A free weekend snatched from the scant few you get in surgery residency...Sharon and I decided to visit Eugenie in the City. Having packed the night previous, I fled the hospital Friday afternoon, and we were finally on our way that evening after the requisite midsummer's flight delays into New York. The fields of Idlewild embraced us with a blanket of warm heat and the rush of activity. Our cab pounded through BQE traffic and finally dropped us across the street at the Angelika theater. Alas, the picturesque carwash on Houston has been replaced by a huge, metallic Adidas store. Eugenie was working on a Photoshop rendering of a Home Depot for Westchester, and as soon as she found an appropriate stopping place we waded through the evening heat to the East Village and a Yakitori bar around St Marks.
The place was grooving to "No, it isn't straight Techno, it's Breakbeat" and plying its trade to edgy urban subculture youths with plenty of leisure time. I think about "leisure time" a lot now. As I walk down the street I think to myself, "well that fellow can stay out as late as he wants tonight, because he doesn't have to get up at 5 AM to round the service," or "she can wander the streets in her au courant bedroom slippers because there's no chance that her pager will go off and she'll have to dash to the hospital." Anyway, we ordered a Yakitori sampler with grilled chicken meat balls, scallions, beef...late at night, meat on a stick will always be a staple...with cold Sapporos too, of course. Sharon liked the chicken the best. The skewers not being enough, we ordered grilled Nigiri, Japanese rice balls filled with tuna. The next day, we took out pastries from Balthazar, and examined Eugenie and Ron's new office on Chrystie.
From there, on to the newly remodeled MoMA where we took in the permanent photo collection and a new exhibit of Friedlander's photography. We took a short respite from the city's hustle and bustle in the sculpture garden and then caught a subway back downtown. Walking from the 20's into the West Village, we looked for Balducci's, which, sadly, has disappeared.
That evening, it was Lupa, Mario Batali's more affordable eatery on Thompson. Justin joined us after a day at PS1. The wait was 2 hours and worth it. Sharon had ___________, I had the gnocchi, each a perfect pillowy sauce transport object, Nini had a wheatberry risotto, and Justin _______.
It's been a long time posting here. It's been a long year.
I'm retrospectively writing the remaining entries--oddly enough, I had less access here in the Lower 48 than I did in Europe or Hawaii!
Obviously, much of Savannah's tourist traffic has been drawn by the gravitational pull of "The Book", i.e. Midnight in the Garden of Good & Evil. This effect is only beginning to wear off now after its epic enlodgement in the New York Times Bestseller list. Surely if Clint Eastwood's film adaptation were as critically and popularly successful as Mystic River, we would have had to elbow out of the way some matron from Wisconsin for our bed & breakfast accomodations.
I think Savannah benefits from the presence of SCAD. It's students keep the town from feeling too staid, too complacent amidst its mossy genteel squares. Tidbits of conversations overheard at Gallery Espresso:
"I'm using Maya [a computer 3D rendering program] to render this scene in an airline graveyard"..."and his hands will be flamethrowers"..."every detail of the Royal Tennenbaums is just right. I especially like how Wes Anderson uses music"..."Have you seen Garden State yet? we're thinking about seeing it tonight. I think it's cool how he can be in a mainstream television show and make an independent movie like that"...And the conversations move rapidly between texturing scenes in a 3D animated movie, anime, a student's wicked stepmonster, and somebody's pet ferret.
Thus in our peregrinations about the town, the "edginess" of the SCAD students' artistic explorations, to their shabby chic East Village-type accomodations inject a liveliness--yes, sometimes immature, even sophomoric, but bracing--to the humid, magnolia-stately environment.
Our second day's walk took us again to River Street where Sharon had spied a Christmas Shop (it has come to my mild astonishment, that there are Christmas Shops everywhere at all times of the year!) where she found an ornament to appropriately commemorate our visit.
I don't know why she needed to smell the ornament though!
Some scenes along our walk:
By the way, the gamut of these JPEG image files washes much of the color out of them. The originals look much better. I promise.
Along our way, we explored the Colonial Cemetery. Its main entrance is marked by an arch erected by the Daughters of the American Revolution, and immediately within are the wafer-thin tombstones so common in old cemeteries in New England. The eastern brick wall of the cemetery is lined with headstones--presumably those that have fallen or displaced. The sky is overcast and we feel thin cold pinpricks of an occasional sprinkle. There's an occasional crepe myrtle with fuscia blossoms. Many long-dimmed lives from a harder era. Such-and-such killed in a duel. A child snuffed out after only 4 years.
That night, for dinner, we tried something different. Our guidebook noted that a Moroccan restaurant located on the main shopping street was both quite authentic and featured...bellydancers. Their review was enthusiastic and thus we set off for the "Casbah", which is housed in what used to be a storefront, it's windows mysteriously shrouded in drapery. Within, was a dark, crimson velveted space well populated with mostly families. In the name of authenticity, a pitcher of water was poured over our hands once we were seated in order to clean them for the forthcoming meal, since they were to be our only utensils. I started with a Cornish Hen Bastila, a tasty dish of cornish hen mixed with onions, parsley, spiced eggs and toasted almonds, wrapped in a philo dough pastry, baked and garnished with cinnamon and powdered sugar. One thing I will say about eating with your hands is that Moroccans must get acclimatized to handling hot food in their fingers. Accompanying this, I had an iced mint tea.
We followed with marinated and grilled boneless butterflied chicken breast, dipped in a honey-nutmeg sauce, caramelized apricots, roasted almonds and sesame seeds for Sharon and a "Sultan's Kabob Feast" for me, including three skewers of chicken, lamb, and beef kabobs, all cooked perfectly; not the least bit dry or over rare. Sharon's chicken was flavorful and moist (an accomplishment with a boneless breast).
Oh, and the bellydancers...As I reclined on pillows, surrounded by the aromatic tobacco smoke of my hookah, the Sultan's favorite entered the tent, her waist engirdled in golden medallions, her smile demurely obscured by her veil...Actually, the dancing was pretty straightforward and tasteful; there were many families with small children, and two big blonde cornfed boys were egged on by their parents to have a picture taken with the dancer by their younger sister.
I would have liked to have Baclava for dessert, but both of us were too full to partake.
Once a beach umbrella had found it's way into the back of the Allroad, Sharon and I were off for the 5.5 hour drive to Savannah. It's a straight shot down I-95 among the innumerable cars (many of the SUV and RV persuasion) with "New Jersey" and "New York" license plates. For the most part, an easy drive as long as you don't expose yourself too the panoply of speed ambushes that South Carolina hides behind every overpass and speck of median vegetation.
Our retreat is the Eliza Thompson house, built in 1847, it is now a bed and breakfast including both the main house and a carriage house surrounding a brick courtyard with koi nosing around a fountain and cafe umbrellas for the daily breakfasts.
Soon after we had unpacked, we ventured down Bull Street to assimilate some of the flavor of the town. Savannah's residents are lucky to have a town of squares, leafy, be-statued respites from a typical grid. At one instance will be a square dedicated to a Polish count stricken by grapeshot attempting to take the town from the British during the Revolutionary War, to an Indian chief, who welcomed Savannah's first colonists with open arms.
In this late afternoon, the town was hushed and humid--not many tourists prowling the streets. We encountered a cool and airy cafe (from where I am typing this entry) known as "Gallery Espresso", a bohemian haunt for SCAD (Savannah College of Art and Design) students and locals that has become a daily stop for us in our short stay here. It is populated with comfortable, threadbare, and stained armchairs and couches, and an 3-gruppo (Faema E61's) espresso machine of a make I'm not familiar with.
As expected, Savannah's streets are wide and lined with Spanish Moss-laden trees. We walk north towards the Savannah river and the rather touristy River Street, packed with restaurants and shops in what used to be Savannah's bustling cotton warehouses.
Our first meal in Savannah was at the Olde Pink House, a classic Savannah location, one of the oldest buildings in town, its pink coloration originally coming from red clay bricks bleeding through white stucco. The meal (Sharon's being scallops with eggplant, mine being a simple strip steak) was well prepared, not lacking in flavor, but perhaps in fireworks or originality.
According to the traditional Johns Hopkins terminology, I am now a "Junior Assistant Resident"; no longer directly in the line of fire for Tylenol and Sonata orders, no longer doing 25 post-op checks for the Ortho service, no longer the default victim of "make the Intern do it"-itis.
Just this level of removal from being the sealing compound in the cracks of modern healthcare permits a bit more consideration of what may be going on with a patient. Last month in the Surgical Intensive Care Unit was rewarding partly because working with such astute nurses is a joy, but working with sicker, more critically ill patients pumps a little more "juice" and thoughtfulness into the job.
And now, though my Intern-year vacation was April, I'm on vacation yet again. As my allocated two weeks for JAR-year, I may well not see another vacation for more than a year. Even so, I enjoy having this little bit of space in my life. I tore apart my espresso machine to identify a balky hot water valve, and gave it a particularly satisfying cleaning--I feel as if I'm recovering some dormant facets of my life. I'm enjoying my espresso, roasting my beans, perusing the active little Internet subculture of espresso-enthusiasts.
Three more call nights. My pager went off 152 times the last one. This frenzy of beeping/vibrating will shake the equanimity of the calmest of dispositions. I'm still not sure I've recovered entirely from this assault.
The picures above: a sunlit bench at the NC Botanical Gardens, and David Seo roasting the groom at Dave Yoo's wedding.
A Nikon D2H paired currently with a Sigma 15-30 EX. I'm slowly learning how to use it, and am having fun in the meantime! By this point, I think I'd pushed my Canon G3 as far as it could go. The above pictures taken at the NC Botanical Gardens. From about 140 exposures, I got perhaps 10 that I was happy with compositionally and qualitatively. I've been saving the images in NEF (RAW) format and using Adobe Photoshop and its Camera Raw plug-in to save to my Powerbook.
What better way to combine creativity, digital technology, and the outdoors?
The day opened unpromisingly with rain, and concluded sadly with rain. The clouds, oppressively low set, the temperature in the 40's, the light hard and concreted.
Today was our trip into the Tuscan countryside to see the hill towns of Pienza, Montepulciano, and Cortona with Jonathan Arthur, a Cornish expatriate who moved to Italy with his artist wife sixteen years ago to start his family. As we sped down the Autostrada in a Benz stationwagon with a wheezy differential, I queried him about the Italian martial character ("They are not a very militartistic lot...they had two sorts of battles, of maneuver and by siege...they would maneuver for most of the spring and summer until they found a good flat spot for a battle, assemble their forces, muck about for a bit--at the Battle of ______--they only man killed was an unfortunate fellow who fell off his horse and was trampled to death--stop for lunch and fight until nightfall..."), Italian eating habits (White Collar: start at 0900, stop at 1300, have a substantial lunch, take a nap, and work again between 1600 and 2000, a snack for dinner. Blue Collar: start at 0800, quick snack for lunch, stop at 1800, and a big dinner), olive oil (Tuscany is about the most northern range for olives. Farther south, the typical method of harvesting them is laying a net below the trees to catch the olives, but more northerly, they must be picked by hand. Extra virgin being the early harvests with the greatest "bite". [note from my own study that virtually all virgins are hand-picked because fallen olives can bruise and then ferment and rot]).
The first stop, Pienza, a genuine Renaissance town, because this newcomer (construction starting in 1459), was purely a production of Pope Pius II, Aeneas Sylvius Piccolomini, who erected the town on the site of his birthplace village Corsignano as an ideal town to one day rival Siena (supposedly Piccolomini was still piqued that his noble family was exiled from Siena to Corsignano). It never reached this stage in spite of the fact that Pius II prompted his cardinals to build their own pallazi there, and the fact that Piccolomini issued a Papal Bull optimistically christening Pienza a "city". After his death, there was no further impetus for subsequent popes to pay it much mind, and it remains a small town famous more for Pecorino cheese than a rival to Siena.
Of that cheese I can't say enough. We walked into a cheese shop there and were enveloped in the earthy, pungent odor of Pecorino. There were many varieties lying open on the shelves from Pecorino stagronato nella Vinaccia (leftover grape pressings), to Pecorino di Fossa (buried in a hole, forcing the bacteria to work anaerobically), to Pecorino al Tartufo (scented with truffles), to Pecorino semi stagronato (very old, covered with bay leaves and a musty-looking mold, but heavenly in taste), and then Pecorino Fresco (the youngest). These cheeses are wine-like in the complexity of their bouquet, the differences in age contributing to their different characters. After sampling them in the cheese store (we bought a great deal and vacuum-packed them for transport), all I could think of all day was that damn cheese.
The town itself is tiny and often described in the travel books as jewel-like. This is a suitable description because it is small and inset, almost artificial in it's antiquary perfection. It was here that Zefferelli filmed Romeo & Juliet and the town does seem lost in time. There is a beautiful path that overlooks the Tuscan country side (see the photos below). After an all too brief stop (and an encounter with a ferociously docile hotel cat), on to Montefollonico for a wine tasting with a very small estate bottled vintner.
Our winemaker is a retired professor of philosophy who was pulled into his old family business. His entire effort is concentrated in a small 14th century cantine. A bit cluttered, raising some initial skepticism in me somewhat, but the proof is in the pudding so they say, and after sampling his "Super Tuscan" Acerone IGT and his Nobile di Montepulciano Riserva DOCG we were believers. I do think the wines we tasted could use some aging so will likely sock them away for 5 years or so.
We then had lunch at "13_______" which is run by a handsome divorcee who used to run the same restaurant with her husband who then ran off with a younger woman. According to Jonathan, the town divided itself along the lines of those supporting her dining at her place, and those supporting her ex-husband and his mistress going to their new restaurant (which is now out of business). I initially ordered coniglio or rabbit but they were out so had grilled lamb instead, and started with truffle-scented gnocchi. My sister began with marinated Tuscan vegetables, and then had roasted duck, my father had tagliatelle with truffle sauce, and my mother a Tuscan vegetable soup with bread.
Finally, on to Cortona, a town first inhabited by the Umbrians, then the Estruscans, then the Romans, then sacked by the Goths, the a free comune during the 11th century, then a subject of the Kingdom of Naples, and then a subject of Florence. It's this town that lives under Frances Mayes's Tuscan sun. One story of the filming of the Diane Lane movie is that the producers decided that they must have fountain in the main square (which did not exist beforehand), but that the elderly ladies of the town found its endowment to be scandalous which resulted in the unfortunate fountain's emasculation. We didn't spend much time in Cortona as the day was coming to a close and we still had a drive to go for our return to Florence. Before 11 September it would have been mobbed with tourists. This has diminished somewhat since. We did see a wonderfully well-behaved dog, Tango, who resides under a shelf of ceramics in the main square.
Today was a museum day. We had a guide, Simone, take us through the highlights of the Accademia (where Michelango's David stands forever looking off in the distance, contemplating the upcoming battle), and the Uffizi (old Italian for "Office"). Ironically, in my studies of modern art in college, Greenberg's school of art criticism concentrates on the turn away from perspective and figurative art to the two-dimensional, stylized and gestural; whereas the transition from the medieval to Renaissance is the opposite, moving from non-perspectival, flatness of Byzantine iconography with no shadows and no sense of depth--no sense in their religious imagery that Christ or the Virgin Mary might be mortals that we can connect to emotionally--to Giotto's early 14th Century Madonna Enthroned hints of shadows in the draping of the Madonna's robes, and of breasts, and the first intimations that these are more than icons, abstractions staring from the candlelit recesses of a medieval church.
