Life At the Foot of Squirrel Hill

Life At the Foot of Squirrel Hill

Where else can you find a Kosher Dunkin Donuts?

I live just at the bottom of Squirrel Hill. Saturday mornings my partner Michael and his 13 year old daughter have a routine of going to the (Kosher) Dunkin Donuts for breakfast then going to the climbing gym together. Normally I go with them, but I worked yesterday and today.

We got the bronze alert of a system wide disaster so I know about the shooting before most of the city. However when I texted my partner…he already knew…the Dunkin Donuts is just 2 blocks from the Tree of Life Synagogue. My mothers caretaker drove past the synagogue just 30 minutes before the shooting. I drive past it twice a day every time I go visit my mother.

It’s Mr Rogers Neighborhood … for real.

If you havn’t read enough stories and articles about Pittsburgh, and specifically Squirrel Hill… it’s an amazing place. I have had many opportunities to move away from my hometown of Pittsburgh and live anywhere I want… since ER physicians are in demand all over the country. I always have returned here not only because my family is here, but because I simply LOVE Pittsburgh.

Shadyside, Squirrel Hill, Edgewood, Regent Square, Point Breeze, East Liberty … these neighborhoods have surrounded my waking hours for the past 20 years.

Collectively they comprise a diverse old immigrant and new immigrant city, multiple ethnicities, and terrain unmatched by any other city…more bridges than Venice, more stairs than San Francisco, Canton Avenue home of the steepest street in the world, and the only place where commuting hassle is measured not in how many miles or minutes you spend in the car, but how many rivers you cross. The working class blue collar roots still ground the city in a “hard work works” attitude, yet it’s also home to progressive technology firms such as Google and Uber.

Finding My Home

Before I started medical school, I lived in the suburbs. I looked forward to my days off work, when I was studying to take the MCATs, when I could drive into town and study at the 61c, a long standing independent coffee shop in the middle of squirrel hill on Murray Avenue.

Two years later when I started school at Pitt, I was so excited to move to the East End and start an exciting new part of my life. After residency when I moved back to Pittsburgh, some people were not shy to suggest I move to Dormont or the South HIlls to be near my new job.

But to me I didn’t think for a second that I would live anywhere other than the East End. So many of my lifelong friends, even from prior to medical school lived in the area within a 2-3 mile radius, including my mother who excitedly moved to Shadyside the year I started medical school.

For a year and a half while renting, my good friend Tom Cahill and I looked for my “dream house”. It was literally 18 months and 1 dream later when I described to Tom a house that was in my dream…two weeks later I was a first time homeowner…in the East End of Pittsburgh.

Even now on my days off most of my daily routine occurs in squirrel hill…my bank, the post office, my eye doctor, the grocery store, multiple coffee shops, people watching, FRICK PARK and (the Mac Miller) Blue Slide Park are some of the activities we all share up at the top of the hill.

Not a day goes by that on some level, I don’t think about how fortunate I am to have found a house I love, in the city, but just far enough outside, in a thriving, vibrant, small town feel community…the East End of the city.

There are  no words for how I’m feeling…

I am saddened with a complete loss of words at the lives lost, one a former colleague and the others no more than 1 degree of separation (this is Pittsburgh after all). However, the past two days, I’ve been impressed and soothed…but not surprised, but the shows of community support. Vigils being held in the pouring rain, organized by high school students from the public city school of Alderdice at the foot of Murray Avenue. All ages, all religions, all nationalities … holding one another as family and expressing their fierce pride in our city, our home.

I worked all weekend and missed the opportunity to attend the moving candlelight vigil at Forbes and Murray on Saturday evening. But tomorrow I know what I’m going to do. My therapy-dog-in-training and I will head right up to the place we call our home and hand out fuzzy kisses and free pets and pay our respects to those who lost their lives in their place of worship.

Thank you for reading.

Instinct is Learned

Mr. Reynolds is a vivid 83 year old who lived alone at home. He walks everyday int he morning first thing before he has a small cup of coffee. His kids bought him an ipad and he uses it to browse the Washington Post, the Wall Street Journal, and the Pittsburgh Post Gazette while eating breakfast.

Every morning it’s the same breakfast…toast with honey and a small cup of yogurt. Then he’s ready to start the day, just when the rest of his neighbors are waking up.

Today however, he ate hist toast and his stomach grumbled, louder than usual.  He thought to himself that he’d better get to the bathroom quickly… and he was right.

