Remarkable how fast those guys go. Clip-clop, doesn’t seem fast, but they keep really constant speed over everything. They pack in water and supplies for Phantom Ranch, and pack trash back out. Very cool. We must stay there someday. 

The River

8:30 am: We see the bottom of the canyon! and arrive at the Colorado River, bright green. 

The 3 Layers

There have been three layers of canyon: the very big painterly one, the middle sub-canyon that appears 2 hours into the hike, and then the final mysterious crevasses where the actual river runs now. The way it unfolded was brilliant and super-cool. In other words, I have no adequate words for it. 

Arriving at 8:30 is heartening. We are ahead of schedule. I did scrape my knee after the second switchback up top, and turns out, I have 4 sizable gouges in my knee, but the adrenaline blocked all the pain. Some blood seeped through my thick pants. My red badge of courage. Lunch of 2 bagel sandwiches, water. I always soak my feet in rivers or oceans when available (habits of a Florida boy), so 5 minutes in 35 degree water is about all I can take, but wow it is awesome after 7.7 miles. Brush off the sand, socks, boots back on. We are back on the upward trail at 9 am. 

The Upward Path?

Son: “OK Dad, I’m expecting us to go 1 mile an hour including stops, so we should be up by 5 pm, just before sunset. Let’s get going.

Dad: “I can do it. I feel pretty good.”

“Yeah, but it’s UPHILL now.” 

A couple more mule trains pass us going up. Some horseback riders from Phantom Ranch. Not many people on the trail really. We were up before most, so we only see 3-4 hikers in the first 3 miles, then only 10 going the other way in the rest of the hike (Ranch lodgers or Angel campgrounders). We flip the masks on for every one who passes. The ascent is hard on the old knees, but manageable. We allocate 30-minute scheduled breaks for water and trail mix, seems like a good schedule. Met some mules: they have names! (Betsy, Parker, Ralph). 

Finally, the sun hits part of the South Rim trail (otherwise in shadow all this time). And from pretty-cool, it becomes BAKING HOT. How does that happen so fast? I’m suddenly grateful for November, and a non-busy trail. Now we are looking for shady spots to rest and hydrate.

The False Summit

It is amazing to emerge from lower canyon to mid, and mid to upper. The false-summit problem comes up repeatedly. The top looks so close! but SERIOUSLY? THIS is not the summit, and there is another couple thousand feet! Too bad I did not note the starting altitude on my watch. 😦

My son notices that my pace is flagging as we ascend, and asks me in the later miles: 

“Want to rest here?”

“No. If I stop, I will lie down and cry, and I won’t ever get up again.”

“Ok”

The Non-verbal communication

The last 2 miles, we see kids and families hiking tentatively down, we see the dropoffs and switchbacks we did not see before. We see the massive vistas that we did not see before. The son starts getting annoyed with Dad taking SOOOOOO MANY PHOTOS.

Reviewing photos, now we can see him being fed up. Funny I didn’t see it when taking his photo. So much for my ability to spot nonverbal communication (one of my supposed specialties). 

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We arrive at the top, giddy as schoolkids. Dad Survives. We shuttle back to the car. It is only 2:30 pm at the top. Take that, pessimistic son! 

Son: “Proud of you Dad. Good job. That was amazing. Whoo!”

Dad: “I need a BIG PIZZA and then shower and bed. These rubber legs are DONE.”

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CMIO’s take? Don’t forget the hiking poles. And, sometimes sons (and canyons) have hidden depths.

INFORMATICS: Put the road signs on the road, not in the garage

Why make folks go to training or read a tip sheet if you could guide them just-in-time as they do their work?

Here’s a lovely example of our Physician Informatics Group (Large PIG) evolving as we improve the “intelligence” that our Electronic Health Record (EHR) supplies to our hardworking providers (physicians and advanced practice providers).

In the past

clinicians might have pulled up an app on their smartphone dedicated to the ASCVD: atherosclerotic cardiovascular disease RISK CALCULATOR, punch in some numbers and get a result to type back into the EHR.

Later on, some well known national websites would do the calculation for you. Still requires finding the website and typing in numbers.

Even later, we would put hyperlinks within the EHR to link you automatically, but the typing was still required to get an answer.

