Whither must I wander

My dad spoke at his high school's candlelight ceremony yesterday (kind of like graduation, but more introspective and less celebratory), and his speech (which was awesome, in my unbiased opinion) focused on a poem by Robert Louis Stevenson, which I really liked. I think I've been drawn to literature/songs/themes of wandering lately, as I have recently become nomadic (seriously, it takes a minute in the morning to figure out where I'm waking up). So anyway, here it is (the poem, not the speech):

Home no more home to me, whither must I wander?
Hunger my driver, I go where I must
Cold blows the winter wind over hill and heather
Thick drives the rain and my roof is in the dust.
Loved of wise men was the shade of my roof-tree
The true word of welcome was spoken in the door
Dear days of old with the faces in the firelight
Kind folks of old, you come again no more.

Home was home then, my dear, full of kindly faces
Home was home then, my dear, happy for the child.
Fire and the windows bright glittered on the moorland
Song, tuneful song, built a palace in the wild.
Now when day dawns on the brow of the moorland,
Lone stands the house, and the chimney-stone is cold.
Lone let it stand, now the friends are all departed
The kind hearts, the true hearts, that loved the place of old.

Spring shall come, come again, calling up the moorfowl
Spring shall bring the sun and the rain, bring the bees and flowers
Red shall the heather bloom over hill and valley
Soft flow the stream through the even-flowing hours.
Fair the day shine as it shone on my childhood
Fair shine the day on the house with open door
Birds come and cry there and twitter in the chimney
But I go forever and come again no more.

FAQ: glioma vs glioblastoma

Been getting a couple questions about brain tumors lately. Obviously because of Ted Kennedy (so sad) but also because of a family member recently diagnosed with glioblastoma (also very sad). Here goes:
A glioma is a tumor that arises from cells in the brain called glial cells. Basically these are all the cells in the brain that aren't neurons; they are the "glue" that holds the neurons together. Any tumor that comes from glial cells is called a glioma. But each kind of glial cell (for example astrocytes or oligodendrocytes) can have its own tumor arise from it, and each tumor has its own name. A tumor arising from astrocytes is called an astrocytoma. A tumor arising from oligodendrocytes is called an oligodendroglioma. These are types of gliomas.
Astrocytomas comprise 80% of primary brain tumors in adults. (Primary simply means that the tumor doesn't originate as cancer somewhere else in the body and metastasize to the brain.) There is a spectrum of badness for astrocytomas. Grade IV astrocytomas are the most aggressive and have a special name: glioblastoma. (I didn't come up with this naming system, people.)
Contrary to popular belief (or my interpretation of popular belief, I guess), brain tumors rarely present with headaches. This is because there are NO nerve endings in the brain, so tumors don't cause pain. Crazy, right??? (If there was some way to get inside your skull pain-free, you could undergo brain surgery without anesthesia.) They usually present in one of two ways: with seizures (a la Ted Kennedy), or with something called mass effect. Mass effect means the signs and symptoms that arise from having a mass in the brain, since the brain really doesn't like to be pushed around inside the skull. Symptoms include mostly nausea and vomiting, though a classic sign is vomiting without nausea. One more time: headaches rarely mean brain tumor.
Hmmmm....any other burning questions about brain tumors?....

Why didn't I become an I banker??

I'm pretty sure that inpatient internal medicine is going to get the best of me. I am 2 (two) weeks in out of 7 (seven!!!) and I'm already ready to throw in the towel. I'm not entirely sure how/why anyone actually goes into internal medicine, and ends up alive with cognitive and emotional function intact at the end. As my resident put it (he's only a PGY-2), "When I was in medical school I wanted to save the world. Now I just want to make it through each day alive." This is seriously the most draining rotation I've done this year. Thoughts about that? Other opinions on the most exhausting one? I'm not even sure the hours in surgery were worse, given that you had post-call days off q4. As an example of my morning: We worked up a new patient (obviously I'm not revealing/changing the details...I know you're reading this, HIPAA) for new-onset weakness, and she ended up having f***ing mets all over her brain from an as-yet-unknown-but-probably-lung cancer. That was real fun. And my patient from last week with ten zillion medical problems that we managed to stabilize was just discharged back to her nursing home. She's 45 years old. How can people do this day after day?? Maybe one day it'll make me so numb that it won't depress me anymore. But then that in itself might depress me. Oy. I leave you with the eternal wisdom of Scrubs:

Dr. Cox: You see Dr. Wen in there? He's explaining to that family that something went wrong, and that patient died. He's gonna tell them what happened, he's gonna say he's sorry - and then he's going back to work. Do you think anybody else in that room's going back to work today? That is why we distance ourselves; that's why we make jokes. We don't do it because it's fun. We do it so we can get by. And... sometimes because it's fun. But mostly it's the getting by thing.