I met him an hour later in a gurney with the chief complaint of ‘bloody diarrhea’.   He looked great to me, comfortable, normal blood pressure and heart rate, he wasn’t pale, no pain at all. The only finding was maroon colored stool.

I sent off a bunch of labs thinking he had one of 3 main intestinal related issues…bleeding ulcer, bleeding polyp / diverticula, or hemorrhoids.  Hemorrhoids were less likely since the blood is usually bright red.  Likewise lower intestinal bleeding is often still bright red since there’s a short distance for it to travel and the bright red color is maintained.  Hmm…that leaves a bleeding ulcer from the stomach.  int he stomach the blood is exposed to stomach acid, which turns the iron black.  Black stool is a bad sign..but maroon stool is even more ominous, as the blood is accumulating quickly enough to let some bright red blood mix with the blackened blood turning it a dark shade of maroon.

But Mr. Reynolds looked great.   Many bleeds are brief and stop on their own. He’d had no further episodes since the first one.

After an hour his labs came back. His hemoglobin was 9.4.  A little on the low side but not overly concerning.  I looked up old labs and only had ones from years ago.  His old, presumably “baseline” hemoglobin was 14.  But I had no way of knowing how quickly he had become anemic.  For all I knew it could have been gradual over years or a few months.  Surely he’d not lost 5 units of blood since this morning because his blood pressure and heart rate were normal and he felt fine.

Then his nurse grabbed me.  “Doc Shazam,” she said forcefully. “Mr Reynold’s blood pressure is 90/50”.  “How does he look?” I asked.  “He still looks fine.”  Reluctantly, due to the IV fluid shortage, I asked her to start a 500ml fluid bolus.    I hesitated because lots of folks when they are relaxing in the ER, especially if they’ve taken home blood pressure medicines, may develop a blood pressure a bit on the low side.  I’d hoped that was his case, but this nurse is good.  She’s not one that comes to me for every little thing and she’s a great problem solver.  IN this case her problem solving included telling me his pressure was on the low side.

“Let’s add a lactate and redraw his hemoglobin,” I called towards her desk.   She heard me.  “OK,” she smiled and strutted away to draw some labs. She seemed happy with my orders, i think they were in line with her concerns.  But I still thought I was overreacting, wasting resources, wasting a half-liter of precious saline and the bag it comes in.

15 minutes later, I learn his lactate is 6 and his hemoglobin is now 9.  “That can’t be right,” I told her.  His lactate can’t be 6…he looks FINE, I told myself for the umpteenth time.  But that hemoglobin…could be lab error I thought.

I started putting the pieces together and while the patient looked fine, and had responded nicely to the fluids with a  pressure now of 114,  I’ve seen enough patients get very sick, very quickly once they cross a threshold.  Unfortunately they don’t come with gauges that tell us where that threshold his.

I decided if it was my family member in that room, I wouldn’t want the doctor to wait until he turned downhill, scrambling to replace blood and calling in resources exigently.

I ordered a unit of packed red blood cells and a pack of platelets since he was on aspirin and plavix, called the admitting team who had already seen him and updated them on what I’d learned and what my concerns were.   He thanked me and was in the ER within 5 minutes to assess the patient himself.   His repeat lactate was 5.3 suggesting he’d begun responding to fluids and blood and his repeat hemoglobin climbed to 10.

When I went into his room the GI team was there and they took him to the GI lab a few hours later.

***

Fast forward to the end of my shift and the hospitalist came down to give me an update.

“You were absolutely right with Mr. Reynolds.  The GI doc found bleeding varices in his stomach that they had a hard time controlling. I did a CT and found cirrhosis and signs of portal hypertension. We’re transferring him to tertiary care for a TIPS procedure.”

“I had an instinct,” I told him.   I’m so glad I listened to it. It was subtle but in retrospect it was absolutely the right thing to do.

“Instinct is learned behavior,” he proclaimed.   “You’ve seen it before and you knew the right course of action. Thank you for helping him.”

It made me appreciate that medicine really is a practice. You can know the right thing on paper and on board exams, but in the real world, cases don’t present like books and numbers and vital signs don’t follow the right patterns.   The wisdom of experience only comes from seeing many previous patients crash quickly and rebound slowly.

Mr Reynolds was lucky he came when he did and that it wasn’t my first year on the job.  I went home humbled and scared that I’d taken his case too lightly, but ultimately I’ve learned again and strengthened that clinical instinct.