NOW

we have built a smartphrase (while using the EHR, in any text field, type “.ASCVDRISK”, hit the RETURN key, and Voila, the answer above:

Risk calculated based on what the EHR knows about your patient: age, sex, diabetes, smoking, blood pressure, cholesterol. AND THE ANSWER: 9.1%. FURTHERMORE, disappearing help text guides you to use this information appropriately, and only saves the relevant info to keep in your progress note.

My colleague’s wonderful metaphor for Clinical Decision Support like this?

Put the road signs on the road, not in the garage.

It is already hard enough to use an EHR with patients. Don’t make me go looking for that training document from weeks or months ago, don’t make me think. Make it easy to do the right thing. It is a small celebration every time we can do this right.

CMIO’s take? Thanks to Rich Altman MD for a beautiful new tool in our system. What road signs can YOU take out of the garage and put on the road?

Predictive Analytics or Predictive Shrub?

What can informatics learn from a plant?

https://www.wired.com/story/the-humble-shrub-thats-predicting-a-terrible-fire-season/

The chamise plant in California is a harbinger of a high risk fire season this summer. Fascinating analysis of ecology-based prediction.

CMIO’s take: What can informatics learn from a plant? Sometimes simple methods can be effective.

My code: “You cannot overestimate the unimportance of practically everything.” (NYTimes)

Wait, what?

www.nytimes.com/2021/04/17/opinion/letters/personal-philosophy.html

Happy weekend! I just saw this on the NYTimes.

Read this sentence a couple of times. Then read the 100-word “life philosophy” letters to the editor. This one, from David Pastore, Mountainside, N.J.  …  Wow. 

CMIO’s take: Do you have a life philosophy to share? Please comment below.

I can see clearly now, my Sprain is gone (ukulele)

Thanks to my collaborators on the Patient Radiology Image Viewing team at UCHealth: Evan Norris MD, Ciarra Halaska, Justin Honce MD, Peter Sachs MD, and Kate Sanfilippo. Come see our talk at Epic XGM 2021 (eXpert Group Meeting) next month! Session Rad 1.4

What’s the TL;DR? Allowing patients to view their radiology images in their patient portal, alongside their radiology reports, is technically feasible, and does NOT cause increased anxiety for patients or increased workload for providers (in fact, ZERO phone calls, and yet our patients view 39,000 images per month!). Eighty percent of patients liked it. Many showed their images to their providers, some saved copies, some posted on social media! Some had technical difficulties, some had trouble understanding the images.

It is a good start, but there is more work to be done!

Wanna know more? Here is our pre-print publication.

CMIO’s take? It is wonderful to work on teams with great colleagues in the service of better, more transparent patient care.

Your Colleagues Don’t Read Anything You Write (NYT)

TL;DR: Improve your email writing skills so that colleagues will read your stuff!

OK, this is distressing. Just like the statistic that 1/3 of prescriptions are never even filled by patients (what?!), turns out colleagues really don’t read your emails. Pause here, and just feel that surprise and disappointment seep in.

Take a breath. Ok?

Having read Bit Literacy a few years ago, a digital riff on Getting Things Done, I have always known there are better ways of handling the email deluge. For example: the Eisenhower box: Do it, Decide to Schedule it, Delegate it, Delete it.

from jamesclear.com

Also the idea that there are URGENT things, and NON URGENT things, and IMPORTANT things and NON IMPORTANT things. Email tends to be the URGENT and NON IMPORTANT and we all have long term strategies that are NON URGENT and IMPORTANT, and how do we move our daily work from one to the other. This is the story of my life.

However, in the service of improving email communication, Mr. Orendorff, of the New York Times updates the best-practices of WRITING emails to improve your chances of being read and being effective. My favorites:

  • Make the Subject Line useful: REPLY REQUESTED: thenyoursubjecthere or FYI ONLY: thenyoursubjecthere. Even better, if I can possibly ask my question or make my statement really short, I write it entirely in the subject line and end with my initials, signalling there is NOTHING in the email body.
  • Write a TL;DR. Cool internet slang for Too Long; Didn’t Read. As an internal medicine physician, I’m always guilty of being over-explanatory. Write the extra short summary at the end of your email AND THEN if you did well with that last part, you can DELETE your original email and ONLY SEND the TL;DR. Good job!

CMIO’s take? Read the article and change your life (and your colleagues lives) Today!