Slow Medicine

This has been on my mind for a while, but I read a cool article on nytimes.com that really brought the issue forward again. Seriously, why do we treat death like it's something we can avoid??? We're all going to die. Deal with it. I am, you are, everybody is. You can't put it off forever. Why do people think that good medicine is just curing everything?? Shouldn't the goal at the end of life be maintaining a good quality of life for as long as possible, not merely delaying death?? So this article: it's about a movement at Dartmouth Medical School called Slow Medicine that emphazises comfort rather than cure at the end of life, and you can read it here. Think about it: if you were diagnosed at age 85 with cancer, would you choose surgery, chemo, and radiation, possibly ending up bedridden with DVT's and PE's and urosepsis and godknowswhat else, just for the possibility of another year or two, and not a healthy year or two at that, or would you rather say, "no thanks, I think I'd rather die on my own terms." I feel like I might go for option B (though in reality hopefully I'm quite a few years removed from a decision like that...maybe I would think differently if I were actually 85). It's certainly understandable to be afraid of death and to want to live as long as possible. I mean, life's short and pretty damn fun. But it ends for everyone eventually. When can we make the shift that the goal of good healthcare is helping people live good, quality years at the end of their life and then dying with dignity and with as little pain and suffering as possible? When will our collective mind stop treating death like something that can be avoided forever? Ok, please read that article, it's short and so interesting. And don't pay too much mind to my ramblings. Inpatient medicine is making me bitter and cynical about drastic end-of-life care, and incredibly sad about the state of some unfortunate people's lives. But that's a depressing story for another post. Please go outside and enjoy your working lungs, healthy muscles, the fact that you aren't paraplegic from a freak accident, or have crippling rheumatoid arthritis, or have had 3 strokes, or live in a nursing home at the age of 37. (This has been a fun week.)

Spring has Sprung

The grass has riz. I wonder where the birdies is?

So, it's officially spring. I think it took a little longer to arrive in the Berkshires than other places near here (like Tarrytown, NY, where that pic of flowers was taken a couple weeks ago). The trees here have pretty much blossomed, and although the temperature has taken a nose-dive over the past week, the flora have still managed to explode. We (Berkshire friends and I) are spending the day in Lenox, and it's so beautiful here. Some of the houses are crazy huge mansions. And we saw the "house" where Cider House Rules was filmed (well, the outside of it). I am trying to pack in non-medical stuff before I start inpatient medicine tomorrow. When I think about it starting I picture a large black sheet being lowered over my life. I may be fatalistic and pessimistic, but maybe this way there's no way I can be disappointed by the experience. If you expect to stay til 9 every night, when you get home by 7 you're happy, right? Well, I hope everyone is enjoying spring. Go outside and smell the flowers, like this crazy kid. :)

I sold a piece of my soul, but the wine sure was good

I finally went to my first drug company dinner last week. I really just wanted to get a free dinner at a yummy-sounding restaurant in town, as I always feel pretty guilty taking anything from drug reps (normally I don't even take pens or anything, just on principle). But the prospect of a free dinner got the better of me, and I justified it to my conscience by saying that they're selling a drug I'm never going to prescribe (it's for osteoporosis...and EM people don't really treat that chronically), and I could write about it here to sort of make up for it. (right??) It was pretty interesting, and overall pretty bizarre. The main speaker was (I think) an endocrinologist, and she told some made-up story about how her own mother was thrilled to learn about this new osteoporosis drug (which obviously I'm not naming here...I'm not doing free name-advertising for them). The whole thing made me pretty uncomfortable, what with the knowledge that drug companies spend almost 30 billion dollars (I can't even get my brain around that) a year on advertising, most of it directly to doctors (i.e. not direct-to-consumer advertising like on TV). And rising drug costs are at least partly responsible for the rising cost of health care and insurance, leading to fewer insured people, etc etc etc. But I digress. I enjoyed the dinner (it was actually pretty yummy, and had lots of free-flowing wine), but with every bite I could taste a little bit of guilt. It sucks that a for-profit industry is so entrenched in (and in a big way driving) what should be an essentially non-profit, for-the-greater-good industry and profession. If sales tactics didn't result in increased use and prescription of drugs, companies wouldn't take entire offices out to dinner or give stethoscope tags or free pens. The office where I had outpatient medicine had free lunch every single day sponsored by drug reps. One day I walked into the kitchen and the rep was holding up a big brochure and describing the effects of her new lipid-lowering medication, while trays of (literally, I am not making this up) KFC fried chicken and mac and cheese sat on the table. I guess she was trying to create future customers?? I'm going to stop here, before thoughts of the current state of health care in this country cause me to become apoplectic in public. I hope everyone is doing well!!

Adventures in the Berkshires

So to continue drinking up the Berkshires experience, last night we took a trip through the woods (literally) to the famous Dream Away Lodge in Becket, MA for some dinner and music. According to its website, it's a 200-year-old farmhouse that used to be a brothel and speakeasy. Now it's a restaurant/bar/lounge that appears to have few patrons but many children and dogs roaming about. Although the website says "reservations for dinner are very much in order," we (there were 11 of us) seemed to make up over half of the customers, though there were many other people standing around that appeared to live there (and our waitress took our order while holding her 5-week-old baby, just to give you some idea of the atmosphere). There was also some really good music by Heather Waters, and we ended up getting our own private concert while we lounged on comfy couches. The whole experience was kind of odd but very enjoyable. You seriously think you're in the middle of the woods when you come across the place. (The directions on the website say, "Turn right on Watson Road and proceed slowly for three winding miles through the forest.") I'd definitely recommend going there (but don't get the fixed price menu...the food's not good enough for the high price), and also checking out that singer, cause she was pretty good. (Where else but western MA can you get good music in an old farmhouse that used to be a speakeasy??)