Thus Brunelleschi's "discovery" of perspective began drawing figures out of the flatness of a painted medium, allowing subsequent artists to dissociate images from the iconographic, allowing depth both figuratively and psychologically as paintings allowed their subjects to become more human. Witness Fillipo Lippi's Madonna and Child with Two Angels--the Madonna, exquisitely beautiful (a fallen nun no less as Lippi who was raised by monks ironically had a habit of seducing pretty nuns), exquisitely real, holding a baby who looks like a real baby surrounded by angels that no longer float abstractly in the air, but are grounded.
Of course, Michelangelo considered painting inferior to sculpture, and his work is preeminently humanist, with David representing a non-Christian Classical theme, ambivalent in gesture and expression, his sling at rest--about to be used? or in laxity after use? To place his sculpture in context, one has to remember that the practice of the day was to make plaster models of a sculpture and use a special device to triangulate points in a piece of marble to guide the chiseller. In essence, the final step of sculpting marble was a mechanical, rather than an artistic process. Michelangelo abhorred the idea of treating marble as a blank medium and sought to chisel or reveal directly from his blocks the "essence" of that piece. For instance, the block of marble from which David emerged was known as Il Gigante. A challenge in Carraramarble; sixteen feet high, impossibly narrow, filligreed with cracks; the victim of a half-hearted attempt by Agostino di Duccio; refused by Da Vinci. In Michelangelo's mind, David was living inside the whole time.
This is actually the second time I've seen David, and he seems more ambivalent a gesture than the first time. Seemingly relaxed, but the tensile character of his right leg, the veins throbbing from his right forearm and hand, the trace of jugular, he really seems ready to spring into action for all the relaxation of his pose, which perhaps really is a pose.
In the Uffizi, we saw, among the aforementioned Giotto and Fillipo Lippi, Botticelli's Birth of Venus and Primavera.
Yesterday, my sister was complaining that her chest hurt. After I drew an ABG, ordered a stat EKG, and stat cardiac enzymes, my parents and I left her to her with John and set out on our own. It had rained in the morning, but we were optimistic that there wouldn't be any further precipitation and set out in search of pizza. We crossed the Arno, and began our reconnaisance in earnest. A flanking maneuver on the south side of the Piazza della Signoria found us in the Pizzeria il David where we found ourselves next to a elderly, but hale English couple. Though the service was slow, we had a good Pizza Napoli and a Pizza with sausage. The crust was thin and crispy, the toppings minimalist, just enough to provide flavor, not overburden the crust.
In the meanwhile the sky lowered and we began to notice people hastily moving inside with us. It had started raining quite heavily, with a healthy breeze, and a significant drop in temperature. As we left il David, it grew heavier, and we had to take shelter in the Aringhiera in the piazza along with hundreds of other tourists, shivering as the breeze whipped through the square.
Finally, the deluge lifted a bit, and in these little lacunae in the day's tempest, we finally made our way to the Palazzo Pitti, the final headquarters of the Medici clan, and home to their enormous art collection. As I've mentioned the palazzo is a rusticated monstrosity. The artwork is arranged pretty much as the Medicis kept it, in other words, not in a curatorial or chronologic order. This makes it hard to properly appreciate its interspersed Filippo Lippis, Caravaggios, Titians, and Rubens, where the Uffizi makes the thematic progression up to the Renaissance, the Mannerist era, and on much clearer (more about that later).
I don't have any good pictures that properly convey the cold and the rain, but have this one of my mother exiting the Palazzo Pitti to blue, virtually immaculate skies:
As we walked home, with the sun returned from his brief hiatus, there were these scenes along the street:
Once we returned home, I found my sister and John in repose:
I should probably take some time to describe the Villa Bobolino. It was built around 1880, with the typical villa configuration; three stories, French doors opening out onto upper floor terraces. The owner is a Dutch woman that I haven't had a chance to meet yet. She bought the villa a few years ago and had it remodeled recently. It's a bit fanciful--modern Chronicles of Narnia, but has some nice Phillipe Starck pieces. It's been featured in some Dutch magazines and is nicer than some of the ponderous antique filled places we saw in the catalogs when deciding on a villa. With the French doors unshuttered it's airy and quite, yes, romantic. Pictures soon.
This morning we arose early-ish only to find that my father had blown the villa's fuses with his 110V hairdryer. He said that it practically melted in his hand. This required an emergency consultation with Messr De Looze, our landlord and was expeditiously remedied. We then set off for the Mercato Centrale. The main food market for Florence just northeast of the Piazza San Lorenzo. The market is housed in an enclosure and is filled with a variety of butchers, greengrocers, fishmongers. The pictures below give a sense of the variety of alimentari sold there. Particularly interesting is an Italian delicacy known as the Dirty Bird. It is also known by its Latin name as Foulus fowlus. While one would think this bird to be very rare, it is actually quite common. For instance part of its North American range is known to be a stretch of 70 in Raleigh between Brier Creek and Crabtree Valley Mall. Many Dirty Birds may be found squawking about a certain parking lot in the evening hours. The best way to prepare a Dirty Bird is to flatten him under a brick and grill him ( Pollo Squalore Griglio).
Addendum, 7 April 2004
After resting in the early afternoon we ventured out again to Via de´Tornabuoni where royalty such as Salvatore Ferragamo (among the snottiest salespeople I've ever encountered, but really nice leathergoods and those classic Ferragamo ties), to Gucci jewelery (an extremely friendly and courteous young lady there), to Prada (where the sales staff were kept extremely busy by the constant flow of customers--including my sister and myself for sunglasses), to Pucci (a Florence native, my sister coveted a short short skirt that was labeled at 1700 Euros), to Giorgio Armani (where my father chatted with a Swedish saleswoman, trying to guess her nationality, who admitted that she wasn't the usual towering height of her fellow countrymen), to Gucci clothing (where I contemplated Tom Ford's last collection for them and the fact that I could never get away with tight-fitting Western inspired shirts and boots).
In the evening, we prepared dinner with our market purchases. Soon the house was suffused with the aroma of olive oil, basil, sauteed shallots with which my mother prepares her mussels. To start with we had carciofi or artichokes dipped in lemon butter, followed by the mussels, and then spaghetti with vongole little clams that you don't find very often in the US. The artichokes and mussels struck me as being more tender than their American counterparts. The mussels were also meatier.
Again, I awoke late. I suppose my internal clock is out of whack with the change in timezone. The original plan had been to hit the Mercato Centrale, but it closes at 1400, and I was dressed by 1310. Instead, we caught a cab to Esselunga--Florence's equivalent to Star Market (Stah Mahket). Unfortunately, we were to learn that our cab driver over took us for a ride because the fare over was almost 20 Euros where the ride back was 8.60 Euros.
Waiting for our "ride" to the supermarket, carciofi at Esselunga, and dining al fresco at Villa Bobolino:
There really isn't much to say about Italian supermarkets. They are pretty much the same as ours (I was disappointed to find). I had hopes that their food-oriented culture would make even a run-of-the-mill supermarket a better than Whole Foods cornucopia, but no, pretty much the same. A lot of pre-packaged junk foods, convenience foods. Just a lot more bottled water.
We walked out of there with a couple hundred Euros worth of groceries, caught the non-rip-off cab home and ate a simple al fresco snack of bread, cheese, meats, and fruit on the terrace.
After arriving at the Villa Boboli around midnight last night, and reading for an hour about the Florence's conflicted past, I slipped into a profound slumber which could have continued indefinitely excepting my mother's knock at 1000 this morning. After all of us got ready, we ventured out on foot past the Porta Romana and down Via Romana, past the Piazza Pitti where we stopped at a cafe for lunch of coffee, lightly grilled panini, insalata Cesare, and piatti Sfzi___. I had a Campari Orange too.
We then continued on to the Arno which we crossed on the Ponte Vecchio (incidentally the only bridge not severed during the Second World War, the Arno being an important strategic line in the Italian campaign), the closer we came to the bridge the more tourists there were, festooned in their Oakleys, Pumas, and athletic gear that have become the uniform of travelers everywhere.
The weather was high sixties and dry. Perfect for sightseeing. Alas, no Baedekers or "Macintosh squares" here (see Merchant Ivory's film adaptation of A Room with a View).
Since this was a "familiarization" walk and there was no point in trying to see sights while the turisti were out in force, we just walked through the key spots: the Piazza Uffizi, the Duomo, the Piazza Santissima Annunziata with its statue of Ferdinand I made from bronze molten down from Turkish cannons from the Battle of Lepanto. This last plaza also houses on it's eastern aspect the Spedale degli Innocenti, a foundling's hospital (and likely the first in the world) where there used to be a rotating window where unwanted babies used to be abandoned until the late 19th century. Another feature are tondi featuring babies in swaddling clothes.
We rested there and then made our way back by way of the Via Cavour, passing the upscale shopping area (and stopping briefly in a Miu Miu boutique) and back across Ponte Vecchio. We detoured into the Bobolino Gardens financed by a visionary who made his fortune with pre-baked pizza crusts imported to the United States...just kidding...The gardens are the only central public gardens in the town and were comissioned by the Medicis. They lie behind the Palazzo Pitti and stretch a long ways southwest. The palace's backside has a courtyard and entrance where you can easily imagine horse-drawn carriages disembarking eminences of the time for a grand ball, or volta, or whatever it is they danced to. There is also a huge bathtub (carted off from the Roman baths in Caracalla). The garden lies astride a significant hill and provides dramatic views of Florence. Since my battery hadn't been charged in three days, alas there are no pictures currently. I'll have to go back for those.
The garden has long cypress-lined walks, many hiding places, and just feels suffused with history. At its highest point you can look west down upon a field of olive trees that looks just as you would imagine that spot where George first professes his admiration of Lucy in A Room with a View (and prompts her to play much Beethoven); suffused with sun, olive trees rustling in the breeze, wildflowers sprinkled about the grass.
After whiling away our time there, we made our way back to the Villa Bobolino where I downloaded my photos and we rested for a couple of hours until dinner time which we spent at Beccofino, a restaurant tucked between Ponte alla Carraia and Ponte Santa Trinitas. There we had Pea Soup with Mint, Risotto with Lard(!) and Celery Root, and Sea Bass Carpaccio followed by Tuscan Beef with Red Onions and Fingerling Potatoes, Roast Pigeon with Prunes, and Roasted "Baby" Chicken followed by Almond Cantucci, and Pistachio Mousse.
Then home. Then sleep (after reading for a few hours).
Morning, looking out on the terrace and garden:
Getting ready to set off, and looking in the distance off Ponte Vecchio:
A tondo on the foundling's hospital in the Piazza Santissima Annunziata:
A night time long exposure from the Ponte Santa Trinitas:
Leaving out of Raleigh-Durham yesterday afternoon I saw a mother beating her child in the Continental terminal..."You're ODD, Oppositional Defiance Disorder. I don't know what to do with you," I'm not sure I understand why some catchphrase pseudo-diagnosis might rationalize her boxing her son's little ears. I was embarrassed and appalled for everyone who saw this.
Tonight we leave out of JFK for Florence and a two week stay in the Villa Bobolino via Frankfurt. This includes a 8 hour layover in Germany for John, Eugenie and myself while my parents fly on ahead.
I'm presently in NYC where it's cold and drizzly. After a buzzy commuter flight to Dulles yesterday, I was imprisoned in a terminal tucked in the forolorn recesses of that airport for 5 hours before I could catch a flight last night to JFK. Then, after having 3 hours sleep over the last forty hours, I sunk, catatonic, for 8 hours sleep on Eugenie's couch.
This morning I picked up some croissants and madeleines at Balthazar. Their chocolate madeleine's are unctuous and...chocolatey (big surprise).
If you want to send a text message to my phone in Italy, try this. It may or may not work, but John, being well-traveled, says that SMS should work in Europe at no extra charge.
Below are a few pictures of Watson & Crick, my sister's little monsters:
Spinach Salad with Radishes & Onions
Pureed Celery Root with Potatoes, Gruyere & Saffron
Brasato di Maiale
Crostata di Mirtillo with Creme Anglaise
Christmas tradition is that the younger generation make the feast.
In the past I've done a goose (we like gamy birds); another year, a Welsh leg of lamb (with honey and thyme). Since the four of us have never actually been able to actually completely consume our Christmas dinner in the past, we went smaller, a bit homier this year with a recipe from Mario Batali (hands down runs the best cooking show on the Food Network) of pork shoulder braised in red wine with juniper berries, rosemary and pancetta, ringed with a salad of grilled scallions.
Brent at Wellspring found us a nice Boston Butt about 4 pounds, which was within the target range for something we could finish. My sister takes credit for interpreting Batali's recipe with aplomb, rendering a flavorful, complex, and tender (something we were fearful of not accomplishing) main dish. Eugenie also cheated by adding some butter at the finish. She also made the cranberry crostata, which has now become our traditional Christmas dessert. I went with the relatively simple Dean & Deluca recipe for celery root and potatoes. There is little chance of missing with such straightforward ingredients. Basically the celery root is pureed with heavy cream, butter and saffron, then incorporated with mashed russet potatoes and shredded Gruyere, topped with Gruyere, and thrown in the oven until the cheese on top is golden. My mother claimed that she couldn't taste the celery root--perhaps the gustatory receptors for celery root are variable from person to person.
Batali's recipe calls for marinating the shoulder for three days. Since we only bought the pork on Christmas day we cheated and marinated for one day and (including a stretch at room temp overnight--the room temp phase was more an oversight than intentional, as I'm not writhing in agony with bacterial dysentary, I think it was OK).
I got to keep my two front teeth for Christmas.
One thing about being here is that everything is always in motion, the sea of course moves constantly & breaks over the coral reef. Also the wind moves just about everything, the tent flaps animatedly around me, the pal fronds clatter like leafy scissors even the roots of the trees protrude out of the sand & vibrate some low harmony.
Transcription of my Belize travel journal continued
I spent last night in a hammock & rocking in the stiff breeze made me think about how such a life is so marked a contrast to our normal cosmopolitan lives. Here I am, yielding myself to the wind & the sand & the stars & at home I lie w/in 4 sound walls, in a temperature controlled environment, on a coil-sprung bed--there's practically nothing left to chance there. Here, I am at the mercy of the sea--only because she has been reasonably obliging have I been able to function comfortably. It is a totally different mindset & even though I've become used to living out-of-doors, I'm never totally comfortable--I'm always a bit worried that a turn of bad luck can turn life into something very unpleasant.
I probably need too much control over my environment, at home I have many mechanisms to assert that control (as meager as they are). Outdoors, I feel a constant drive to maintain some orderliness, perhaps I should go with the flow more. Which kind of person is better at surviving? Not just here, but in general.
I do have to sit back & appreciate what I have here--who would believe us when I tell them I slept in a hammock, rocked by the wind looking up through the rustling fronds of a coconut tree to the stars?
The last few evenings I've been thinking about xxxxx ...
...& it was my birthday 4 days ago, I'm a quarter of a century years-old, what do you make of that? & now I've been thinking I should take a year off & go to Mariner's school. Is this a silly dream worthy of a quarter century old-timer, or a silly reverie of youth? I have such a vivid image in my mind of a tilted deck of a boat going into the wind close-hauled--it must be the coastal ancestry exerting its distant memories.
