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. 

Wall Street Casual (NYtimes) vs Loki?

Some of you remember me, with pre-pandemic bow-tie.

Soooooo long ago. Good old days?

During the pandemic, our family went into full-on Joseph Lister anti-sepsis mode. I’d dress for clinic in a button down shirt, casual pants, mask and face shield, strip down in the garage on getting home, yell “contagion!” to clear my path to the laundry, and wash everything in hot water immediately. No dry cleaning piles, no laundry baskets. Right into the machine.

No watch, no bowtie, no glasses, no dress shoes. My shoes were washable Keens. My wallet became a paper-clip with $20, a credit card, my entry card and ID, and a folded letter that certified that I was essential personnel in case I got stopped at a quarantine checkpoint.

Here we are a year later, and clothing-wise, not much has changed. Casual seems dressy enough. We’re still masking, and starting Monday, I think we’ll be back to wearing face shields, as the Delta variant rages on.

I think the Loki variant is a lot more fun, personally.

My Failure Resumé (a talk)

What lessons can we learn from CT Lin’s failures?

Thanks to the Colorado Chapter of HIMSS (Health Information Management Systems Society) and to Bonnie Roberts and Rich Morris for co-hosting my presentation.

Based on my recent Failure Resumé 1 pager. Here are some personal stories, life lessons, and 3 exercises to help you build a failure-tolerant future.

With, of course, a bonus ukulele song at the end.

CMIO’s take: Have you written a failure resumé? Are you building a failure tolerant future? Let me know in the comments.

The Narrows at Zion Canyon: a visual travelogue

In November of 2020, my son and I toured the Southwest US. One of our stops was at Zion Canyon National Park, where we were excited to experience the Narrows. It seemed a great way to escape the pandemic and get away. Spend a few minutes on the journey with us!

Driving, we arrived late in the day at Zion lodge, in darkness. We saw this improbable sight outside our cabin in the morning: canyon walls rising thousands of feet overhead, just outside our door.

We had rented dry suits from Zion Adventures, and laid out our clothing that evening for the hike ahead. In case you’re wondering about the hyperlinks, no this is not a paid post. Just a joyful recollection of an aging parent…

Double boot liners, grippy-soled rubberized river boots, an impervious suit with rubber-gasketed pants and sleeves, and a huge diagonal waterproof zipper across the chest. Hard to wrangle but exciting! We felt like spacemen. We wore several clothing layers underneath.

Normally the Narrows is a super-popular hike through the spring, summer and fall. We had thought that with the pandemic and with wintry November weather, we would have no trouble booking a shuttle ride from the Lodge in the park up to the entrance of the Narrows, 3 miles away. Suffice it to say, plan ahead. Fortunately, we found a last-minute shuttle option with seats remaining. Whew, disaster averted. Otherwise, the lodge had offered us “bikes to rent and ride up there, suits and all.” That would have been more adventure than I needed.

We walked the paved path for the 1st mile. Giddy and nervous, we passed a number of casual hikers who stared at our gear, our dry suits, our 6-foot wooden walking poles, our backpacks. Here, with the residual heat deep in the canyon, the last remnant of fall colors contrasted with the snowscapes outside the park.

And then: the pavement ends. Into the stream! I can feel the cold water sloshing around inside the boot. Hey! my feet stay dry! I don’t care about splashing because I’m sealed in up to my neck, and my backpack has a dry sack inside with food and water. The cyanobacteria poisoning warnings do not deter us. Upstream we went.

Did I mention the incredible geology? We feel puny in its presence.

I was surprised at the grip of these rubber soled river boots. Crunching upstream over large and small rocks was easier than expected. Where was all the slipperiness, the unstable rocks, the twisted ankles? The equipment smoothed that away. I grinned at my son; this was a blast. The water depth was up to a foot and the going was not hard. The current ran a couple of miles an hour.

As we saw fewer hikers, the enormity of the cavern became apparent. At one point, it appeared that the walls were maybe 3 football fields tall, 1000-feet-high sheer walls of stone. These walls plunged right down into the river with no shore or beach to speak of.