 

A Living History – Eleonore of Bavaria

A Living History – Eleonore of Bavaria

Nuremberg chronicles - Nuremberga

She was silver-haired and weepy-eyed, with bluish gray bags under he lower-eyelids. Her grandson sat staring at his ipad. He looked like an Irish bartender–with a red beard and a toothy smile. He was patient and spent over five-hours at her bedside, with nowhere specific to go.

She spoke perfect english with a slight european accent, but the more I listened the more familiar it sounded. Taking her full history, I asked extra questions as an excuse to listen to the pleasant sing-song voice. She stressed and drew out her ‘S’ sounds with a soothing tone that reminded me of the Kaa, the crafty, sly snake from Ruyard Kipling’s The Jungle Book.

Satisfied that I had her work-up sorted out in my mind, I finally asked her where she was from.

“Nuremburg,” she said, swallowing the “em” syllable and turning the city into two syllables instead of three.

“Ich kann auch Deutsch,” I carefullly replied.

“Ser gut!” she said, smiling.

I dared not go any further with my German…it’s been 25 years now since I lived in Keil, but at one point I was fluent in High German.

I glanced at her birthday on my patient sticker sheet, and realized she was a “tween” during World War II. Nuremburg was at the center of Allied bombing raids between 1943-1945. During the age when my step-daughter is just getting acne, wondering if boys are creepy or a little bit cool and running for student council, my patient was hiding from Allied bombs with over 90% of her city destroyed in just 1 hour during one of those raids.

Her parents moved a total of 3 times during the war because their house kept getting destroyed. It’s a true miracle that she survived and that she was here in my ER, with her Irish themed grandson and a red-headed granddaughter as well.

I admitted her without fully knowing what was causing her pain, and hoping it was not a life-threatening spinal infection. I would have loved to spend a few hours getting to know her better and understand what her life was like…when did she finally escape the war and did she ever enjoy the freedom of running for school council instead of running for her life? And how do you treat acne during a war?

Split Decision

Split Decision

These days I divide my time between clinical and consulting work.   in my consulting job I work as a medical command physician for ambulances, helicopters and airlines needing advice and direction on all sorts of medical emergencies.

For the past several months I have been fielding several calls a day regarding screening for *possible* Ebola patients wanting to board a plane or currently in the air and suddenly developing symptoms.

Of all of those phone calls…only one of them had recent travel in Liberia and originated from a West African airport.  All of the rest were from random passengers that vomited, or had diarrhea…but had no travel history, no fevers, no exposure to anyone who had an recent travel history, exposure to the virus, etc, etc.

Part of my job is to reassure and clear those patients who have absolutely zero risk of carrying this particular virus.   But there is so much fear and paranoia that we are fielding calls about nearly anyone who vomits.

God forbid a passenger on Coumadin develops a nose bleed!  That’s a sure call to screen for Ebola even if the passenger is a little old lady from Pasadena who always gets a nosebleed on a plane.

 

A Gift to Remember Me By

A Gift to Remember Me By

Last night at dinner, this girl, Virginia, said, I’ll see you tomorrow! It old her that I was leaving in the morning. She asked for a gift to remember her by. I told her I didn’t have much (which was true, I packed ultra light, and brought no gifts) she asked if I could give her my necklace (I said no). I told her I would draw her a photo instead.

So I brought out this sketchbook that Kwin Krisadaphong sent me, and she asked for that as a gift. I showed her Kwin’s inscription and told her I couldn’t give away a gift to me.

I quickly sketched out this picture with a nice sketch pen I carry with the book. (She asked for the pen as well. )

I tore out the page and handed it to her after writing a message in both English and Spanish, then reached around to hug her and slipped the pen I to her back pocket. She pulled her shirt down over the pen so no one else would see.

It’s hard to want to be able to give everything to every child, but some of them somehow seem to make a bigger mark than others.10333385_10203949741775539_5831120630524831564_o 1601955_10203949741655536_2200180618000528146_o 10410722_10203949738815465_648259956400244290_n

Lights, Stethoscope, Action!

Lights, Stethoscope, Action!

Safely arrived in Honduras, met our transportation to the village, saw many old friends already, it almost feels like home.

The Sun is setting, the breeze is cool, the kids at everywhere, the meal was great, the parrots are chirping and the strangest thing is there are lights coming on in the village.

2 years ago there was no electricity here at all, then all of a sudden electric poles went up, now lines and lights.

We have seen one patient already, a boy with a leg infection from a motorcycle accident.
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