My Belize travel journal, continued
We ventured off Pumpkin after goodbyes to Dash (a terrific dog w/caramel colored eyes & a mane like a lion's). Yesterday's wind had diminished to a breeze & paddling was much easier. On the way here we stopped at Round Caye, an uninhabited island w/dense palms, a tiny beach & a shore cluttered w/coral stones--the detritus of a fecund sea. We wandered around a bit & contemplated an old conch shell, its corners worn smooth--it looked petrified, prehistoric & I begin to think how we have histories of our civilizations but the reef & the fishes around it don't. All we see when we snorkle or SCUBA are brief glimpses, we don't know the narrative of the coral ramparts of the reef here on the the Silks--the interplay of weather, water, stone, & fish.
The Silks are three cayes arranged in a delta w/the vertices pointing North, West, & South. They are beautiful, almost stereotypical, save for the little bit of trash on the one we're on. After Danny speared three good-sized hogfish for us we two snorkled off the reef. On the outside it's about 30 feet deep--really deeper than I've seen w/my own two eyes--that's the thing about snorkeling, what we see on the surface is so completely different from what we see under water--it's a fair kingdom of brightly colored inhabitants & massive fortresses w/delicate hanging gardens of fan coral. It's astoundingly otherworldly--I know how an astronaut would feel if he set foot on an inhabited planet.
For dinner I cooked up the hogfish in tomatoes, onions, habanero, soya sauce, a dash of lime--A-OK, the boys were satisfied.
More from my Belize travel journal
After a hard paddle against the prevailing Northeasterly wind we arrived at Pumpkin Caye whose sole inhabitants are a dog "Dash" and the caretaker "Shaky"--he's a deformed elderly man who scratches out a lonely existence on this craggy little island. We spent the day there at my behest--I found the wind hard going& frustratingly slow & the thought of another 5 or so miles wasn't something I had any desire to undertake.
Treally, the rest of the day was lost to me--I had a touch too much sun and was put out w/a headache & some nausea.
After making dinner for the boys I went straight to bed.
As the sun makes its leisurely, orange-tinged descent down the horizon, I reflect on our first day in the cayes.
It seems that bumpy rides are the theme of this trip--after packing we took an hour long skiff ride to our present location. Closer into Placencia we had a 3-4 foot chop that was truly kidney and gonad shattering. It was a thrill though. We finally arrived at a reasonable approximation of paradise--sandy beaches, wind-bent coconut palms.
I had my first introduction to snorkeling here and it was honestly an introduction to a world I've never known. It is still strange to me that you can breath and look underwater at the same time. Sometimes I'd find myself holding my breath forgetting that I didn't have to.
Even though the coral here is modest in comparison to the Silk Cayes according to Danny, I saw a lushness in both flora & fauna that I've never been able to perceive in such little space.
The light's failing now so I'll stop.
Further transcription of my Belize travel journal
After riding through the waste of a banana plantation, we entered the forest--it was only a secondary rain forest that has grown up over an old logging area but it provided some introduction to the abundance of rain forest here.
The ride there was an amusingly bone-jarring trip in a beaten Chevy van all spot-welded together. Its driver, our guide Ellis, is a wiry fellow w/a huge mop of hair and particularly musical Creole accent. He emphasizes each consonant equally "There's a fucking sol-it-ary eagle." His eyes are sharp, he can be cussing & jiving away swiping the van back and forth on the dirt roads & spot a toucan up in a tree at 200 yards.
Along w/us are two sunbrowned and attractive American girls--one blonde, one brunette. I didn't speak with them much--they seemed young, a young Placencian fellow brought them along, apparently the brown-haired one is his girlfriend & I wonder about the pretty American girls you find in places like these, smoking their cigarettes, diddling the young locals--I find it all a bit alluring but I don't really understand it.
Ellis shows us leaf-cutter ant trails, how you can use the soldiers to suture wounds together, the amazing variety of flora: custard apple trees, rubber trees, philodendrons, heliconias, birds of paradise. I admire all these & I xxxxxx xxx xxxxxx xxxxx xxxxxx xxx--xxx xxxxxx xx xxxxxxxxxxx xxxxxxxxx xx xxxxxxx xxxxxxx x xxxxxxxxx xxxx xxxx xxxx. xxxx, xxx x xx xx xxxxxx x xxxxxx xxxx.
After an equally bone-jarring ride back (1.20 hours), we drop off the Serenity girls (that's where they are staying) & motor home to pick up the bread (15 loaves) for the trip to the cayes. The lady who makes the bread is a cheerful giggly lady called Miss Lydia who cheerfully hands us our bread in here cheerful kitchen, we also get some cherry pops wrapped in cellophane from her--mine ruptures and I drip red juice all over myself.
For dinner, we join the Millers, John, his dad Harry & John's blonde (in all the connotations of the term Colleen) girlfriend. Oddly enough, all the way in the Carribean I'm eating a respectable plate of Chicken Chow Mein seasoned w/the local Habanero sauce.
The Millers are eminently practical men--the father was a forest ranger, the son a marketing instructor in the local college business school (Chico State). They've been in Belize for 2 weeks hence. They drove down in a non-stock 4-wheeler pickup truck w/a camper, a motorcycle and a powerboat. Both are husky fellows w/jolly but disciplined temperaments. Alot of common sense, and the facility to repair just about everything in sight. They love telling stories & you learn a lot by listening because they have encountered so many mechanical problems & such & have found solutions for them.
Further transcription of my Belize travel journal
A day of decompression & reminiscences of high school days. A lot of it was spent on the beach looking across the ble-green waters to the cayes moored like fronded ships in the distance. Danny & I talked a lot about the people we remember, the things we did back in Durham. Belize, unlike Alaska, is spacious--the sky is a wide blue bowel w/massive fortress-like clouds scudding through it. This spaciousness is amenable to expansive thoughts & remembrances--& I'm beginning to think that I might need to spend more time out & w/the water w/a mint-green bow streak behind me. Maybe I should do the Mariner's school.
Part of what I want in a xxxx is a window into another world of preception, & since I haven't found that (FK's control xxxx xxxxxxx seems now so insular & self-conscious), I'll take the world & ocean & sky as that--maybe I should have started with that.
I'm getting a better sense of the town & its cluttered ramshackle ways--there's little need for propriety, its utterly casual, loping along the boys I see, a little buzzed, taking what it can get. So far I'm loving it.
Strangely, K's being a bit linear & I'm being a bit loopier (a reversal of what I expected, maybe I'm mellowing).
A transcription of my Belize travel journal
After a satisfying dinner of conch fritters and pork chops, esconced in a hammock w/the Carribean breeze blowing the sand flies away, it's difficult to wrap my mind around the fact that I was stuck in the quotidian rhythms of medical school, & here I am on a sandy, palm treed spit of land, pointing out, like a little finger into the heart of the Carribean.
Placencia is a little town of shanties nestled among the coconut trees. Life appears as easygoing as the cadences of the creole spoken here. Children wander the street in droves carrying smaller children.
The people here are attractive--some unusual mix of pirate and slave--they amble among the trees, you can see them cooking in their stilt-legged homes; when you say hello they say "OK". A simple affirmation of a simple life.
It's our first afternnon & evening, & I'm appreciating the distance from the internecine pressures of school--my only goal for now is to live happily, secure in my knowledge that the only obstacle to this goal is myself. It's to juice myself up after the slow leakage of the last couple of months.
My desk faces southwest and sunrise is washing a hazy peach ribbon across Chapel Hill's heights. Logically, it's all the sun's angle on our latitude, and the refraction and reflection of light with dust and moisture in the air; but how unsatisfying is this reduction--no justice to the miraculous concoction of scattered light that makes that roseate glow, or how the subtle breeze stirs the netting of bare tree limbs that frames this sight.
And it happens every day.
Three hundred and sixty-five times a year it arrives like clockwork, unheralded; also, at least 365 times a year someone spills their milk, helps someone across the road, cuts someone off in traffic, makes a new friend, loses another. The earth keeps spinning, the planets keep aligning and disaligning. As they say, life goes on.
So every day, even with the miracle that is a sunrise, you hope for something different, something that heightens things beyond that constant spinning. At the same time, when this doesn't happen, as unfortunate as you may feel, you have to tell yourself that Apocalypse won't occur suddenly, the glaciers won't melt, Hatteras Lighthouse won't sink into the sea.
The proposed design for the Freedom Tower in Lower Manhattan. Herbert Muschamp writes that it's better than we have any right to expect from a compromise collaboration--let's hope so.
It's a paradox I suppose, but we're a hopeful species that yearns for something miraculous while living our lives among miracles we stop seeing.
Explanations are often unsatisfying the same way equations of particles and light explain away a sunrise. At work, I seek them, but acknowledge that even a good explanation doesn't necessarily get to the heart of the matter. In spite of this, when it comes to breast cancer, I don't stop.
On the other hand, when it comes to your life, you oftentimes must stop. I used to keep on searching for explanations, but found that only breeds dissatisfaction and unhappiness.
So I'll stop here.
At the same time, I regretfully accept that the earth keeps spinning.
"Someday, perhaps, the memory of even these things will be pleasant"
--from the Aeneid (no doubt this should the motto for internship!)
Thinking of happiness again. After a week adjusting to the new milieu of Durham Regional, I looked forward to settling in at a table at Foster's. After two cappucino's and the omelet special around noon, a sour-faced lady suggested I leave because "we ask that you not study on brunch days" and that there were people waiting (incidentally there were free tables and undergrads scattered throughout...studying).
I left not having the energy to argue.
To pump my spirits up I read parts of A River Runs Through It to myself. What a jewel of a book.
Yesterday constituted my last day in the Durham VA Hospital. I've come to know and respect many of my patients there, but the VA is a taxing place. The paperwork demands there intrude on patient care rather than facilitate it; and, well, it's a government agency.
My hopes that my Sunday would be uneventful never came to be. Suffice it to say that I got perhaps 1.5 hours of sleep.
Worse, I was informed that in spite of my being post-call, I was to report first thing in the morning to Durham Regional and scrub in a case. Being sleep deprived and worn down by the frictions of the VA service doesn't exactly spawn much enthusiasm for being required in an OR across town the next morning, but I went.
Once in though, everything else just melted away. It was just the beep of the monitors, the sound of the bipolar cautery, the ratchet-click of clamps, the simple satisfaction of tying knots. Yes. This is why I chose surgery.
In the last day, I've been contemplating survival.
No doubt that internship is physically, psychologically, and morally taxing; and that there are more enjoyable--and perhaps fruitful--ways of spending a year of one's life. Yet some of us manage without becoming too embittered while others become "toxic" and frustrated. What's the difference?
Internship is a necessary evil. Unfortunately 90% of one's time and effort is spent doing rather unenlightening things--but you still have to go through it because the remaining 10% you just can't get anywhere else except by being the junior house officer on the line at 3 am when your patient's urine output and blood pressure are sinking.
The "operational tempo" of being your patients' primary caregiver--to borrow a military term--forces us to interact with other people to a level uncommon in other professions. I enjoy these interactions on the whole, and the good ones far outweigh the bad ones in my mental balance. For instance, there's a nurse that I've become good friends with that I'd be ecstatic to work with as my Nurse Clinician once I've built a practice. I think you can develop lasting professiona/personal relationships if you try to maintain a reasonably positive outlook in your life as an intern.
One intern told me yesterday that she used the F-word in the middle of a supermarket after the cashier refused to accept her check for 12 bags of groceries. "I'm never like that!"
Another fellow intern asked me how I put up with it especially since I'm a bit older and could easily have chosen a different career path.
I don't know.
I can only guess that some mechanism in me extracts or perceives the good things over the bad things. I wish I had a formula.
Perhaps it's the little things. After rounding my patients a second time in the late morning and checking their labs, I walked over to the Duke Gardens. And looking across the greensward, with squirrels stirring the leaf litter behind me, an Indian Summer sun, the gothic edifice of Duke South rising in the distance, I could feel the knots loosening a little, probably just enough for me to maintain my sanity.
The deck was an impasto of white paint, streaked with rust stains, and he was nervous. It had been perhaps 15 years since, and this time he was alone. This metal deck he was looking at was liquid once, and now it was frozen, and slowly flaking underneath that paint. It growled beneath him as they reversed the engines and the landscape stopped moving.
He lifted his fiberglass shell to his shoulder. Clumsy on land, lithe in the water.
On the rocky shore he loaded it, balancing, and stuffing it from gunwhale to gunwhale. The water here was fishy and oil-streaked; he would leave that behind soon.
With a rasp, and a wobble, he was off and cutting into the opaque water. A light chop, the wind behind him. Rotating with each stroke he sought his rhythm--he would find it in a couple of days. Meanwhile the gravity was subsiding, it's pull first sliding away from his arms, his core, then his belly.
At the moment, he could feel everything: the breeze finding its way into his unzipped collar, rounding his shoulders, lifting the short hairs behind his neck; the brine dripping off the splash rings and pattering on his sprayskirt; the oscillations of his kayak into the chop; the slow wink of his marine radio.
So I've had a couple of days off and have found an ability to envelope myself in sleep (and bedclothes) that I never knew existed. Save one thing...
My dreams are saturated with the white-tiled, fluorescently lit hallways of the hospital. I wake up agonizing about urine output or hypoxemia.
I'm generally able to impose a barrier between home and work, but these last couple weeks of nights have imprinted the hospital's patterns in my synapses.
The leaves are darkening and edging into color. The sun's acquired that auburn cast, and there's a vein of briskness in the mornings and evenings where there once was a humid mist-cloak. And it's now our fourth rotation of the year. The rotation on the churning General Thoracic service is over and I've just finished yet another week as Night Float, this time on the "colored" Red/Gree/Purple and Pediatric services.
Luckily, no codes this time.
But now that I have a couple of days off, my clock is entirely discombobulated having spent two of the last three weeks on nights.
For the first time in a long while, I had the luxury of sitting down to read, and try to thoughtfully put together a writeup for the Society of University Surgeons.
Incidentally, Go Red Sox.
And, let's give Arnold a chance and see what he can do. There are many paths to political success, and I certainly don't think that planning to be President from kindegarten on is any more legitimate than being a surgeon or being an actor first.
Another night, another code, another lost patient. During this month's rotation, the Night Floats the past two weeks had no worse than calling security to help catch a disoriented, combative little old lady; and now in the last three days there've been two codes on the floor. This last one we ran for 35 minutes, shocked more than I can count, and ran through just about every med in the cart, to no avail.
My pager goes off: "There's an emergency in room X". The JAR and fellow are already in the room. He's bagged. V-Fib. Clear. Epi. Shock. Shock. Shock. RT is here. Intubate. She starts compressions. I shoulder in and relieve her--compressions are extremely fatiguing and you need to relieve the person delivering them. Rhythm? Pulse? Clear. Shock. Pulse? Compressions. The JAR and fellow start placing chest tubes on both sides. Stop compressions. More Epi. Rhythm? Pulse? I hit the charge button and grab the paddles. His chest is a slick of conductive gel. Clear. Shock. Pulse? Round after round. V-Fib. Pulse? Shock. Shock. V-Fib. Vasopressin. Bicarb. Amio. Lidocaine. Torsades. Magnesium. Do we have Bretylium? We're running out of ideas. Finally we call it. The pitched whine of the defibrillator charge chime in the background. We've given the unfortunate fellow every chance we could. A medicine resident turns it off.
His mother is a huddled wreck wrapped in a blanket in the waiting room. The Chaplain is stuck in another code situation. We sit down with her.