From there the river got deeper and faster. In about an hour and a half we arrived at the fork to observation point on the right, with photographers set up to catch the changing light in the canyon. Then we took the left fork to “Wall Street,” presumably named for the impressive sheer walls narrowing in.

At times, the water rises to the hips. Some hikers with only waterproof pants turn back. One couple raised their jackets, exposing bare midriffs to keep their clothes dry, and gamely walked through the first deep crossing. That must have been cold, with the water at 40 degrees. It is sunny, but also snowing.

At a rock outcropping, we paused for lunch. We find a few larger boulders, unpack and have our bagels. Suddenly ravenous, we savor the calories, noticing snowflakes drifting down 1000 feet into the canyon. The light is peculiar: in shadow, with sunlight bathing the Canyon just around the curve, blue sky overhead. It looks like indoor light because of all the bounce and reflection.

This is our turn around point. We rest, recharge, hear the stream burble, feel the snowflakes, our hunger sated, snug in our dry suits, we smell the fall giving way to winter.

It feels – cold, but I’m sweating from effort. The canyon appears unforgiving, but we have supplies and equipment up to the task. Flash floods and cyanobacteria poisoning are a risk, but we have mitigated them. Unlike more extreme adventure-seeking adrenaline junkies, this is the degree of risk and adventure I’m ready for.

It is time to head back. Downstream, like downhill, would be quicker. My main concern was balancing Seeing with Photography.

There is the disappointing idea that the more photos one takes, the less the brain experiences. Or maybe not. Yes, there’s more to show off when you get home, but were you really present? Or did you just line up and frame the shot? But, if you don’t take photos, how interesting is your blog post later? #FirstWorldProbs.

I tried to do both. Who knows.

Downstream was a pleasant splash. Yes, it was 1.5 times easier and slightly faster. There was little resistance to swinging the shins through the water as it flowed with you.

There are great speedway-sized curves to this river, as the millennia of water microscopically carry away molecules of rock every day. The views are magnificent.

It is a hike that promotes mindfulness. Your focus is required for not-stumbling, for pushing upstream, for awakening your senses. The constant, echoed river babble precludes idle chatter.

It is: exploration, sightseeing, photography, companionship, escape, reflection, effort, appreciation for dry-suit and photographic technology, wonder, mindfulness, pure sensation, focus, curiosity, pride of offspring, joy. All at once. Each in turn.

We emerge from the river, dripping and yet perfectly dry. We make our shuttle home.

A perfect day.

The Eppendorf, CRISPR, Covid, and my medicine origin story

This post is THREE THINGS. A personal origin story, a (brief) book review, and a connection to recent stories on Pfizer and Moderna Covid vaccines. And, when we’re done, it might even tie together!

Image above: Dr. NoFronta Lobe, Mad Scientist. No this is not me in the research lab; this is me, a kindergarten parent at Halloween

My Origin Story (I was a budding molecular biologist in 1985)

I was alone in the brightly-lit sterile-white research lab; having spent 20 hours on a long, multi-day experiment. It was nearly midnight on Saturday in 1985. I was a college junior majoring in molecular biology, with aspirations of a scientific research career. I was studying P4 bacteriophage, a virus that attacks E coli bacteria.

The work sequence, I could now perform by heart: inoculate, incubate, centrifuge, enzyme reaction, pipette (fancy eyedropper tool) into an Eppendorf tube (a tiny plastic tapered tube. From a Q-tip-loaded with a single bacterial colony, I had carefully grown a quart of bacterial culture, then sequentially purified my sample down to 20 drops of a pearlescent white DNA solution.

So: 20 hours for 20 precious drops. 

Eppendorf tube, Fisher Scientific

Exhausted and looking forward to heading home, I was on my last steps before overnight refrigeration, so as I held the open Eppendorf in my left hand and my pipette in the right, I randomly thought: “What time is it? Am I going to miss the last Orange Line train going home?”

