Flying Tigers, and Boxing Joe Louis … in the exam room?

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.

from aliem.com

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.

from lecturio.com

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?”

Joseph Silva MD, Dean (formerly of UCDavis School of Medicine) via California Northstate University website. Hi, Uncle Joe!

“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 …

“Stop.”

=I paused=

“Pneumothorax. Interesting. What is his educational background?”

from gentledoveministriesinternational.blogspot.com

“… Um, he is a prisoner. I did not ask.”

“So, he could be a medical student, and you would not know?”

“No sir.”

“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)

from slideshare.net

“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.

Joe Louis | Boxing history, American boxer, Joe louis
Joe Louis, heavyweight champion, from pinterest.com

I learned that one of my patients used to practice-box with Joe Louis, the heavyweight champ.

from http://chinaburmaindiawwii.blogspot.com/2015/06/flying-tigers.html

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.

Thanks, Uncle Joe.

Skid marks … and Bad Parenting?

Author and son, out for a ride.

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. 

The scene of the crime.

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.

Be careful out there, y’all. 

The Boys in the Boat (book review)

From the Everett Herald

The Boys in the Boat: Nine Americans and Their Epic Quest for Gold at the 1936 Berlin Olympics https://www.amazon.com/dp/0143125478/ref=cm_sw_r_cp_api_glt_fabc_M81Q4K17N2RTE3JE8RYA

OMG. 6 out of 5 stars. This was intended as a fun summer read. But also, it has catapulted me into the Great Depression, WW2, Leni Riefenstahl and groundbreaking cinematography, the rise of Nazi Germany, collegiate regattas, and the elusive and ephemeral ‘swing’ of rowing. I listened to the audio book. I usually listen at 1.25x or 1.5 or sometimes even 2x: the narrative is usually more important than the writing.

But this. The story, even though the end is known, is riveting. The story of Joe Rantz is the heart and soul of the tale. The author weaves so many threads into a tapestry that envelops and then propels you forward, like the coiled might of 8 undergraduate underdogs, their brilliant coxswain and a cedar-hulled shell, coming from behind as 70,000 voices yell ‘Deutschland! Deutschland!’ to the German boat several lengths in the lead.

This, I listened to at 1.0 and savored every moment.

Go ahead, read the other reviews, but don’t tarry: the Boys in the Boat await you. I am jealous that you will experience this for the first time.

Here’s an 11 minute retrospective, including the granddaughter of Joe Rantz.