Later, after the rest of the family arrives, there's a horrific wail that echoes down the corridors. The other residents are dealing with an MI in the unit. I'm sorry, we tried everything. I know you all did. Thank you. His wife's knee is quaking.
Monsters & Goblins come out at night.
This week I've been serving as the "Night Float" for the Cardiothoracic service, meaning the interns during the day hand their patients off to me at 1730, I tuck them in and take care of any issues that may crop up overnight, as well as attend to any work that couldn't be finished during the day.
Unfortunately I lost a patient the other night. We still are trying to piece together why. His family dealt with it with as much aplomb as you could imagine, but declined an autopsy, meaning that we'll never have a definitive explanation of what happened. I've made clear to the upper levels that I am completely open to any advice on things that I omitted to do, or should have done better; but overall, I think we ordered the appropriate tests, and made the appropriate moves. In retrospect, (and the attending physician called me directly the morning after to discuss this--a slightly nerve-wracking experience), it would have been better to have transferred the patient to the intensive care unit.
The patient likely would have coded there as well, but these are the places to be if something like this is going to happen.
The problem is that while he was foremost in my mind among the patients I was covering, I didn't see him as being so precipitously unstable. His family also notes that he seemed fine all the way up to the moment that he became unresponsive. Interestingly, the nurses tell me afterward that the family would have rather have let him go quietly rather than calling a code.
I get heartburn less than once a year, but had to guzzle a quarter of a bottle of Maalox to prevent my stomach from auto-digesting the rest of the evening. The nurses sympathetically minimized calls the rest of the night.
The other day, I sat and watched the HBO special on 9/11/01. I had to--for instance I'd never allowed myself to watch footage of those unfortunate souls that threw themselves off the towers, tumbling obscenely to their ends--I was afraid I'd forgotten how horrific it was, especially footage right after the collapses with the downtown covered in ash, no sound but the shriek of locators; firemen and policemen bent over, stunned as all the trappings of modernity precipitated softly about them. And seeing the benign, dolphinoid form of a passenger liner disappearing in a tower is still barely believable. You could almost imagine something like that scene in the original Matrix when Keanu Reeves rescues Trinity out of the helicopter and induces a glitch in the computer program that doesn't quite accept the improbability of this act, allowing glass to ripple like water; the problem is that 9/11 happened, and there was no real glitch.
This is (was) my first legitimate full weekend (as in Friday thru Sunday) off so far. I wish I could say I did something ambitious with it, but I spent it doing the little things such as waking up at 8.30 or cleaning my closet, bringing my watch in for service, eating pizza, going to the bookstore. The small things that leaven what might otherwise be a very dry, flat affair.
The current rotation, Transplant, so far has been a good one. There's a level of camaraderie on the team that I see very little of on the other services. Cross-coverage can still be challenging, but that is the nature of the beast in a new era of 80-hour work weeks. I think/hope that hospitals realize that bemoaning the difficulties of continuity is unproductive, and developing systems that promote continuity in a hours-constrained environment is the only solution.
Being back in the home institution rather than the VA is a welcome change. You feels less isolated in the Mothership; where the VA didn't even provide a call room to decamp to.
I'm almost one sixth of my way through Internship. Not that I'm counting.
More small pleasures this weekend: I watched the beginning of "Airport 1975", mostly to savor the 70s soundtrack, fashions, decor, and the urgency inherent in that era's disaster films--the adorable little girl loaded on the plane for her kidney transplant, the nuns sitting in coach, Gloria Swanson sitting in First Class, the First Stewardess tired of her aimless relationship with the airline executive (Charlton Heston), the trio of drunk regular Joes (Mr. Roper, Ben Stiller's dad, and one other recognizable 70s character actor)...lovely.
Well I spent most of July 4th planted facedown in my bed. Call on my current rotation involves 24 hours on with 24 hours off the next day, an intervening "short call" day, and then 24 hours on again. I've never been much a sleeper during the day, but I'm pretty impressed with my ability to be Glasgow Coma 3 within half an hour of getting home.
When interviewing for residency positions, a interviewer astutely asked me at one point whether I felt like I could accomodate entering a new milieu where I would be bottom of the totem pole when up to now I've been regularly interacting with Chairman-level people in a collegial environment. Good question.
The simple fact is in a clinical context I am indeed an intern and have a lot to learn about what wielding an "MD" (paint still wet) means; and that entails a lot of "yes, sir; no, sir". A surgical chief resident simply isn't going to ask me about the difference between metagene analysis of breast cancer and hierarchical clustering. There is a good deal of administrative/secretarial work, but paying dues is part of any process isn't it?
I have a lot to learn, and the learning curve is still near vertical.
Then there the small satisfactions: I placed a chest tube in the MICU in a patient with a huge exudative effusion/empyema in his right thorax. The chief walked me through it--when you punch through the parietal pleural and see 1600 cc of pus come out of the tube and fill an entire Pleur-Evac, you know you did good. The patient claims he feels better. After seeing his pre- and post chest Xrays you'd think he would! Imagine carring almost a 2-liter bottle of Coke in your chest, that's gotta come out.
Note: I can't speak too much in detail about this year because I know another intern a few years ago got some heat for keeping an online journal of her experiences at this institution.
One thing I can say, and this will be the same for Interns from ages before me, and Interns generations after me, is that it can be an aggravatingly chaotic experience. Part of the learning experience, by nature, is information overload--and then on top of that, someone starts bleeding, or having a chest pain.
Ironically, the 80-hour work week rules make it harder to both learn and do your job. It's very hard to follow-up on something when you must sign out by a certain time. This also means you leave a pile of unfinished work for the next intern--something I truly despise doing.
My "in-house" diet for the last week has been 1 liter of orange juice and perhaps a banana or two; one day a nurse clinician was nice enough to give me her sandwich. My pants are already fitting more loosely. Our workroom is also very hot and I'm chronically dehydrated
The learning curve in internship is vertical, there's no way around that; the human body is such a complexity of fluids, molecules, bone, and electricity that the only way to learn it is hands on. And the responsibility inherent in being a doctor can only be learned by being responsible for patients. Senior medical students get to play at this, but internship is an immersion treatment in responsbility (which also means learning when to defer responsibility up the chain of command).
A busy week. After ATLS, we spent the week getting our certifications in Basic Life Support (essentially CPR), and Advanced Cardiac Life Support. This latter course prepares us to be a member of a "Code Team"--what you see so dramatically on medical TV shows when they slap the paddles to a flatlining patient...except you don't really put paddles on a person with a flatline. Almost everything you see during a code on a show like ER is wrong: from the rubbing defibrillator paddles together, to shocking an asystolic patient to life, to the big adrenaline syringe to the heart.
Anyway, it's been a long week. Not because the material is that challenging; the American Heart Association has been very good about making the decision-making in cardiac life support fit a logical framework, but because you spend long days shoehorning in facts in order to pass written and practical exams at the end of the day where you normally might do this over a leisurely week in another setting. And you also want to avoid sheepishly sitting back down in the examining room because you didn't pass the written the first time around.
Today was tiring just because it was boring. This was our orientation to the surgical services which meant sitting in the Endosurgery suite having various people jaw at us for 8 hours.
And then the slow enlacing knot in the middle when you start realizing that, in a couple of days, you are the guy on the line. You are the support system that allows Seniors, Chiefs, and Attendings to do what they're supposed to do--operate. You are the first person the nurses call. You keep the Floor buffed and polished so the Chief doesn't return to chaos at the end of a tiring day in the OR. And you're facing the steepest learning curve in professional life: the Intern year on a surgical service.
Sunday I went over to Dave and Pearl's parent's place for Nathan's 100-day celebration. Great food and much ga-ga-goo-goo over the little man who seemed a little overwhelmed by all the action at times. He's very photogenic.
The 2nd day of ATLS was generally more of the same. The lecturers tamping what we needed to know into our braincases, practical sessions and then the written exam and practical exam. We had an interlude that is famous in Duke lore: Dr. Georgiade's "Shark Talk", where he narrates us through a famous old text I think originally compiled for Mediterranean sponge divers about how to swim with sharks.
Basically, we have to think of the hospital as being like a shark tank in which residents are little fish. Most of the time, assuming we swim quietly, we won't get bitten, but in our years of training it's inevitable that we will be bitten, or fishes near us will be bitten. Dr. Georgiade's talk gives us pearls of wisdom on how to respond to these circumstances, e.g. when other fish are being bitten, get out of the water; don't try to help and get bitten in the process, perhaps inciting a feeding frenzy. Of course, Dr. Sabiston was known as the "Great White".
Back to ATLS, As I sat next to one of the course administrators checking my exam, things were looking good. First 20 questions, none wrong, next 10, one wrong, on to the last 10, four wrong in a row...I start getting worried...8 wrong max to pass...it's a sprint to the finish...but I pass. The practical? I kill two patients before I pass.
Then in the evening, Dr. Jacobs's dinner reception for all the new interns. He and his gracious wife have moved into a pleasant new house in Hope Valley. I actually had almost gone to the wrong reception, his road forks, and I took the wrong one and ended up at the Pediatric chairman's party. I knew something was wrong when I got out, saw a resident I didn't recognize (from ATLS) introduced myself, asking him if he was Ortho, and having him respond that he was Peds.
Anyhow, the reception was a pleasant affair. I got to meet our new Program Director. He seems personable, and I know he was one of the resident choices, so I'm sure we'll get along for the next 5+ years. The catering was quite good; grilled summer squashes, stuffed pork loins and some quite passable dessert squares. I had a jolly time at a table with a couple of the other General Surgery interns and an OHNS intern. Apparently none of us is married (where every single Ortho guy is married or engaged); and some joking ensued when the chairman told one of my compatriots that they'd increased the number of incoming PA residents to 17, and that most of them were women. His face visibly brightened at the prospect and I couldn't help calling him on it.
Dr. Jacobs said he refuses to function as a matchmaker.
Interesting aside, Dr. Jacobs told us that he has commissioned a Time-Motion study of surgical residents at work because he wants hard data to take to the hospital administrators to deal with the hospital inefficiencies that are surely to come to fore with the new work-hour rules. I think this is a really smart thing to do. I'm glad he thought of it. He said, having gone through surgical training, he obviously knows the data first hand, but he needs to have the numbers to show to the people upstairs (who clearly haven't been surgical house staff).
He's looking out for us.
Today was the first day of ATLS, the course that certifies each of us to be member of a trauma resuscitation team--obviously a necessity for all surgical specialties (especially when you consider scheduled elective cases are in reality controlled trauma). As I topped the steps to the 3rd floor of the hospital, I found myself walking behind a quartet of big, strapping guys, all in polo shirts, khakis, and dress shoes, all around 6'2".
They really couldn't be anything else.
And when it comes down to it, of the interns, the largest fraction at Duke are Ortho. I think there are half as many General Surgery categorical interns as Ortho. I wish I was interested in fixing bones because I think Ortho is a fantastic specialty, but alas, I'm stuck with the "general misery" of peritonitis, running the bowel, stabilizing trauma, &c.
Honestly though, today I realized that my choice, though not the most rational (because I could have gone the accelerated-track Internal Medicine clinical research route that would have me subspecialty boarded within 5 years), is probably right for my disposition. We had a practical pig lab where we performed procedures on a hapless (but anesthetized and intubated) swine. I felt at home with instruments in hand, cutting tissues, tying sutures. I have tremendous amounts to learn, but the action, the ratchet of clamps or the feel of a needle driver in tissue, and the focus on the patient's entire well being--not just their ears, nose, throat, or brain, or bones, or pee-pee apparati--is the "fun" of General Surgery.
I'm going to goof many times down the road, and will surely bemoan my lot, but I think this is right.
I hope this is right.
Incidentally, I'm writing this from a new computer. It's time I retired my 1st Generation Titanium Powerbook, the poor fellow has been routinely thrashed to the limits of his capabilities. And titanium and all, he's a little worse for wear. His screen isn't quite so bright and cheery in the mornings, and he tends to be cantankerous when he boots up. He did serve me well in Hawaii.
I've taken to calling his replacement, a 17-inch Powerbook, "Essex" because this is one big machine, more like a flight deck than a laptop. Now aluminum, it's surprisingly light and thin, and it's much more responsive (having twice the microprocessor its predecessor had). I also take migrating to a new computer as a chance to clean the slate, and reorganize my directories, my email rules, blow out the cobwebs.
For a mildly anal person, this is quite pleasing.
As you can expect, being in Durham is rather anticlimactic. No tradewinds to mitigate the heat, our foothills versus the cliffs of Na Pali.
And tomorrow, it begins. Two days of Advanced Trauma Life Support, then next week, Basic and Advanced Cardiac Life Support. I also attended a meeting yesterday between IBM and members of the breast cancer group to hopefully start to develop an integrated clinical and research computer system that will bridge research and patient care, and if it's done right, ultimately lead the way to actually making "personalized medicine" tangible. This weekend I have to start putting together a formal proposal for piggybacking the CODEx Project on to one of the American College of Surgeons Oncology Group (ACOSOG) breast tumor studies.
Then my first official day on the payroll as a House Officer is the 20th when the formal orientation begins, and analogous to the green police rookie, I'm handed my badge and pager. Yesterday the graduate medical education office gave me my medical license, my DEA number (for prescribing narcotics), a slip for my parking card, and another for my six pairs of polyblend white pants and five white coats.
I don't know whether my holding any sort of medical credential is a good thing.
Tonight I must cram for ATLS tomorrow. They expect us to have read the 300+ page text and to have taken a pretest.
20.23 Hawaii-Aleutian Time, 8 June 2003
I don't like last days. My theory is that we evolved with twin impulses: to explore, but also to settle down in that village near a clean water source, good yak hunting/betel nut gathering/breadfruit growing, and the smiling girl you got for a dowry of a long-haired yak. Modern travel is capable of such rapid and complete dislocations, the prehistoric villager in me often finds it hard to adjust. Since there isn't much in the nature of exploration going home, no tension there.
The fact that I was actually leaving did not even register until after I'd seen the express checkout under my door. Habitually, I'd awoken thinking about what I might do with the day--I'd entirely forgotten that I would once more willfully embark on a pressurized steel tube and find myself 2500 miles away in 24 hours.
Now that my departure was made tangible in crisp hotel stationery, my mood darkened. Rationally, eight days traveling on my own is about as many as I can go before wearying of my own company, but that old inertial reel in my brain was happy for me to remain. Naturally, it's more than inertia, the weather's great, the natives are friendly (and aren't eyeing your iliopsoas muscle for steaks), the landscape is stunning.
The last day is a useless day because you can't be too adventurous if you have a plane to catch. No road to Hana or upcountry exploration for me with the 23.40 Maui-SF redeye in my future.
First I called the rental agency to extend my rental into the evening. The thought of otherwise spending nine hours in the airport was too monstrous to contemplate. Of course they charge me another $41 for the privilege
Once packed, I regretfully filled out the information for the express check-out form, made a last inspection of my room.
My plan was to find coffee and/or lunch in Kaanapali and then explore Lahaina. For lack of reliable choices, I found myself back at Whaler's Village. The guidebooks suggested that the Hula Grill would make a passable choice for their Tahitian Ceviche, so there I went.
Driving through Kahana/Kaanapali reinforced it's bland condominium atmosphere. Dozens of indistinct complexes whose only claim to personality lay in the design of their signs with names like "Kaanapali Sands", or "Kahana Whaler"--replace those names with "Palmetto", and you have Hilton Head, or Seabrook Island, "Sea Oats", and you a have Duck or Corolla.