So, I moved to look at my watch…

And since my watch is on my left wrist, the Eppendorf tube in my left hand did a 180…

And I watched as all the liquid ran out … and onto the floor. 

I looked at the upside down Eppendorf, and then down at the floor and the drops of liquid there, uncomprehending. 

*How… what… nnnnnNNNNNOOOOOOOOOOO!!!*

My late-night-fogged brain finally registered SHOCK, DENIAL, ANGER, BARGAINING. The lab was deserted, I deemed it safe to express myself:

“F$*&@! S!#%! D&$%!” I said, eloquently.

Desperate, I dropped down and started using the pipette to suck up DIRTY droplets of DNA extract from the floor and replace it into the Eppendorf. After a few minutes I had about 1/3 of the liquid, now brown-tinged, back in the tube. Resigned, I put the tube in the fridge. 

NO time to fret, no time to start over. Nothing else to do. I got on my jacket and faced the Boston winter, and jogged for the Orange Line stop. 

Once on board that last train, I started to sob. There was no way that soiled sample would be any good. This COMPLETELY SUCKED. 

And, I realized, I really did not want to be here. I realized: I could do the scientific work, but, unlike some colleagues who revelled in long hours in pursuit of new knowledge, I was despondent, not very good at this, and missed being around people. 

That was the night I decided that bench research was not for me. I had thought my calling was in pure science, but this DNA catastrophe taught me where I didn’t want to be. I needed Humanism AND Science. So, medical school it was. I’ve never looked back. 

Molecular Biology after 1985 (CRISPR!)

Thirty-five years later after my profanity-laced change of career, Walter Isaacson chronicles the recent successes of genetic research, including the discovery of CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) and CAS9 (CRISPR ASsociated protein #9).

Book review rating? 5/5 stars.

In a nutshell: Jennifer Doudna and Emmanuelle Charpentier, and many others raced to understand these strange “repeating sequences” in DNA and mRNA, realizing that they were bacterial defenses against “phage” viruses.

In this work, they discovered that CRISPR-Cas9, an mRNA plus protein complex could identify attacking virus mRNA and SLICE IT UP, deactivating it. They realized that this ancient protein complex could be taught to identify ANY RNA or DNA. Gene editing, invented by bacteria as a survival mechanism a millenia ago, co-opted by humans. Precise genetic scissors.

I enjoy Isaacson’s writing style. Not only does he clearly explain the adrenaline rush of scientific discovery (and the delicate dance between scientific sharing versus the race against other labs to publish and claim credit), but also the technical details of how CRISPR works.

Isaacson writes about Doudna and the response to Covid-19. What is even more astonishing about Dr. Doudna, the bench researcher and lab leader at Berkeley, is that she had the socio-political skills to bring together 40 leading geneticists across the Bay Area to successfully set up a brain trust to develop Covid-19 testing and vaccine development. This team lays much of the groundwork of the accomplishments of this past year.

Drs. Doudna and Charpentier were, deservedly, awarded the 2020 Nobel Prize in Biology “for the development of a method for genome editing.”

A personal note: my brief journey in molecular biology never quite crosses Dr. Doudna’s path, but I recognize the genetic tools mentioned, and studied the work of the luminaries in the field. I feel like a distant cousin to these scientists.

Highly recommended read, to understand the genetic foundation of our modern age.

Molecular Biology: the Covid fight

Here are 2 stories about Covid Vaccines, from the New York Times and WIRED.com, fascinating glimpses into the genomic-industrial complex. As of May 14th 2021, 36% of US adults are vaccinated against Covid-19. It is highly likely that these speedier and more effective mRNA-based detection tests and vaccines will forever be part of our lives. This could shorten development and improve accuracy of future vaccines.

WIRED.com story on Moderna’s Covid Vaccine trials

https://www.wired.com/story/moderna-covid-19-vaccine-trials/

CMIO’s take? Our modern world is built from advances in scientific method, computing and now genome editing. Despite my early failure in the lab, I feel fortunate, in the field of medical informatics, to be close to all 3.

