jenniferhawke.com

“Madame Michel has the elegance of a hedgehog: on the outside, she’s covered in quills, a real fortress, but my gut feeling is that on the inside, she has the same simple refinement as the hedgehog: a deceptively indolent little creature, fiercely solitary — and terribly elegant.”

At first this book scared me because I thought I was too dumbed down by science textbooks to enjoy its’ more lofty philosophical and artistic qualities.

But I’m about 2/3rds through now and I really, really like it.

A friend (thanks, Roger!) passed along this NY Times article to me the other day week. It made me think about the physician’s role in end-of-life care. More specifically, it made me evaluate my position on end-of-life care and the type of physician I will become.

While there are universally accepted protocols for treating conditions like flu and diabetes, this is not as true for the management of people’s last weeks, days and hours. Indeed, a review of a decade of medical literature on terminal sedation and interviews with palliative care doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.

Discussions between doctors and dying patients’ families can be spare, even cryptic. In half a dozen end-of-life consultations attended by a reporter over the last year, even the most forthright doctors and nurses did little more than hint at what the drugs could do. Afterward, some families said they were surprised their loved ones died so quickly, and wondered if the drugs had played a role.

Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. Still, most families felt they and the doctors had done the right thing.

~ from the NY Times

The entire article is moving and worth a read. I found it intriguing because I really like dealing with old people in medicine. And I feel drawn to some of the harder specialties like oncology and palliative care.

As such, it is inevitable that the ethics of pain management and medication in end-of-life care have a few lessons up their sleeves for me. I intend to learn a lot from patients and their families on how they want to spend their final days.

Because when the time comes, I hope someone is listening to me.

So, I got an email the other week from a publisher wondering if I’d like a review copy of Atul Gawande’s new book, “The Checklist Manifesto.”

I responded, “Heck yes”. I LOVE LISTS.

I am a big fan of Gawande’s other two titles, “Better” and “Complications” and was considering investing in his next book. Once it came out on something cheaper than hardcover, of course.

And then it showed up on my doorstep. Hardcover and all. I’ve burned through the chapters in a couple of days, but can tell I will go back and re-read most of it. It’s a simple but inspiring solution to succeeding at highly complex and unpredictable jobs: make a checklist so you don’t miss anything.

“We have accumulated stupendous know how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mentioned demoralizing and frustrating, across many fields — from medicine to finance, business to government.

… the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.”

Gawande is a surgeon. And nowhere is this more true than in medicine. In med school we joke that it’s like trying to take a sip of water from a firehose. There is just so much information to memorize. As physicians, you may not need to know tiny details of the glucose degredation enzyme pathway on a daily basis, but there are still a ton of details to manage with an emergency case of DKA in a patient.

Right now, as a student, I’m practicing an established set of checklists that were created by people who studied medicine before me: labs, reviews of systems, medications, allergies, etc. I ask a predetermined set of questions in a history & physical to make sure I don’t miss anything. I check the same CBC and BMP values every morning. Pre-rounds have a different set of questions for a patient with pancreatitis than frostbite. The checklists evolve according to each situation, but I still feel certain things falling through the cracks with my lack of knowledge and experience.

I’m curious to see how the book ends. And I’ll be sure to share the checklist I come up with to help organize my daily 3rd year med student tasks.

“It is by chance that we met, by choice that we became friends.”
~ Unknown

I wanted to thank the following ladies for upping to the holiday cheer quotient around here:

Jillian – I curled up in bed with a cuppa cocoa last night. I have been drooling over the latest homemade bottled Christmas gifts on your blog.

Laurie – The cards are beautiful. I am looking forward to thinking up occasions to mail them in the new year.

Joanne – So much oatmeal, so little time! YUM! Thank you for rounding out the food groups in our holiday snacking plans.

You gals rock. Thank you!

We have so much to be thankful for.

This holiday season, take the time to talk to family about important (and too often avoided) end-of-life care plans. Sound like a morbid way to celebrate? I can’t think of a better way to show love than to know the answers to these 5 little questions.

Clear the fog. Engage with grace.

1 month and 1 week
2 months and 2 weeks

about a month before our wedding, i got a sparkly card in the mail from my grandma. the front was a picture of a Super Bride-to-Be swinging on a star. it was awesome.

she also sent three photocopies of our Saskatoon Star Phoenix engagement announcement and her wishes that i enjoy this time now because soon it will be all “us” and “we”. i have been compiling a little post about all the marriage advice i have received through congratulations, well-wishes and well-meaning wishes since we announced our pending nuptials.

“Congratulations! We never thought this day would come for you!”
~ Auntie Joni

“Try to do the things for him that you know mean the most to him, because you can’t do everything all the time.”
~ Tiffany

“Marriage has 3 key components: fierce loyalty, a profound sense of destiny, and hot sex.”
~ Dawn

“Marriage isn’t 50-50. It’s 100% and 100%.”
~ Grandpa Hawke

and one of my all-time favourites…

“My mother Mary — who is still ticking along at 91 — always told my sisters to marry younger men: ‘They don’t last as well, so get a young one.’

You two seem to have the Mary W formula for a successful marriage about right.”
~ Brian W

what’s your advice for a successful marriage?

it’s always sad when two of my favourite subjects come together in a negative way.

Two neuropathologists are prominently spotlighted in an article by Malcolm Gladwell in the October 19 issue of The New Yorker. The article explores a provocative question raised by autopsy results on football players: namely, should football be illegal?