The Hula Grill is right on Kaanapali beach, under woven umbrellas. Swarming before you is the America's upper middle class: good looking children, shepherded by attractive mothers, dragging their boogie boards behind them, younger folk, tattooed and attired self-consciously, using all of their disposable income. "Wassaaabe, Dude!" In the strait separating Maui from Lanai and Molokai are parasailers. The waitstaff are all Mainlanders, inevitably working here for the privilege of living in paradise.
It's a generic, but serviceable experience, and I later find a cup of coffee in the Waldenbooks.
Once I bore of this, I set off for Lahaina, hoping that it will provide me a few hours of diversion. Five minutes down 30, I pull off into the Lahaina Cannery Mall. Knowing that parking is an impossibility in the center of town, I leave my Town & Country there and walk across the concrete flood control ditch that used to be the Paupau river.
The outskirts of Lahaina, are humble residences among bougainvillea with rooms inevitably rented out to surfers and driveways filled with their beat up pickup trucks. I wander across the Japanese Shingon Mission (built in 1902) and the town's sand dune cemetery. The first picture is the north end of Front Street in Lahaina, just after crossing the Paupau flood control ditch. Following are two shots from a little evangelical church on Front--odd reassurance since I thought I was in paradise already! The fourth shot is Front Street coming into the center of town and Lahaina Harbor. I couldn't bring myself to take pictures of mobs of tourists, so no pictures of the town itself. But here is a picture of some bricks--I know there is a story here, I just don't know what it is. Finally, some flowers as I'm leaving town.
I follow Front Street into the town center. By location alone, Lahaina is an idyllic spot. A stone sea wall separates it from its harbor in which sailboats and charters bob in the tradewind. Front is lined with palms as you come to the falsefront shops that look so picturesque from a distance. The first establishment you encounter is, disconcertingly, a Ruth's Chris Steakhouse, then there's a Hard Rock Cafe, and finally the onslaught of what I call T & T stores (T-shirts and Tchotchkes). The streets are mobbed. A bus disgorges a Korean tour group. Sweat-soaked, I leapfrog from air-conditioned store to air-conditioned store. There are two Haagen-Dazs and two Ritz Cameras.
I begin longing for the cool comfort of my Town & Country.
In less time than I expect, I find the turn north off of 30 onto 380 towards Kalahui. The ride across Maui's flat ismuth takes no more than 15 minutes, I spend much of it behind a blonde with two surfboards strapped to her Volvo.
With 9 hours left to kill, in the least interesting town on Maui, I'm left with one choice: A shopping center. I end up at Queen Ka'ahumanu Shopping Mall. There's not much worth mentioning about this place. It's a open air mall, it's got a Gap, a food court, and a movie theater. After wandering about for an hour, I decide that I may as well watch a movie which will keep me occupied and cool for two hours. The Italian Job serves this purpose.
I can look at Charlize Theron forever.
Exiting the mall, the fortresses of clouds obscuring the West Maui Mountains are limned in indigo and crimson. After watching Mini Coopers speeding about LA, I peel out of the mall parking lot in the Town & Country, fill it up, and return it (happily) to Dollar. And 3.5 hours later. I'm on my way back to the Mainland.
Missing details and photos later (since I'm home now and must unpack and do laundry).
One demerit against the Hidden Maui guidebook. I just returned from a profoundly mediocre meal at China Boat in Kahana. It was a typical bad Chinese restaurant with a chaotic ambience contributed by the proprietor's children zooming throughout the dining area. Inexplicably, they were also running repeatedly in and out of the restroom.
Indifferent food, indifferent service (which really isn't a criticism because a Chinese restaurant wouldn't be Chinese if it had good service). And why do people describe dishes as being in a "brown sauce"? How unappealing is that? Can you imagine a French chef describing something that way?
Walking in, and knowing Chinese restaurants, my internal culinary alarm presented me with two options (1) flee, or (2) stay for the evanescent possibility that they might wow me with an innovative use of some Hawaiian species of fish, or that the imprimatur of a guidebook mention might mean there was something special about the place. I chose (2). Like the character in the Indiana Jones movie, I chose poorly.
Should have gone with first instincts, and now I've wasted a meal in paradise (something many people must be doing in Maui considering there's an Outback Steakhouse 3 miles down the road).
I had considered dining at the hotel which would have been unoriginal, but a far safer bet.
Perhaps I should have crashed the luau they're throwing down by the beach. I think GM must be sponsoring an incentive junket for middle management. They've been swarming the hotel with their plastic name badges.
They don't have the sleekness of executives--perhaps they're sales. Note to one that I've seen the last couple evenings: blue blazer + shorts = fashion faux pas. I don't care if you had the best sales numbers in New England.
Your wife should know better than to let you do that.
Perhaps I'm a little ornery about the demise of my camera, and the bad meal.
For penitence, I will go out on my lanai and soak in aloha spirit.
I woke up relatively late, 7.00; goofed-off, wrote the last entry, and finally got around to breakfast after walking down to the beach. The hotel, unusually, doesn't go right up to the water. After they had acquired the property, they found that the area abutting the beach was a Hawaiian burial ground. This led to some controversy for the resort, but they did the right thing and deeded the sacred ground to the state while setting the hotel back behind it.
During breakfast I worked on the draft of the commentary Joe and I are writing for Cell Cycle. I received pitying looks from other guests probably wondering why this guy can't relax.
A couple next to me: He is off at the buffet, the waiter asks her if she'd like coffee; yes she would, and "my husband likes it with cream and sugar." She seems both surprised and delighted with the novelty of saying that word.
My activation energy was low, but I dragged myself out to my Soccer Mom conveyance and decided to drive north on 30. I think car rental agencies pretty much discourage people from exploring the northwest corner of Maui because the road is winding and treacherous. It's called the Kahekili Highway (Edit: In fact the rental agencies specifically prohibit driving rental cars here--though 90% of the cars I saw were rentals), but highway is an exceedingly generous word for it.
Driving it is supposed to give a flavor of what Maui might have been like before tourism. The precarious road climbs cliff sides and plunges into little valleys. At first it is two lanes, then a wide one lane with a dotted yellow stripe, then macadam barely the width of my Town & Country (what a preposterous name for a minivan). At this point, after negotiating a sphincter-tightening stretch, I chicken out and turn around at the first opportunity. I just haven't the faith (or the insurance coverage) to risk Soccer Mom Mobile. Pictures below. The photo with the sideview mirror is where I turned around right above what I believe is the Waihe'e Valley (echoing with rooster cries):
All of these photos were taken with the Canon G3, a very capable, and quite feature-laden camera. I still am getting used to not bringing the camera up to my eye to take a photo. Framing a shot from the LCD is an adjustment, but it does have the advantage that I can angle the screen and take shots that I couldn't make through a viewfinder. Technology-wise, it's a better camera than my Fujifilm RIP, the flow is just different.
After getting home, I took a late lunch by the beach: A "Lahaina Sunset", Maui onion rings, and ginger beef handrolls. I spilled my drink brushing away a fly, but the server was kind enough to give me another without charging me. I met Felix, the local cat.
Walking up the hill back to my room, all of a sudden I felt bone-sappingly tired.
07.57 Hawaii-Aleutian Time
Here's my hotel room. Click on the thumbnail to get a full size version:
After a period of recrimination accompanied by self-flagellation with one of the fresh orchid stems in my room. I decided to go buy a new camera. The concierge told me that there's a Ritz Camera at Whaler's Village in Ka'anapali, so I made the short drive south down 30 to where it all began for Maui (and even Hawaii) as a posh tourist destination. This used to be sugar country, but American Factors (now Am Fac) decided in 1963 to convert a sleepy railroad stop and plantation wharf into what is now 4000 rooms worth of development.
It has the looks of an upscale community circa the 60's and 70's with that era's high-rise mentality. I can see in my mind's eye sideburned tennis instructors in short shorts driving shiny Pontiac GTOs and bored tourist wives from the Mainland baking by the pool...I'd better stop before this turns into a boom-chaka-wow-wow movie plot.
It is pleasant, but bland and condominiumized like hundreds of places in Florida or Southern California. Whaler's Village sounds like it could be a quaint street of false storefronts where whalers used to come and say "Yar!" (whatever that means), but is basically Copley Plaza in Hawaii: there's Gucci, Chanel, Louis Vuitton, Coach. I like these things, but was ambivalent about whether I really needed to find myself in such a place.
Ritz Camera didn't have any digital SLRs in stock, but had a Canon G3, which short of the semi-professional cameras, has stellar reviews from the digital photography crowd, so I went ahead and purchased it. Unfortunately the cash register computers were having issues, and Tweedle Dum and Tweedle Dee, as nice as they were, were having trouble getting things going again.
I finally escaped Ritz Camera, and tarried no longer than it took to actually see what a Tommy Bahama store looks like. It was dark and 20.30 when I got back to my room, so I ordered room service. Goat cheese and marinated pear salad with toasted walnuts and pancetta and Kona crab wontons and a pineapple charlotte with coffee. The meal was not bad, but so exquisitely arranged that it was hard to unify goat cheese, pear, walnuts, and pancetta into one experience. Fried wontons are straightforward. Pineapple charlotte was appropriately decadent.
16.57 Hawaii-Aleutian Time
All right guys. You can make fun of me as much as you want; but remember, I'm in Hawaii.
Your damn Skippy I am.
That aside, So far today has been a travel day. I woke up before 6.00 to pack (was too tired last night to do it then--imaginary wives and children wear a guy out). And spent an hour doing that. Composed a thank you note to Dustin and Jackie; gassed up the Stratus; returned Chava's surfboard to his spot below the tree next to the parking lot; and checked out. I left Kauai with some regret, but figured, like MacArthur, that I would return one day (perhaps I'll try the striding through the surf too).
I left the Sheraton at about 8.30 and stopped at Don's Camera to pick up the battery charger he was so good to procure for me. He's a middle-aged, I would guess Japanese-Hawaiian who's friendly, but no-nonsense. He directed me to the shortest route to Lihue Airport. I returned the Stratus and checked in. A luck would have it, the Aloha flight to Maui before mine had standby space, so I caught that flight. My only mild concern was whether my baggage would end up on this new flight or my original flight.
After a stopover in Honolulu, where I had a good aerial view of its port with laden container vessels, and a Coast Guard cutter, the little 737, now stuffed to the gills with Mainlanders in a festival of colors (people really get into their Hawaii schtick coming here), labored with a gravelly rumble southeast to Maui.
Bad premonition: I've always thought that the thrust reversers on 737's are sort of cool so tried to take a picture of the engine as we flew into Honolulu. The camera turned on, but none of the buttons worked. I wrote this off as its low battery state.
Luckily, my bag did materialize on the conveyor for the new flight, so I was off to the car rental agency...where there was a line practically around the block. It seemed that every person off the plane was using Dollar while the Avis, Hertz, Alamo, Budget, &c. counters looked abandoned. I managed to get on the second shuttle bus after beating up 3 sets of senior citizens--all right, it was just one elderly couple I took out with an atomic scissor kick. Well maybe I just waited politely in line, even as a honeymoon couple broke into the queue ahead of me.
At least Dollar seemed prepared for the onslaught. They were processing people through quite efficiently.
I had reserved a compact, but the attendant told me that I'd have to wait for one to get cleaned. She could give me a minivan if I didn't want to wait. A man waits for no Dodge Neon, so I took the Dodge Town & Country minivan. Perhaps she noticed my invisible wife and kids. I didn't quite retain the attendant's directions out of Kalahui so navigated by seat-of-the-pants method. Invisible partners are poor navigators (but than corporeal ones are often poor as well). I felt like I was going south and did end up on 380 that exits the town and intersects with Maui's circumferential highway, Highway 30. Driving though Kalahui, it's clear that Maui is an altogether different sort of place than Kauai. The first establishment I passed was a Lexus dealership, and I soon passed a Home Depot, and the requisite collection of fast food joints. Driving my infinitely suave Town & Country to Kapalua, the impression I got from what I could see from the road is that Maui is much more built up, with high rises (where nothing in Kauai was taller than 4 stories), and the generically pleasant upscale strip malls you see in places like Hilton Head. Within 40 minutes I turned into Kapalua.
This place is meticulously mowed and gardened. My hotel is perched on a grass bluff next to the golf course (they hold the PGA Mercedes Championship here), with the beach down below. It's designed to be reminiscent of tropical plantation house with the hotel line's signature pineapple motif reflected throughout. It's quite a bit more luxurious than the hotel on Kauai. People also remember your name.
Since my room wasn't quite ready, I wandered down to the poolside restaurant because I hadn't eaten at all today. There were only two other groups there (it being 14.00), a couple with the man glued to his cellphone to which he responded in monosyllabic eruptions and his wife withstanding his crippled level of sociability with aplomb. The other group were big, floridly beefy golfers with pastel-colored polo shirts, big class rings, and loud Southern accents.
I ordered a raspberry-mint lemonade (didn't realize that it was a hard lemonade), and a grilled eggplant, ahi tuna with aioli sandwich on flat Turkish bread. It was very good. I managed to finish the Wall Street Journal when the Front Desk informed me that my room was ready.
I've been upgraded to a suite. I have two bathrooms (one with shower, the other with bath and shower, a sitting room, a walk-in closet, a lanai that spans more than 20 feet and overlooks two holes of the back nine--I can't quite see which.
If any of you can get out to Maui today, you're free to stay. I'll make the invisible quintuplets sleep outside.
For broadband access I have to rent a 3G cellular modem. I've never seen one of these things. It's $13/day, and after some snafus with the first modem, and then the wrong cable with the second, I've gotten this second one up and running. I didn't mind the trips to the Front Desk though because the girls are pretty.
After charging a battery in my nifty new battery-charger, I powered up my camera for some pictures...None of the buttons work. I didn't mention that on my Na Pali kayak trip that the "dry bag" that the outfitters had supplied me hardly deserved the name. One of the seams was busted. Now I had laid the camera bag as the topmost item in the "dry" bag, and had noticed that my camera bag was damp at our lunch stop, but I wasn't too concerned because the camera wasn't soaked like my stuff in the bottom, and I successfully snapped a couple pictures--which I posted below--after lunch. Now, I think the little bit of salt water, or even the humid environment inside the "dry" bag must have corroded the camera's circuitry. It will turn on, but I can't do anything with it.
There's a particularly useful word in the lexicon for this situation: B-U-M-M-E-R. All caps, full-stop.
20.00 Hawaii-Aleutian Time
This morning I scheduled a private surfing lesson with Chava Greenlee. A huge (but not fat) 6'2" Hawaiian who, along with his father, constitutes Aloha Surf. Apparently the method he teaches for standing on the board is differs from other instructors. Instead of hopping up, he advocates doing a push up, the planting the rear foot in the middle of the board, and then bringing the front foot forward and planting it. The board itself is about the size of the USS Nimitz, or perhaps an Essex class carrier and with a board that huge, it was easy to get up on the first try. I see why surf instructors guarantee a person standing up their first lesson. It really isn't that hard.