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.

IMG_9195.jpg

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). 

IMG_9242.jpeg

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.”

IMG_9341.jpg

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

SNAFU tent: Optimizing a Covid-19 Mass Vaccine effort at Many Levels

Dancin’ away troubles at UCHealth’s SNAFU tent for Covid Mass Vaccination

Optimizing the Mass Vaccine Event

This will be a fun exploration from a CMIO’s perspective. Let’s think about individuals and work our way up to national optimization, from a personal perspective. And, don’t miss the SNAFU Tent Vaccine Dance at the end…

Seven Levels of thinking

  • Level 1: Make myself efficient
  • Level 2: Make my pit-crew efficient
  • Level 3: Make all pit-crews efficient
  • Level 4: Make the entire Mass Vaccine efficient
  • Level 5: Optimize Mass Vaccine for volume or cost
  • Level 6: Optimize Health System Vaccination plan
  • Level 7: Optimize National Vaccination

1. Make myself efficient

Readers may remember recent writeups where I incrementally overcome my lack of skill as a physician at vaccinating. I’m a quick study, and when great nurses and medical assistants are around to teach, I got better quickly. See above, with the pre-peeled bandaid/ vaccine/ alcohol swab grip, and second hand to manage the smartphone electronic documentation. I’m MOB-ILE.

Here’s the set up: have an assistant play “keep ahead” by peeling bandaids. The hardest part of the job is peeling bandaids with gloves on.

The next hard part is that vinyl gloves stiffen in cold weather. So, use the sani-wipe jug to elevate your glove box closer to the propane heater. Smart! Actually even that wasn’t really warm enough, so I took to doing this:

I call this “praying to the propane gods.” Or, holding the gloves up for 5 seconds of warmth: makes a huge difference in the ease of putting them on (150 times that day).

Handwarmers: Even better idea

Of course, Bernice comes to me near the end of the day and tells me “Dr. Lin, put 2 handwarmers in your coat pockets and put your next pair of gloves in them, so you always have warm gloves to swap.

“D’oh!” as Homer Simpson would say. Why didn’t I think of that?! Thanks, Bernice.

Colorado Rockies’ Dinger drops by

2: Make my pit-crew efficient

This section is actually mis-labelled. My pit crew made ME efficient. Unlike previous days, where I built up such an efficient process that I was able to stay ahead of my pit-crew colleagues in our 4-car pit-stop, today I was teamed up with 3 outstanding medical assistants from Lowry Internal Medicine, my own UCHealth clinic in Denver: Marina, Yanira and Bernice. The tables were turned: now, every time I looked up from my completed vaccination, the other cars in my pit had already gone! Too fast, gals! You’re too fast for me. 😦

Team Lowry, with my BFF’s.

View of the Mega tent with 4 of the 8 rows, and the pharmacy (vaccine reconstitution tent to the right). The other 4 rows are out of sight to the right of the pharmacy tent. We can vaccinate 32 cars in 8 rows at a time this way. Furthermore, we would huddle and learn from each other “How are you going so fast? What is your set up? How do you ask the screening questions? Where do you put the sharps container?” etc. Thank you, smart colleagues, for teaching me.

3: Make all pit-crews efficient

To further smooth the process, given what we had learned on previous weeks, we posted 4 SNAFU tents after the Mega-tent that we would refer to for any slow-downs or technical concerns. For example, one car pulled up with 3 people to be vaccinated. I would perform one vaccination, and since my row was ready to roll by then, I would place a red card on the windshield, indicating SNAFU and the flaggers would direct the car to receive the remaining 2 shots about 100 yards away. This simple workflow adjustment (4 SNAFU tents for all 8 pit-crews) kept ALL 8 lines moving. This was a difference (for me) between vaccinating 124 people one day and 158 the next. Super smooth.

Another example: a patient drove up and their Electronic Record account showed “second vaccine already administered.” I couldn’t solve it with my smartphone Rover app, so I referred him to the SNAFU tent.