Featured are Dr. Ann McKee, neuropathologist at the Veterans Hospital in Bedford, Massachusetts and Dr. Bennet Omalu, forensic neuropathologist and San Joaquin Valley (CA) chief medical examiner. Drs. McKee and Omalu have done some interesting autopsy work which suggests that chronic traumatic brain injury leading to dementia suffered by football players is much more common, even among high school players, than previously realized.

What’s alarming is the presence of abnormal collections of a protein known as tau, one of the proteins one sees in cases of Alzheimer disease, in brains of young ex-football players. As an example, McKee provides photomicrographs from a case of an 18-year-old high school football player and says: “He’s got all this tau. This is frontal and this is insular…. This is completely inappropriate. You don’t see tau like this in an 18-year-old. You don’t see tau like this in a fifty year old.”

You might counter that this is simply the result of a few bad-luck hits on the field, but research involving the University of North Carolina football team suggests otherwise. Players at UNC wear impact sensors in their helmets throughout the season. Results from these investigations suggests that even routine hits during practice can add up to cause concussions and, theoretically, set the stage for chronic traumatic encephalopathy. (On the first day of training camp one UNC lineman was recorded as having been hit in the head thirty-one times!)

Back in 1905, Gladwell reports, the question of whether football should be played in our nation’s schools was raised to the level of the White House, when President Theodore Roosevelt called an emergency summit to discuss the issue. At the time, a professor at the University of Chicago called football a “boy-killing, man-mutilating, money-making, education-prostituting, gladiatorial sport.” And in December of 1905, presidents of twelve prominent colleges met in New York and came within one vote of abolishing the sport at their institutions.

What does this mean for football in America? Nothing. Fans are willing to spend a lot of money to see men slam into each other’s heads on the field. But, as a parent, you can do something.

You can forbid your son from playing football.

~ Brian E. Moore, MD (via KevinMD.com)

“Like a band of gypsies we go down the highway
We’re the best of friends
Insisting that the world keep turning our way”
~ Willie Nelson

have i mentioned that Brandon’s dad is a truck driver too?

i love it when they send us pictures from the road on their phones. new-fangled technology is so coool.

this post and these photos are dedicated to the roadtrip genes we obviously inherited paternally and the gods of good gas prices as we hit the highway again tonight.

i was just going to come here to tell you that i’m busy and don’t have time to write.

how annoying.

i may neglect email and bathing, but i make time for you.

it’s dark and rainy and thundering. which means Maddy is cozying up on the bathroom tile under the sink and i’m tired of getting up before dawn. i mentioned to Brandon this morning that we haven’t slept-in together in this house even once since we moved in. sad, no?

i am pleasantly surprised at how much i’m enjoying Internal Medicine. the patients are sick and it’s hard to keep track of 5 or 6 conditions and 20 or 30 medications in one person, but it’s a lot like solving a puzzle. i’m currently learning how to gather the pieces. my pockets are literally bulging and you should see the inside of my head. index cards are falling out of my ears.

Brandon is considering taking a job for a few days a week. i’ll let him talk more about it on his site, but suffice it to say, we are poor med students that like to spend money on expensive gas so we can drive around to Husker games and i can’t legally work in this country yet. plus, i’m sure he’ll enjoy getting out of the house and talking to someone other than our dogs. i’m actually pretty excited for him. yes, his Big Important Exam is still coming up and yes he’s still studying his little butt off, but the job he interviewed for yesterday sounds pretty cool and may actually relate to the kind of thing he wants to do long-term.

speaking of driving around! Husker games! and dogs! tomorrow we’re dropping the kids dogs off at the babysitter vet and skipping town to pick up a couple of friends in Dallas. then it’s on to Waco for the Nebraksa-Baylor game. i met a neurologist from Lincoln yesterday and, upon hearing i married into the Husker lifestyle, he said “i hear Bo says the entire team is getting the H1N1 shot, except the wide receivers. they can’t catch anything anyway.”

if i’m not posting from the road, i’ll be back sometime Sunday.

happy Halloween, kids! stay safe and stay spooky.

————
photo: me not cutting my fingers off. taken by Brandon.

i started Internal Medicine. everyone says they learn a lot on this rotation and, after only one day, i can see why. we saw 18 patients today and that gave me about 1800 things to look up tonight.

this is going to be a mind-numbing and grueling rotation, with long days and work straight through Thanksgiving and Christmas and New Year’s (oh boohoo, i know!). our (10? 11? hour) days start at 7am and i’m on a team with 4 residents and 3 other students. yes, that makes 8! i’ve suddenly become part of the white-coat pack that shuffles behind the doctor and moves from room to room in an albino herd-like fashion. it’s a little different than the solo flying and co-piloting i did on OB and at the Family Medicine outpatient clinic.

speaking of Family Medicine, it’s done!

after each rotation we get mini performance reviews from the supervising resident or attending. some of them are even nice enough to take the time to give you concrete feedback (you know, other than just “you did good”) with advice for how to fix things as you move forward.

during the the performance review i got from the Family Resident attending on Friday, he said something along the lines of: “i know students are told it’s okay to say ‘i don’t know’, but your — and i’m assuming it’s the Canadian in you — mild mannered and non-confrontational personality makes ‘i don’t know’ sort of a sucky answer for you.” he also said nice things like how i’m highly motivated, great with patients and staff, insightful, bright, articulate, and read more than any other student he’s had rotate through.

but even the most articulate “i don’t know” is worse than a theory or blind guess in the dark.

so, if you’ll excuse me, i’m off to read. i need to be able to come up with some big girl words if i’m put on the spot tomorrow.