For beginners, instructors wait for a small wave, tell you when to start paddling and actually push the tail of your board toward the beach. This last little kick is what I think makes it easy for beginners to stand. Not to say that I didn't boof a dozen other times. I think the hardest part is judging waves and just all the paddling. After towing Jim around for 6 hours, I was pooped. At the end of the lesson, Chava left me alone to work on it myself, except another surf school arrived and my relative lack of skill, and the thought of taking the head off a 11 year-old sent me to shore for a cheeseburger at the poolside grill. My second hamburger, since I'd ordered one from room service when I got home late last night (and it really wasn't that bad--it was genuinely medium rare, the fries were crisp, and the entire dinner was hot. Of course it cost something like $200).
So today wasn't a particularly epic day, but was fun. I've gotten too much sun over the last couple of days and the cold that I've been fighting (and seemed to have disappeared this morning), is manifest as a mucus-heaviness behind the face, and nasal drip out of the left nostril, if you care to know.
One annoying thing: whenever I eat at the hotel (I have a $100 credit that one of the employees was good enough to remind me to use), they assume that it's for two. Two days in a row I've had to scratch out the second $20s for my invisible wife's breakfast. Perhaps Hawaiians can see things I can't remark in corporeal form. They might as well charge me for my 5 children too.
To use up my voucher, I ate at the Japanese restaurant here. When my table was ready, the person that seated me asked the hostess where the second party was, and the hostess just told her that my wife was coming later.
They even know my extacorporeal wife's schedule! Perhaps she should have said that my wife is still having her pedicure and that because she changed her mind mid-way between Hyacinth Pink nail polish and Coral Red, she's late.
Just now a woman started berating another woman for having shut-down one of the public computers. I can't see the reason for such rudeness. The first woman started getting dramatic about how she couldn't use the computer now. "I don't know what to do?" her voice rising.
"Here, let me help you", I snapped my laptop shut, walked over, and turned on the computer.
"I thought that grille was locked. You know she shouldn't have shut-down the computer"
"It was probably habit. It should work now." She fidgets as it boots. Just as she's about to raise another crap storm, it transitions from the boot screen to the desktop. I'd guess that she has a sub-clinical DSM-IV Borderline Personality diagnosis. Her husband looks as if he's been pecked to within an inch of his life.
I have no time for rudeness.
I actually rose at 3.00 but managed to fall asleep again until the phone rang with my wake-up call. By 4.30 I was moving briskly towards Hanalei in light traffic. The one-lane bridge was presumably supposed to close between 24.00 and 6.00 for repair work, but when I reached it at a little before 5, it looked open, so I drove across. I presume since I didn't end up with the Dodge Stratus in the Hanalei River means they finished.
Since I was early at Kayak Kauai, I killed time by calling Eugenie. The owner and two guides soon showed up and I got squared up for the trip. During the ride over I had been slamming water, and before going to bed the previous night I drank a Sprite (both carbs and fluid). The kayaks we were to use are Ocean Kayak Cabo's. They're roto-molded plastic sit-on-top kayaks. An unfortunate byproduct of being safe for inexperienced tourist kayakers. Fiberglass decked kayaks are probably too difficult to manage in dangerous conditions (i.e. you can sink one, and you have to train people to do wet exits and recoveries). Rather than being called sea kayaks, these should be called sea slugs. And roto-molded plastic is way heavier than fiberglass.
Among our group were 4 MDs: An ER doc, Gary from Santa Cruz, with his two college-aged sons, Nick and Gabe; Tom's wife (I forget her name) a pediatric attending; a pediatric resident, Brian, with his very good-natured wife, Cabby; and myself. So if someone broke a limb, the Gary could set the fracture while I did the genomic analysis, and the PD docs could give us the mg per kg dosing of medicines we didn't have. There was also Jim and Carol, Jim is a forester with the BLM in Portland, OR. I don't know what his wife/SO does. Then there was...dammit, forgot his name...a Harvard Law School graduate from Sullivan & Cromwell's Hong Kong office, and his girlfriend a Chinese-American chick, Katherine.
Our guides were Josh and David. David is in his late 40's early 50's and had been guiding kayak tours for many years until he met a woman who insisted if he wanted a relationship, he'd have to move to Kauai. I bet that was a hard decision. Josh was a fit young guy with longish hair and full beard, the type you find working for outfitters all around the world. Loose jointed, surfer-drawl, hang loose attitude.
We were fitted with PFDs, hopped in a van with kayaks in town and assembled on one of the beaches that precedes Ke'e at the end of the road. Because Gary and I were odd men out, we were paired with the guides. We received a short lesson paddling that omitted what I consider to be one of the more important lessons, the "power-box" and body rotation. I guess as long as they got the job done.
We finally put in at some time after 7.00. From behind David remarked that I paddle like a decked kayak paddler (i.e. I hold the paddle higher to clear an invisible deck), which I guess is true. While Josh and Gary took point, David and I had the onerous duty of being the sweeper for the group. I think I've gotten used to good podding behavior, but soon we were stretched out in a long file with Carol and Jim bringing up the rear. There is a certain pace that my body mechanics like for distance paddling, and Jim and Carol forced me out of my cadence. Often they were many hundred feet between them and the next to last kayak. David and I often had to stop paddling until they caught up. They're nice people, but seemed blithely uninterested in keeping up.
As we turned the corner and arrived off the Na Pali coast we were greeted with the other side of what I saw at Awa'awapuhi: spectacular stratified, razor edge cliffs. David pointed out fauna like Noddy Sparrows (I thought he was calling them Naughty Sparrows) that have a unique nodding head motion. We went into several caves in the cliffs. One had small waterfall draining over its mouth. The easiest way to see the Na Pali Coast is by watercraft of some sort. There are hikes, but the most time-efficient way to seem them is by boat. We passed several catamarans with tourists crowding their decks. It aways seemed that the cats traveled under power rather than by sail. But then it was a light day.
This otherworldly geography is populated with Ironwood trees originally from Australia. We also often found ourselves among sea turtles (even close to 10 in one spot). Unfortunately there were no Spinner Dolphins.
Paddling with Dave was a pleasure. Two experienced paddlers can move a double quickly and painlessly. Unfortunately, Jim and Carol's albatross-like ways forced me to move into Jim's front seat, and Carol into Dave's.
Jim is a laconic, rangy, bearded guy. You'd think that a 6'2" person who spends much of his life in the woods would be a good paddler, but where paddling with Dave was like gliding over the water, paddling with Jim was like paddling with an anchor in tow. I could see him putting his blades in the water, but his strokes hardly seemed efficacious. I'm the type who can't stand to bring up the rear (unless I'm supposed to), so I was paddling like mad just to keep us in the middle of the pack. Everything feels heavier, the paddle, the paddle stroke. I was getting tired, even suspecting that he was deliberately holding back because I'm one those goal-driven people that laid-back foresters probably would like to teach a lesson. After about 6 hours paddling, we finally reached our lunch stop, a beach that used to be a WW2 airstrip. After wolfing down my lunch, I found a tree and promptly fell asleep.
As I post this, another honeymooner couple is in the computer carrel next to me: she seated emailing her bridesmaids, he standing next to her looking over her shoulder with a proprietary hand on her shoulder. "How do you spell Harley-Davison?" she asks. All honeymooners in the news library look like this.
Kayaking the Na Pali Coast, continued
We repacked on set off at about 14.30. My secret wish that they might rearrange the kayak seating arrangements was not granted, and I dragged Jim, the inert paddler, for another two hours. We pulled out at a beach just beyond the Naval Missile Range on the west side of the island. It was a surf landing without the instructions about back-paddling off wave crests. No capsizes though, I guess again here's where having a conventional kayak would be more dangerous. Capsizing a sit-on-top is a good story but likely harmless.
The van took us through 0.5 hours of rutted track until we finally reached the highway with fish farms on our right. It would be 2 more hours before we reached Hanalei. As we passed Poipu, I pressed my face against the window longingly. Would that I did not have to recover my rental car in Hanalei, and backtrack 1.25 hours back to Poipu.
In Hanalei, after making the requisite goodbyes to the group, I set off, intensely fatigued. I was so tired that, though my eyes were open, I was hallucinating. I safely arrived in Poipu and went straight to bed.
I only got a couple photos because of the saline environment.
A little more detail about my sojourn to the North Shore. Since I was going to have drive out to Hanalei for my sea kayaking trip, I decided to drive out. I also called Dustin to see if he wouldn't mind my dropping in. After leaving a message, his mother Jackie called me back and told me I was welcome anytime when I was on their side of the island.
So at about 13.00 I saddled up the Dodge Stratus, hit 50 east and was on my way. Here are a couple photos taken precariously through the windshield:
Contrary to appearances, I was not about to drive off the road.
In driving towards the North Shore you pass through Lihue, the town I flew into. From the highway side, there's nothing particularly distinguishing about this town. Midway through town, the traffic clotted into a single lane because of road construction.
After passing over the Wailua River, the next major town is Kapaa, which driving through, feels like Anytown, USA. Even if Hawaii is the most isolated concentration of human population in the world (I believe about 2500 miles from the Continental US, and 4000 from major population centers in the East), seeing McDonalds and Taco Bell, and even an ABC store could place you just Durham. The difference, of course, is that along the way looking to your east, you can catch glimpses of several beaches that line the eastern shore.
Eventually the highway turns more inland. By Kapaa, the road feels different. The iron-rich red dirt is less ubiquitous. A sign to the right indicates the road to the Kilauea Lighthouse. Kilauea town is the northermost community in Kauai and marks the beginning of what they call the North Shore. Past that town, is Princeville, which is the main posh tourist area on the North Shore. You can see several meticulously manicured holes of the Princeville Golf Club along the highway.
The real treat is past Princeville, a few miles later, the road begins to tilt downward under a leafy canopy of huge monkeypod trees (at least I think they are monkeypod). Dappled sun leaves a mosaic of light on the asphalt. It's the kind of road for an automobile ad. At that moment, I thought to myself "well, the South Shore is nice and word 'paradise' can be applied easily, but the North Shore really is paradise." There's a road in the Gran Turismo 3 videogame that looks exactly like it, so I've had the virtual pleasure of driving this stretch at 150 mph. No surprise that Jurassic Park, South Pacific, Fantasy Island, among others have shot film on this side. The descent continues on to the Hanalei River which is crossed via a rickety one-laned bridge. Until 1912, the crossing had to be made on a raft. The flood plain for the Hanalei is considered one the largest wetlands in the state. Japanese and Chinese immigrants used to have rice paddies here, but it has recently been converted back to the native Hawaiian cultivation of taro root.
Less than a mile past is the small town of Hanalei. Aside from agriculture, it's main business is outfitting tours of the Na Pali coast and snagging the tourist traffic on the way or back from the end of the road Ke'e Beach. It's a pleasant town, it's apparent that there's more money in the area (probably from Princeville's wealthy clintele), and its cheesiness factor is low. I pulled into the Kayak Kuaui shop to get a weather trip for the next day's sea kayaking tour, and spoke with Mika, the owner about the trip and his previous paddles in Alaska.
The photos are of the the Wai'oli Hui'ia Church, circa 1912. If it weren't green it could easily stand in for a clapboard church in New England (which is where many of the missionaries so influential in Hawaii's history originated).
I then drove on to take the road to its bitter end, a winding ride down amidst the shade of trees. Though I'm sure there is plenty of tourism, it doesn't feel so as you motor down this paradisiacal path. Residences are nestled among the trees on both sides, and you start seeing more 4x4's with surfboard racks parked on the margins--the North Shore has the best breaks on the island. You cross a total of six more one-lane bridges and finally reach the terminus under a roof of Banyan trees. The Kualau 11-mile trail starts here, and then there's the popular Ke'e Beach. The banyan trees make a natural shelter for cars and people. Everyone is smiling--it seems that they've come to realize that they are in paradise. The water was populated with part-human snorklefish. At first, when you look out onto the beach, you think, just another pretty beach in Hawaii, yet when you walk out and turn around, you're presented with a stunning backdrop of mountains and cliffs. Pictures below:
I again risked my camera by crouching in the surf.
After about 20 minutes, I set back southeast to visit with Dustin and Jackie. One trippy fact is that my sister is acquainted with Dustin's fiancée. And this is a fellow I sat next to on SF-Lihue. One of her former roomates is a friend of Eugenie's, even lived with Eugenie for a couple months when she was between restaurants.
Jackie's house is near the Kilauea Lighthouse in a orderly community of horse farms that would almost recall a tropical Conneticut. Her place is on 14 acres on the top of a ridge that faces northwesterly over the ocean across some fields. They left the gate open for me, and I drove into a neatly manicured complex including a main house with a guest house, barn, and other sundry buildings and gazebos. It's quite apparent from the moment you drive in that this woman knows how to live. As I pulled in, Dustin was just finishing with a 1.5 hour massage (like I said, these people know how to live).
Though the entire complex is always being improved upon, the main house has only recently been finished. Inside is a massive, airy loftspace filled with ceiling fans, artwork, Japanese-inspired decorative motifs. There are cats and dogs all over the place. The bottom level is almost entirely huge sliding doors and screens with a veranda facing west with a large dining table and another smaller, more intimate dining table. Her upstairs is open, with a large screen Sony with surround sound system, a work area, and her bed. There is a new swimming pool (of course) and scattered throughout the complex are miniature lilyponds in large planters. There is also a massive climate-controlled wine closet, and men driving around tractors doing landscape stuff.
After finishing a joint, Dustin borrows his mother's truck and drives me down a rough track to a spot within the Kilauea wildlife refuge. Along the way, we find the dessicated remains of a frog squashed flat by a 4x4 most likely. Dustin wants it because he's been experimenting with resin for art and wants to impregnate this unfortunate amphibian with resin and include it in a new artwork. In flip flops we hop across rocks to a tidal hole flushing with the lives like a giant toilet. Within are 3 sea turtles swimming happily about. We then round a rocky point, seeing Kilauea Lighthouse in the distance (it apparently has the largest clamshell lens in the world--whatever that is), and a beautiful beach across that is inaccesible from the land behind it.
We get back and Jackie has a friend (I've forgotten her name). Pretty in a mousy way, rather New Agey. It's evident that she is Jackie's new lover--they're still in the acute hyperaffectionate stage. Dustin and I tour the neighborhood in a golf cart. At the end of its cul-de-sac is a piece of property for sale: $20M. asking price. When we get back Jackie asks if I would like to stay for dinner. I accept. She's making pasta with either meatballs or tofu balls (evidently the tofu is for Ms. Mousey-New Age). Jackie asks if I'd like to choose the wine. Not wanting to make her crack open a Grande Cuvée Bordeaux, I'm happy with her suggestion of an Italian red (now that I can't recall which).
As the sun stains the western sky, I finish grating parmesan, and we get ready to sit down on the veranda for dinner. Jackie is an earthy, evidently successful woman with close-cropped brass-colored hair and blue eyes. Dustin has a strong resemblance. She's carved out a life that is renumerative, gives her and the freedom to do what she likes (like smooching in front of guests--not that I really mind, I like the idea of women making out). You would suspect a woman like Jackie is a no BS sort, and she does strike me that way. Dustin tells me that before she lived in Kauai she lived in Aspen, and before that, Telluride. She has a genuine talent for living well.
She asks me at dinner why I wouldn't want to come out and practice on Kauai. God, it's tempting, but I have the quixotic notion that I can help more patients doing what I'm doing than working in paradise.
After dinner, Dustin rolls another one and we talk about the nearby sound of "frogs fucking"--as Jackie puts it. Soon it's evident that Jackie and her companion need some alone time, so I bid adieu with a standing offer to come have steak with them.
I speed home to Poipu because I'll need to come back to the North Shore to be at Kayak Kauai in time for the 6 am start. I still have a bit of a sore throat.