After some investigation, we found out later that day, it turns out that another organization in town had incorrectly registered that patient (a common first and last name and somehow erroneously documented date of birth) so that the mistaken vaccine APPEARED in OUR system on this patient (our separate Epic EHR’s share vaccine records now) that he had already had his second shot (incorrectly). We presume this was because some institutions are still using a paper-vaccination process with “document later” staff (as we did last month, in favor of speedy vaccinations). This re-introduces errors that the EHR was supposed to eliminate (bad handwriting and transcription errors). Hmm.

We are glad we are now using the Rover smartphone app. We’ve tinkered with it so that it is now possible to be as fast with Rover as with paper (AND eliminating the transcription step). 50 seconds with paper, and 50 seconds with Rover. Ha!

4: Make the entire Mass Vaccine efficient

We had lots of competing concerns to keep in mind, when thinking about the entire effort. Police were concerned about backing up waiting cars into nearby streets. (whew, we avoided this). How many total staff were needed to register patients? (too many in version 1) How many tents to rent for these events? (originally 1 mega and 18 cabana-style tents, now 1 mega and 2 cabanas) How would we deal with inclement weather? (snow, rain, black ice, wind: the mega-tent is superior to cabanas for keeping staff out of the weather and minimizing wifi and cell-booster mesh network issues; FYI, my new 5G iPhone 12 pro max was awesome in our pilot testing for speedy smartphone documentation)

Our diligent road crew out there dodging and managing tent-avalanches.

We have been pleased to constantly drive down out patient-throughput times, down to 22 minutes (including the 15 minute observation period)! And this past week on Sunday, we drove our total time down to 16 minutes in some cases: 1.5 minutes for registration, vaccination, a couple minute driving time, and then a 10-minute observation period. Wow. We believe we are the fastest Mass Vaccine service in the country at this rate. Even better, we are making observation OPTIONAL going forward, because of our non-existent severe reaction rate.

We believe we can expand beyond 10,000 per weekend, and believe we can do 20,000 or possibly 26,000 per weekend, if the State has vaccine supply and would like us to.

5: Optimize Mass Vaccine for volume or cost

So, what is the goal of a Mass Vaccine event? Publicity for vaccination? Sure, we had news helicopters circling, lots of press, lots of people commenting on how easy it was, and how much they’re looking forward to hugging grandkids.

We can optimize for convenience for frail elderly. Sure, stay in your car from home, back to home, no walking. Can we help people avoid healthcare settings? Sure.

We can optimize for speed: in which case, bring more vaccinators, and rent a second mega-tent. There is room in this massive parking lot for more staff, we can create more lanes and instead of 32 at a time, we could do 48 cars or more. 20,000 per weekend is entirely conceivable, if vaccine supply were up to it (not yet).

Or, we can optimize for lower cost. With our original full teams in the early weeks, we overstaffed and calculated a per-vaccine operating cost in the mid $20’s. Of course, the vaccine itself, is free to us and patients, paid for by the feds. But, tents, staff, project managers, coordinators with police, state, county and city government, vaccinators, training team, pharmacy team, coolers and vaccine supply chain management, traffic tents, snow removal, medical observation team, volunteer-coordinating managers, paramedics, command center coordinators, walkie-talkies, workstations on wheels, smartphone devices, wifi repeaters, cellular repeaters, scheduling of appointments, design of vaccine clinics… pretty soon it is a big operation. After a couple days, and constant re-design, we were able to trim operations down into the $17 range.

6: Optimize Health System Vaccination plan

First Covid Mass Vaccine design, last month, at Coors Field, Denver

Vaccinating patients on-site at University of Colorado Hospital, Bruce Schroeffel Auditorium

Outdoor vaccine guy vs Indoor vaccine guy

AND THEN. We compare our Mass Vaccine efforts to our ongoing (but less splashy) vaccine clinics in 10 facilities across UCHealth, spread across the entire state of Colorado, at even lower per-vaccine cost, with the capability of 5,000 to 10,000 per day. We are hiring permanent staff to run these vaccine clinics and stop borrowing from clinical teams across our system, as we think we will be doing this for quite some time.