Once back, I call the switchboard to give me a wake-up call at 4.00 and set my alarm clock for the same (I've realized that 4/10 times the wake-up call either doesn't come or is a half hour late).
22.29 Hawaii-Aleutian Time
This will be brief because I have to wake up at 4 am to get to Hanalei by 6 am for the Na Pali sea kayaking.
I went out to the literal end of the road where 50 terminates because the Na Pali cliffs are too precipitous to join its other end. I also visited Dustin and his mother Jackie at her exquisite home--she knows how to live. Stayed for dinner. More details later.
Since the kayak trip should take the whole day tomorrow, I probably won't be able to post until the day after.
Now I'd better go carbo-load and go to sleep. Hopefully got some good pictures today, but haven't had chance to look.
12.39 Hawaii-Aleutian Time
I can't say I've done anything exciting so far today. I spent much of the time on the phone trying to track down a charger. I talked a couple times with Fujifilm's office in Oahu, and then Don of Don's Camera here on Kauai, and yes, I'm going to be able to get a charger which will be sent here by tomorrow. Unfortunately, I have the whole day kayaking from 6.00 to 19.30, so won't be able to get it until Wednesday.
In preparation for kayaking the Na Pali coast with Kayak Kauai's guided group, I had Dave phone in a Scopolamine script for me (thanks, Dave). The people said at the shop that sea-sickness is common and non-refundable. So I figured I'd better get my money's worth even though Scop patches make me feel a little loopy.
The rest of this morning, believe it or not, I was working on a piece for a new journal called Cell Cyle. The editor invited Joe to write a free-form commentary on our recent Nature Genetics paper. And before I left Joe asked about it so I figured it would be better if I hopped to it and sent him something. I feel somewhat torn because at once, since I'm here I feel obligated to go out and explore, on the other, I have, besides the commentary, to read the Advanced Trauma Life Support textbook and take the ATLS pre-test, scan the Advanced Cardiac Life Support book, review EKGs, and start outlining the roadmap Pearl and I are going to write up to integrate CODEx principles into projects at Duke, and ACOSOG.
One compensation was being able to take this laptop out onto the lanai (that's Hawaiian for balcony) and scope bikini-clad bathing beauties on the beach with the tradewinds swirling through the palms as two hula-skirted ladies fanned me with koa fronds...or, not.
A couple more photos (I'm sure my battery is going to expire any moment):
The first is a picture of the main street in Koloa town as it exits northwest. The storefront now houses the Southshore Pharmacy that filled my Scopolamine prescription but used to be the storefront for the local sugar plantation's company store. I had a pretty good "Kauai Pie" ice cream at Lappert's down the street--a concoction of coffee, coconut, fudge, and nuts. The second photo is more palm trees off my lanai looking out southwest.
I'm debating whether to drive to Hanalei on the North Shore later today.
I have a sore throat.
I'm sure it was the Japanese sporting a goatee sitting next to me on RDU-Chicago, he was coughing much of the way while I tried to subtly hold my breath and press myself against the opposite side of the plane begging the powers on high that I wouldn't get sick on my last vacation. Circle circle dot to dot...
18.46 Hawaii-Aleutian Time
After breakfast I decided to check out Waimea Canyon, a deep fissure on the west side of the island, and Kokee State Park that encompasses the alpine hinterland south of the Na Pali Coast. You take 50, which is the main highway that curves around the coastal margin of the Kauai like a belt that's a little too small and that the island can't quite cinch closed (the Northwest region is too rugged to finish the circle). So taking a left out of Poipu, you proceed west through valleys of sugar cane and rust-red dirt and small towns such as Lawai (no more than a crossroads), Kalaheo (a Portugese community), Eleele, dilapidated Hanepepe, and finally Waimea, the scene of Hawaii's first contact with the West. In 1778, Captain James Cook, Britain's renowned explorer, looking for the Northwest Passage in the Resolution and Discovery (Britons are good at naming ships aren't they?), sighted first Oahu and then Kauai. The next day, off of Kauai, Captain Cooke met the natives for the first time as two canoes came alongside and recognized that they were of Polynesian origin, calling them children of Tahiti. When he came ashore a few days later at the mouth of the Waimea river, the entire village prostrated themselves before him. The rest is history (including Cook's return to Hawaii the next year, this time the Big Island, where in a scuffle over a ships boat, the most illustrious mariner in history met his ignoble demise).
After Waimea, I turned north on 552 (mile marker 26), a road that winds precipitously up a spine parallel to Waimea Canyon (supposedly christened by Mark Twain as the "Grand Canyon of Hawaii"). There are several lookouts along this road pictured below:
I continued on, and turned left at the trailhead for Awa'awapuhi Trail (mile marker 17). A Hawaiian family, 3 generations-worth, was pickniking in the back of a pickup truck (pickups are ubiquitous here with the Nissan Frontier and Dodge Ram appearing to be the most popular choices). I smiled at them, but they didn't seem to inclined to converse, so I packed my backpack, set my camera around my neck and headed into the forest.
Like the tropical forests I've seen in Belize and Guatemala or even St. John, the air is redolent of a fecund odor almost like shitake mushrooms. In other ways this trail was reminiscent of the places I just mentioned, a dense canopy, moist air, squadrons of gnats whirling like dervishes. The vegetation looks familiar, though one distinguishing feature is a fern that climbs up trees and leaves strata of previous generations, now grey, dessicated skeletons, on which the younger green ferns grow.
Awa'awapuhi trail descends about five stair-stepped ridges what I would guess to be 2000 feet. Easy going on the way out. Unfortunately, the sky was mostly overcast with an occasional shaft of sunlight illuminating the trail:
Hiking down, I thought about how I have a hard time with nature photographs. Having just reviewed some pictures of San Antonio, I think I feel more comfortable with shooting man-made things, especially architecture. With nature, I'm usually at a loss for a creative angle on a shot. Then today, the light was particularly uncooperative--flat, flat, flat. Besides, I have only a third of my rechargeable left!
An hour later, after being surprised by two red-combed cocks rasping at me territorially, I emerged to the vista below. This is the Awa'awapuhi Valley of the Na Pali Coast with Banyan root-like formations of stratified volcanic rock plunging 2500 feet to the Awa'awapuhi River. According to Hawaiian legend, the valley was formed by an eel slithering its way to the sea. Addendum 2 June 2003: I should consider myself fortunate because several tourists have killed themselves shooting this spot by leaning a bit too far over the precipice. I wonder if there are any full batteries for a Finepix 4900 down there.
While coming out on the trail was painless, going back and climbing up those couple thousand feet in 3.25 miles was a gluteus-thrashing experience. I now understood why the outdoorsy couple I passed near the trailhead had that look of flushed determination. The way back isn't benign for anyone.
With a mile behind me, a mist descended on the trail, pricking my skin with its cool droplets. By mile 2.5 back, it was a fine drizzle. And by the time I was back in my car, carving turns back to 50, it was a downpour.
Such a geographically precipitous place has more weather going on at one time than the entire East Coast. By the time I actually hit 50, it was dry as a bone. In Waimea, I decided to stop at a grocery store to stock up on snacks (shrimp chips, Hawaiian potato chips, Gatorade, and water) and picked up lunch at the Waimea Bakery. Alas, they had just run out of sweet Hawaiian bread for their shredded pork, lettuce and tomato sandwich, so I had to settle for a tortilla wrapping.
Sipping on a can of guava nectar, I wheeled my way back to Poipu in my Dodge Sebring, where I am now, knackered. I'm not sure I'm good for anything else today.
I did schedule a 14 mile sea kayak trip on the Na Pali Coast for Tuesday. And surfing Wednesday. But I have to think of something for tomorrow.
6.01 Hawaii-Aleutian Time
At 5.20 (11.20 Eastern) I pop into consciousness like a cork. After I brush my teeth I do the yawn-stretch-look-out-on-the-horizon-because-I've-got-a-balcony-thing people do. Jeez, the light is coming in fast. I'd better run out and get a shot. After throwing my laptop in my pack and looping myself in a tangle of camera straps I run outside. I turn on my camera: "No Card Read" in stentorian red. I'd left the SM card upstairs in the card reader. No worries. I have an extra card in my camera bag...Except it is filled with some pretty good photos from San Antonio. Mercilessly editing I scroll through the exposures and delete a couple of the less compelling.
The pink in the sky's going. I'd better get this shot. I rush down to the beach. It faces south, so I can't get a frame of sunrise, but I hope to catch some palms against the Southeastern pinkening sky. The better angle is from within the surf. I wade in. Waves kinetically slap my hips. I think about the life being bled from my battery. I wish I could get lower. I consider ducking down in the water to get a shot between waves. Think twice about that one.
Crank the F-stop wide open and the shutter to 1/50. I'm going to have to hold this camera real still while the waves smack me. Those exposures later. Here are a few from yesterday's travels, and then off to breakfast:
20.15 Hawaii-Aleutian Time
I spent a good few hours packing last night. The complication was packing hiking equipment alongside scuba mask/fins/booties. In its first iteration all of this ended up in two pieces of checked luggage. For a single person traveling to Hawaii more than one bag is unacceptable. So I unpacked and repacked until I could fit it all in one wheeled duffle. I had to sacrifice my hiking boots.
I awoke the next morning at 5 am to the familiar sound of Alistair Cooke giving his BBC "Letter from America". This was my usual waking company in October during my Thoracic sub-Internship...except I was hearing it's 3:30 am broadcast then.
It's almost worth waking up just to drive an unclotted I-40 with the grapefruit pink mist of early summer morning in North Carolina.
Addendum 2 June 2003: A brunette in a vaguely safari-ish broad-brimmed hat in front of me in the security line turned to me asking if I thought she'd make her flight in half-an-hour. For an early Saturday morning, the line was surprisingly long. In spite of this, TSA at RDU seems to be working pretty efficiently. "Do we have to take anything out except our computers? Cell phones?" I usually just put my phone in my carry-on and run it through the machine. Supporting her weighty backpack like a papoose, she told me that it was five pounds heavier because her checked bag was overweight. I asked her what the limit was. Seventy pounds. That's a heavy bag. I'm going for six months you see, and the fee was $100. And she finally rushed through the magnetometer threshold to the world while I was held back by the magnetic money clip in my wallet.
United has a lone gate at RDU next to America West. I'm not sure I buy America West's schtick with casual polo-shirted and khaki'd airline personnel sauntering about, substituting informality for professionalism. While boarding a flight, the gate attendant, upset that no "Group 4" passengers were materializing to board the flight began bombarding the gate area with calls for her recalcitrant passengers "Come on, I know there are more Group 4 passengers than that, will you please proceed to the jetway?" Later she berated the entire terminal with calls for the last couple slow-moving passengers, threatening to "release" their seats. One turned out to be a blue-haired little 'ole lady hobbling as best as she could to the finish line.
Apparently a different company is managing United Express flights out of RDU because we weren't subjected to an Embraer Regional Sardine Can but were privileged to fly in the reasonable comfort of a British Aerospace 146. Unlike most passenger jets it has a high-mounted wing and four small, jewel-like jets. It's relatively quiet too. We descended into thick, low-lying cloud cover over Chicago as impenetrable as stirred concrete and emerged a couple of thousand feet over the railroad stockyards next to O'Hare.
To San Francisco we flew on an Airbus 320. I ate too much for lunch. I don't know why.
Looking down on Yosemite as we flew across the California state line and having just read a New Yorker profile of a young woman physicist, I wondered at how a set of rules laid down at the beginning of time (or before) could have wrought such pleasing snow-peaked mountains, citadel clouds, the undulant curves of river beds.
My layover in SF was only about 20 minutes (I had a moment of tension when the flight out of Chicago was 30 minutes late, but the pilot was given a more direct route and put the pedal to the metal). My seatmate on the flight to Lihue was an amiable fellow named Dustin, an artist living in Tribeca who was going to Kauai to make preparations for his wedding in July. Tousle-haired, wearing worn corduroys, he apparently dated one of the stars of Dawson's Creek. His mother runs a nationwide network of convalescent homes and telecommutes, so to speak, from the North Shore of Kauai. He invited me to visit when I drive over to the North side of the island, and I may very well take him up on that offer. He showed me some booklets of his work: very nice stuff involving found art, some biomorphic/primitivist-looking ink/marker work--he'd probably gag at my descriptions of his art. It's hard to do without offending the artist.
We arrived in Lihue graced by a light breeze and midafternoon sun. I bade Dustin goodbye and collected my luggage and rental car (and I just realize that I left two books in the seatback pocket. I'll have to call United tomorrow to see about recovering them).
Like Taiwan, Kauai is a verdant volcanic island, the shoreline plain is set against steep, young mountains with a dramatic patchwork of sunlight and and gunmetal squall lines. Driving on 50 West towards Poipu I was at a loss to describe the incredibly diverse vegetation, only able to recognize Banyan trees and the palisade of Eucalyptus that lines the beginning of 520 as it works south into Poipu proper. I've read now that Hawaii is a natural ecology experiment with plant and animal species from everywhere in the Pacific.
Without a navigator, I made a couple minor wrong turns, but finally found my way without undue difficulty (as you can imagine, there are few roads to confuse) to the Sheraton Kauaui. I've yet to explore extensively, but Poipu is a small town on the southern shore of Kauai known for its accessible sandy beaches. As can be expected, I'm surrounded by honeymooners and second honeymooners (or sixth honeymooners from the looks of it, and Japanese tourists).
My room is a 3rd floor balcony that looks directly out on the beach.
Idiot mistake two: Besides having left those books in the seatback, I realize that I've forgotten the charger for my digital camera. Part of the inspiration for this trip is to go nuts with photography. Having crammed on digital photographic techniques the last couple weeks, it would be extremely disappointing if I'm restricted to one battery's-worth of photographs. I've called Don of "Don's Photography" on Kauai--he tells me that he will see if he can find me a charger on Oahu Monday. Next camera: one that takes rechargeable AA's.
For dinner, I ventured to the Poipu Shopping Plaza and ate at Pattaya Asian Cuisine (the guidebook attested to its reliability and eating in the hotel seemed a cop-out). On the recommendation of the waitress (a spidery-worn, formerly pretty Caucasian woman) passable dish consisting of chicken and pineapple in a spicy coconut-milk sauce on a bed of cellophane noodles. It would have been outstanding if they allowed the sauce to reduce a bit (assuming coconut-milk reduces) and used more noodles. I did finish it though.
And here I am in the hotel News Library. Before dinner I asked if it was possible to hook a laptop to their library network and they were good enough to call in their computer person to find an extra hidden Ethernet port for me to use. As I've typed this entry I've seen newlyweds basking in the glow of couplehood, bending into one another's space, checking their email for wedding photos.
Plan for tomorrow: start scheduling a kayak trip, possibly a helicopter tour that includes a snorkeling excursion to the "Forbidden Island" (a private island owned by the Scottish/Kiwi Robinson family since the 1860s and almost wholly restricted to natives), and planning a 11-mile hike.
Tomorrow morning I'm off for Kauai and Maui for 8 days. It will be a welcome break. Normally before I visit someplace I "study up" on it--learn its culture, its history, even its geography. I've been so busy the last couple of weeks (in spite of having graduated) that I haven't had a chance. I'll be cramming on the airplane.