Volunteers?

It is gratifying that we have lots of folks (many retired) willing to volunteer their time. The challenge with accepting this help is: it can be more expensive to run a scheduling calendar and training for hundreds (?thousands) of part-time (or one-time) volunteers than it is to have a reliable, skilled steady crew to take care of business. For the rare volunteer who COULD come regularly (for 8 or 10 hour shifts!) (for months!), that would be a blessing. And, as this vaccine saga goes on, we may indeed need more help.

Pop-up Outreach Clinics for the medically Under-served

Another effort I’m grateful for, are our Pop-Up vaccine clinics. We are taking our show on the road to multiple community centers and churches in medically under-served neighborhoods, where leaders are helping us schedule thousands of vaccination appointments among their neighbors. I’m heading to several in the coming weeks. (stand by for more posts from the front lines!)

UCHealth has given 270,000 vaccines, about 20% of Colorado’s total to date.

Yup, you read that right.

From this graph, you see our green Mass Vaccination events occurring on 2 weekends. Dark blue is University Hospital with over 13,000 vaccines given per week, and our other regions similarly. Light blue is South region, Purple is North region. Red includes our small hospital and outreach clinics at about 10,000 a week. Again, limited by supply.

7: Optimize National Vaccination

A rising tide lifts all boats.

For those interested, UCHealth has published a playbook for other organizations: https://www.uchealth.org/covid-19-mass-vaccination-planning/ with lots more details.

And Finally: a SNAFU Tent Vaccine Dance?

Is this real? Apparently, yes. Dr. Jonathan Pell and our elite crew of SNAFU tent staffers put together a dance invitation for upcoming cars.

I was surprised to find out how many younger colleagues had never heard of the term SNAFU.

The good news? Our process worked so well, the SNAFU team did not have much to do, a few cars here and there during the day. So much time, in fact, that they came up with their own DANCE.

I have no words.

CMIO’s take? How to get better in Seven Different Ways. Let’s go!

A Good Covid Vaccination Is Like Calligraphy

Join CT on the front line of vaccine clinic at UCHealth!

Hi y’all! I volunteered for a vaccine shift. Me and a couple dozen of my best friends. Here’s the scene: this clinic day was dedicated to second-vaccine doses for nearly 1000 healthcare colleagues, 12 vaccinator stations, and a constant stream of patients down the hallway. Our location can handle 2-3x this number, if we had vaccine supply to do so (and on last Friday, our location and 9 other UCHealth vaccine locations dispensed over 5000 vaccine doses across UCHealth).

Having been a grateful recipient of both my shots, I’m ready to wade in and do my part as well.

Ever wonder what it is like to be a vaccinator at a high-volume vaccine clinic?

On the Vaccine Front Line

First, you receive an email to take your training on EHR documentation requirements ahead of time, and a super quick anatomy refresher on deltoid muscle and intramuscular injections. Easily done, about 10 minutes. Then you report for duty at one of the twice daily 7-hour shifts. You get a quick in-person briefing, some quick hand-holding (ok sounds weird in pandemic times), and off we go!

Here’s my station. Because, as my daughter says, I’m totally into ‘hume-optimizing’ (determining the optimal way for humans to do things – sometimes to the great annoyance of family members or colleagues: sorry y’all) I thought hard and asked lots of questions of my more experienced medical assistants and nurses sitting nearby. Here’s what I learned:

  • Card colors: Green card: hold in air when ready for another patient; Yellow card: running out of any supplies; Red card: medical question (just embarrassing to hold this one up if you’re a physician)
  • Computer: login, find the immunization clinic, filter out discharged patients, sort by time of arrival, click to remove word-wrap to show more patients per screen.
  • The data entry fields pull forward 80% of relevant data to each new patient, as well as the vaccine name, lot#, and details, and I’m down to just confirming patient identity, confirming injection site (6- R deltoid, 7-L deltoid: even the physical mapping makes it easy: when patient facing you, the 6 key is on the same side as the patient’s R arm!), asking the 3 screening Q.
  • Then the shot itself! Vaccine syringe (obvious) but don’t stick yourself or the patient unintentionally. (HOT TIP) And when you insert the needle, do it with a quick pop so that breaking the skin and finishing the motion are in the same moment and the patient’s sensory nerves don’t get a chance to register more than one ‘oh’ of surprise. Specifically, don’t be slow.
  • (HOT TIP from a PA colleague in Interventional Radiology) hold the syringe between your thumb and 3rd and 4th digits, with your index positioned over the plunger. Really? That’s the way? (Sooooo much faster than my jab, then switch hands, try not to be awkward, plunge, untangle my hands and pull back) and the jab+plunge was now less than a second. Level up! (Gamer talk). After my “technique improvement” lots of patients were surprised: “Hey! Didn’t feel that at all!”
https://www.jacksonsart.com/blog/2017/03/28/maggie-cross-chinese-painting/
  • (Irrelevant aside) I notice that this new syringe grasp is reminiscent of the way you are to hold a Chinese Calligraphy brush, like you are cupping an egg and then grasping the brush. Ah, such elegance.
  • (HOT TIP From a brilliant nurse colleague) After the alcohol swab of the deltoid, pre-attach half of the bandaid and let it hang down. That way, you know where to put the shot and you don’t lose track (if no spot of blood) of where it went as you look away to dispose of the syringe. Then flip the bandaid fully on, VOILA! Totally changed my life.
  • Click the needle protector closed with one finger, toss in Sharps container.
  • Mumble sweet nothings to your anxious client while doing the next steps. Answer any questions.
  • Type ‘n’ in the time field to get the time Now. Click Accept to complete the vaccine charting. Their patient portal account is automatically updated, and the State Vaccine Registry is updated (I believe either real-time or at midnight every night)! Add 15 minutes to write onto a sticky note to attach to their vaccine card for them to know when they can leave if feeling okay.
  • Reach for a tiny sticker to put on the vaccine card with vaccine name, lot#, date, location.
  • Smile with your eyes, gesture to the seating area.
  • (HOT TIP from another RN colleague): Wipe down: with gloves on, pull an antiseptic wipe for the desk, chair, relevant surfaces. Whip off gloves, rip and prep an alcohol swab and bandaid —easier with gloves off. New pair of gloves, position a new syringe on desk, check if running low on supplies, raise the green card.
  • NEXT! Cycle time when all was humming, as little as 3 minutes. Less time than it took to read this.

Of course, GEEZ some patients had the temerity to ask questions. Or we would briefly run low on vaccine as the pharmacy team whipped up another batch in the next room, or someone had to run for sticky notes or wipes or gloves etc. Or maybe I NEEDED A POTTY BREAK, OK? Other times, we would have lulls in the action. Then it was up to our green-card-waving skills as to which of a half dozen vaccinators the lone patient would walk to.

Here’s a counterintuitive tip for non-medical workers.

You might think that having your vaccine done by a person in green scrubs or a white coat (in my case, both) would be ideal: they’re the doctors or providers. In our organization, nurses wear dark blue scrubs, medical assistants wear dark purple (violet?). Almost uniformly, the docs volunteering haven’t given vaccinations since … medical school. In my case, 30+ years ago. My recommendation: go with blue or violet scrubs for technical proficiency and years of practice. Of course, if you want a long medical conversation, by all means stop by my booth!

Here’s my tally. Actually 55 by end of day. I figured out that I could keep my needle caps on the desk until I had a break to make my hash marks and throw out the caps. The system worked. I know many of my RN and MA partners were quicker than me or had better patient-attracting green-card-waving skills or took shorter breaks. Not bad for my first half-day shift.

This was unlike my daily work.

As a physician in an internal medicine clinic I would worry about how to reduce the blood sugar of an overweight, depressed and anxious diabetes patient with high blood pressure, severe arthritis, needing wheelchair repairs, a dozen prescription refills and several prior-authorization meds, and now with several new worrisome symptoms and family pressures. As CMIO I would worry about how to balance the anger of providers spending long hours writing notes and orders versus allowing a sloppy, error-prone verbal-order paper-like system. And how to allocate time and effort between reducing physician burnout and improving predictive algorithms when those projects were sometimes in conflict.

Working in a vaccine clinic by contrast was like playing a fun, fast-paced, team-based video game (not that I would know): clear goals, mutual reinforcement, visible progress, strong team camaraderie, repetitive (and improving) physical skills, opportunities for rapid learning, immediate positive feedback and customer appreciation, excitement over doing a public good. We were IN THE ZONE.

Honestly, on good days, both regular clinic and informatics work is like this too.

What’s not to like?

Oh, here’s one of our physician leaders, Dr. Andy Meacham, even with everything he knows about how docs are the worst vaccinators, willing to be my victim. Thank you for your service, Dr. Meacham.

Gratitude

Honestly, it humbles me to part of such an amazing organization that assembled the people, the process, the tools so that I could drop in as part of a well-oiled machine, only a couple weeks into this brand new process. I’ve noted quite a few physician leader colleagues also taking part. So cool. 

“Covid-19, Yes, Your Days are Numbered! We’ll take back our streets and those jobs you’ve plundered!” — CT Lin & his terrible (My Shot – Covid) ukulele song

If all this talk gets you interested in the vaccine, See my recent blog post on how to get in line for a vaccine at UCHealth

CMIO’s take? Serving as a Covid Vaccine vaccinator was one of the most gratifying things I’ve done. I’m signing up for more shifts. See you soon!

I am NOT throwing away my Shot (I got mine today!)

Covid-19 Vaccine! I got mine! And University of Colorado Hospital is set up to give over 1000 doses per day just at our hospital.

As you know, Covid-19 vaccine is out in the wild. Colorado received the first shipment earlier this week, and we at UCHealth received the first 17,000 doses. We set up an infrastructure to schedule vaccinations through My Health Connection, our patient portal. We sent out over 10,000 invitations this week, and already 5000 health care workers have already booked their appointment. IN 48 HOURS! Never have I ever heard of something moving this fast. 97% of physicians/providers state their willingness and intent to be vaccinated.

Among my colleagues, many of us were hitting “refresh” waiting for our invite to schedule the vaccine. Last night, I was super excited receive my invite. Woo! So organized the portal ensures you book both appointments at the same time. Super simple!

Then, super easy on arrival; we use our patient portal to e-check in, verify my demographics, read the consent form for the vaccine, so that my check in can be super simple and super quick. Yes!

And here we are! 8 check-in stations humming smoothly. Everyone masked up, smiling, everyone so excited to be part of DOING SOMETHING to fight back against the pandemic. Bam!

Here we are in our auditorium. Sixteen vaccination stations, with appointments every 10 minutes, and vaccine service hours from 5am through 9pm. I calculate our capacity to vaccinate about 1000 people a day. This just at UCH; we have 9 other vaccine locations throughout UCHealth’s hospitals in Steamboat, Fort Collins, Colorado Springs, Pikes Peak, also actively vaccinating. Our goal: to administer our entire received batch before Christmas day. Zowie!

I got mine! 15 minutes socially distanced in the auditorium to observe for immediate reaction, and then done! In and out in about 30 minutes! Woo!

As you know, the FDA and CDC guidance is: Healthcare workers and long term care residents and staff first (winter), then high risk general public (spring) and then general public (summer). We are getting started, and have infrastructure now to deliver shots just a quickly as possible. We anticipate vaccinating up to 20% of all people of the State of Colorado. Hope to see you here soon!

CMIO’s take? I am NOT throwin’ away MY SHOT! (could it be there is a new ukulele song/rap? … stay tuned!)