Today I did an interview with WTVD which will air sometime before the Race for the Cure on 14 June, and also did a group interview over speakerphone with a reporter from the Wall Street Journal. After the drill of last week, talking on camera really isn't bad at all. Basically, the key is to ignore it completely and just address your interviewer. And like most news reporters, she had the smoothness, and drawn-out, comforting intonation that makes having a conversation in spite of lights and camera easy.
I guess I'm a media slut to some extent because I really don't mind doing this stuff at all.
Still, it will be nice to stretch out on a sandy, Pacific beach watching the cerulean waves roll in, reading the American College of Surgeons' Advanced Trauma Life Support, 1997 Edition.
I'm getting the impression that getting an industry-academic collaboration to really work is like herding cats. Inherently, everyone moves in different directions. The one thing everyone has in common is that they want to get the maximal return on minimal investment--it's just the returns and investments are different for different parties. If our breast cancer project were solely a commercial enterprise, the logistics of setting it up with be so much easier because the ultimate goal would be to deliver a product that satisfies a demand and returns a profit; everything would fall in line behind that.
But what we're trying to do is something different.
We want to develop interactions that provide a return of course, but not just in $$$, but in terms of science, and the infrastructure that can translate good science into good products that will benefit patients in a real way.
With the difficulties getting everyone moving in the same direction, this may as well be alchemy. On the other hand, you can see this as a challenge, a puzzle to figure out, which depends as much on cleverness as on being able to cajole and wheedle. As long as there isn't too much hubris involved, I suppose it's doable. I truly hope this isn't a quixotic enterprise.
But having a good lawyer helps.
Thanks to my friend Ron Eng, who is partnered with my sister in their little firm Formactiv, the house was remodeled (painfully, as all remodeling projects are wont to be) last year. In exchange for the angst of being thrown out of my own house and having workpeople tramping about, I now have this space to work in.
A classmate's father, who recently retired from managing payloads for the Shuttle and worked for Grumman in the glory days when they built the LEM, sent me an application for NASA's Astronaut Corps a few years ago. I kept it, thinking that once I graduated, I might just send it in.
With that application in hand, I have thought very seriously at times of what it might mean to send it in. I spent a great deal of time (and sacrificed many trees) printing out public reports and feasibility studies on a manned Mars mission, and wondered what it might be like being a mission physician on a two year sojourn on Mars and in space. I've read Gene Krantz's autobiography, and Andrew Chaikin's excellent history of the Apollo program. No doubt much of this was daydreaming, and now I have many earthbound obligations, but the Space Program represented for me a combination of both the most visceral of human yearnings, exploration, and the idealism that makes such an urge material, whether in the form of a wooden bark, or a Saturn V.
It's discouraging that NASA is a very different institution now. The blame doesn't reside in NASA alone. Society's priorities have changed. Most respected historians of the Space Program note that the triumphant arrival of American astronauts on the Moon was a sublimation of the arms race with the Soviet Union, and without that ideological/military competition, the urge to pour a civilization's wealth and talent into such a focused goal has dissipated. And with this dissipation comes bureaucratization and diminution of ambition. And worse, the pernicious fatalism that sacrificed seven astronauts.
Perhaps the greatest indictment of this institutional passivity is Adm. Harold Gehman's statement yesterday that, supposing the danger to the Shuttle's crew had been seen with the proper urgency, the Atlantis, which was being readied for the next mission, could have been sent up on a rescue mission with an abbreviated pre-flight.
Drawing a comparison with military pilots, Gehman suggested that there is an "unwritten contract" that the utmost will be done to rescue stranded crew. No doubt this rescue mission would have been exceedingly difficult--there is no provision for two Shuttles to dock to one another, so astronauts would have had to space walk from the Columbia to the Atlantis--and risky for both crews, but the fact that there was no opportunity to even entertain the notion of a rescue is tragic.
Apollo 13 represents the best of American values, absolute refusal to accept failure and the ingenuity of hundreds of engineers and controllers to bring three men in a dead spaceship back home. What happened to this spirit? It is still hard for me to digest the notion that individual engineers can have identified danger to the crew, but that the Shuttle Program's culture accepted that nothing might be done, and fatalistically let the crew perish in a fireball above Texas.
Articles in the Washington Post and the NY Times suggest that there's the possibility that the coronavirus implicated in the SARS epidemic may have originated in exotic wild game that are served as delicacies in Asia. Researchers from China and the University of Hong Kong went to a live animal market in Guangdong (Canton) province and tested 25 animals there. Among them were six the Masked Palm Civets (an animal related to the mongoose)
which demonstrated a coronavirus almost identical to the SARS example in both their feces and saliva. A Raccoon Dog was found to have "genetic evidence" of the coronavirus in its feces (probably a PCR test), and a Chinese Ferret Badger possessed antibodies to the coronavirus in its blood (in other words, the virus itself wasn't found, but antibodies to defend against the virus were).
This evidence is highly suggestive. The Washington Post article has more scientific details than the Times piece. It reports that sequence of the coronavirus from these civets was identical to the human SARS virus save for 29 basepairs.
It is already known that the human version possesses 29.7-thousand letters in its genetic code. The virus found in the animals differs by just 1/1000th of this genetic code.
If the virus did indeed "jump" from an animal reservoir to human, the mechanism may be that the virus lost a small bit of genetic code that truncate a peptide sequence as small as nine amino acids in the virus's external shell. Somehow this modification made this virus highly pathogenic in humans.
This is all hypothesis right now, there are lots of questions to be answered. It's definitely possible that these animals were infected by yet another host that is the "true reservoir". It would also be interesting to come up with a mechanism of how this difference in 29 letters of genetic code developed.
Eating exotic wild game has a long and deeply entrenched tradition in Chinese culture. Masked palm civets are traditionally eaten during the autumn and winter to "help people withstand the winter". It's more likely that, supposing the virus made a species jump, that it occurred during the preparation of food, i.e. slaughtering and cleaning the animal, rather than eating the animal (where cooking would have inactivated the virus).
I had an interesting morning.
The news office wanted to video me doing sound bites for our individualized breast cancer prognosis paper. To distill abstruse scientific concepts into digestible nuggets, you have to think about 10 seconds ahead of what's coming out of your mouth. I don't know how Ari Fleischer does it every day.
I confess it was sort of fun...a challenge trying to assemble my stream of consciousness into something coherent. But by an hour and a half, not so coherent.
I just had a call from a woman from the New Yorker who's putting together content for an "advertorial" supplement on breast cancer. Nothing like finding myself in limbo land between ads for drug companies and editorial content--even if it's in the New Yorker.
She was talking/thinking/typing at the same time (in fact, she even forgot to introduce herself until I asked her a couple of minutes later). This makes me uneasy because misstatements are easy to make in science reporting. It's not that we should subject the general public to the stultifying prose that you see in a scientific journal, but I think science writers have to be good filters; and being a good filter entails getting the complexity of the full scientific story first and then simplifying. If you simplify right off the bat, you're going to get something wrong. I think I'm pretty good at explaining complex concepts, providing that I'm given time to explain them, but the reporters I've talked to always seem to be in a rush.
Hey, there are patients out there, we want to get things right.
Anyway, she wanted me to say how many genes we require for our predictive models. I tried to explain that we shouldn't pin ourselves to a small subset of genes because breast cancer is complex, and different features of the tumor's behavior are going to involve different groups of genes. She retorted that NKI/Bernards/Friend got down to 70 genes, and that Chuck Perou got down to a couple of hundred.
I guarantee that 70 genes will never tell the whole story for breast cancer.
This piece addresses personalized medicine for cancer in general, and covers the CODEx Project along with the NKI/Bernards/Friend group and their current clinical trials.
The Atlanta Journal-Constitution has a small piece (via wire service) on the latest Nature Genetics paper. Actually a bit surprising considering this paper is pure science and not as overtly clinical as the other.
This weekend I decided to turn off my cellphone. I have a blissful 5 weeks before my pager will be vibrating out of its holster by the minute, before I'll be the scut monkey for attendings and senior residents alike, before I wear white pants seven days a week, so I thought it would be nice to reduce the electronic interruptions of my life for at least a short while.
I just checked my messages. A lady from Asbury Park, NJ had seen a newspaper article about the Lancet paper, had somehow gotten my cellphone number, and wanted to know if her daughter could somehow take the test. I'll call her back tomorrow morning, but I don't know what to do if I start getting many such calls. I don't think I can personally answer all of these. And how did she get my cellphone number?
...Well I just called her, nice middle-aged lady just trying to help out her daughter. I think she was confusing our assay with the BRCA1/2 test available through Myriad Genetics for women at high-risk for familial breast cancers. I like talking to patients and their families, so fielding this one call wasn't bad.
Forgot to ask her if she knew Bruce Springsteen.
I must talk to people in lab about handing out my mobile number.
The New York Times Magazine has a long piece about the revival of architecture since Gehry completed the Bilbao Guggenheim. The writer, Arthur Lubow, calls this the "Bilbao Effect", arguing that Bilbao proved that showcase architecture can convert a rusty backwater shipbuilding town to a place people go out of their way to visit. Another example he cites is Daniel Liebeskind's Holocaust Museum in Berlin, which hundreds of thousands visited daily even before exhibits were in place.
All of a sudden, "unbuildable" architects like Zaha Hadid, Bernard Tschumi, and Rem Koolhaas seem to be getting commissions.
This is very hopeful, but consider this: in New York, a city that considers itself a World cultural capital, if not the World's cultural capital, the only recent building of any consequence is Christian Portzamparc's LVHM Headquarters. I suppose one could point to Koolhaas's Prada store, but out of retail architecture are not monuments made. In fact, the most monumental (at least in scale and popularity) new architecture in New York is the mainstream retail fantasy of Times Square.
Yes, architecture has revived...it's just that most of it is in Europe or Asia.
OK, it's true that Gehry has a good number of commissions in the US--most recently the Richard B. Fisher Center for the Performing Arts at Bard College--but what I'm saying is that interesting and innovative design still hasn't inserted itself in the common cultural discourse.
It still surprises me when I meet some hipster with trendy glasses and a Helmut Lang-ish wardrobe who can't tell the difference between Eames and Ethan Allen. There's a disjunction here that I don't understand. I guess the closest we've gotten to design ubiquity is the Aeron chair; now more an icon of the dot.com bust than an harbinger for good design.
Almost 20 years ago many hoped that Maya Lin's Vietnam Memorial might wake the country out of its architectural lassitude, then we wimped out and built an utterly conventional and figurative statue of three soldiers right next to it. In spite of this I'm watching what's happening with Ground Zero with a measure of hope.
Maybe I'm depressed because my favorite local design store went out of business...
This sure has been a week for papers. On the heels of last week's paper published in The Lancet, my paper "Gene expression phenotypic models that predict the activity of oncogenic pathways" is released for online publication today. Here's the link to Nature Genetics's Advance Online Publication.
Essentially, I manipulated cells to turn on genes implicated in cancer, "interrogated" these cells for genome-scale expression data, and used this data to develop robust predictive models for the activity of these cancer genes, also known as "oncogenes". I tested the models in normal synchronized proliferating cells (virtually all oncogenes have normal functions in regulating cell growth--they become cancer genes when they somehow become deranged), and in tumor tissues, with good success.
High-density DNA microarrays measure expression of large numbers of genes in one assay. The ability to find underlying structure in complex gene expression data sets and rigorously test association of that structure with biological conditions is essential to developing multi-faceted views of the gene activity that defines cellular phenotype. We sought to connect features of gene expression data with biological hypotheses by integrating 'metagene' patterns from DNA microarray experiments in the characterization and prediction of oncogenic phenotypes. We applied these techniques to the analysis of regulatory pathways controlled by the genes HRAS (Harvey rat sarcoma viral oncogene homolog), MYC (myelocytomatosis viral oncogene homolog) and E2F1 ,E2F2 and E2F3 (encoding E2F transcription factors 1, 2 and 3, respectively). The phenotypic models accurately predict the activity of these pathways in the context of normal cell proliferation. Moreover, the metagene models trained with gene expression patterns evoked by ectopic production of Myc or Ras proteins in primary tissue culture cells properly predict the activity of in vivo tumor models that result from deregulation of the MYC or HRAS pathways. We conclude that these gene expression phenotypes have the potential to characterize the complex genetic alterations that typify the neoplastic state, whether in vitro or in vivo , in a way that truly reflects the complexity of the regulatory pathways that are affected.
Published online: 18 May 2003, doi:10.1038/ng1167
I've been thinking about this since taking the Radiology elective in February. Rays isn't easy, but once you've acquired the visual vocabulary, a film can tell you a lot very quickly, often instinctively. I've always been visually oriented and find it easier to assimilate large amounts of data if it is expressed in pictorial form. One of the treasured books in my library is Edward Tufte's The Visual Display of Quantitative Information. The best known figure from this book is the famous map of Napoleon's 1812 campaign in Russia by Charles Joseph Minard,
which succinctly summarizes the geographic path of Napoleon's advance and retreat, the Grand Armée's manpower, time, and temperature.
Work in the CODEx Project hammers home that we need to think of ways to present complex clinico-genomic information that is both comprehensible, and yields up important subtleties no different than the nuances a good radiologist sees in a mediastinal silhouette.
I would think this should be an additional focus for the Project as it matures.
Taiwan reports its largest one-day increase in SARS yet. This is depressing--especially since my parents have rushed back. As head of a research hospital, my dad has to go back.
The sad thing is that I'm not particularly surprised Taiwan is having problems. Semiconductor foundries, Apple/Dell/IBM laptop manufacturing, and LCD screens are things Taiwanese are good at. Pre-emptively dealing with problems that don't have the seductive sheen of high tech or money is something the Taiwanese are not. There's also a culturally-ingrained tradition of ad hoc just-good-enough improvisation for solving problems (really no different than on the Mainland). With this sort of culture if it's just money at stake, you get breathless, percolating, euphoric economic drive; when it comes to something as mundane as public health, you get discouraging heaps of crap swept under the rug. This passivity is hurting them now.
On one trip over, I checked out an ambulance. It blew me away: basically a minivan with room for a gurney, no lifesaving equipment, and just a couple hooks for an IV. I asked my dad about EMS services in Taipei. His response: they don't exist. This is a wealthy country. There is no excuse. Here at Duke alone we have two Lifeflight helicopters and half a dozen trucks stuffed with equipment.
Compounding Taiwan's SARS crisis is treachery. For all I care, the head of Ho-Ping Hospital (the one who concealed early cases and essentially killed several of his staff) can burn in Hell.
The Taiwanese has successfully thrown off dictatorship and political repression, creating the only democracy in the Chinese-speaking world, they now have to throw off the repression of narrow-mindedness and passivity.
Front page of NYTimes.com. A bride in India, in the middle of her wedding feast, put her foot down and had the groom arrested when his family tried to extort an additional $25000 for her dowry just as the Hindu priest was warming up for the ceremony.
It's not as if the in-laws had already lined up not one, but two Sony TVs and home entertainment centers ("she specified a Sony...not a Philips"), two refrigerators, two air conditioners and a car.
Supposedly in the commotion that ensued after the in-laws' demand, the bride whipped out her cell phone and called the police (dowries, though practiced in everything but name, are technically illegal).
Strong work. With her newly acquired fame as "Miss Anti-Dowry", she's had 25 new engagement offers.
Wellspring had these handsome soft shell crabs today. I took two home and plumped them in some skim milk. In the meantime I clarified some butter. My mom had left some cranberry vinaigrette--I probably would otherwise have made some tomato/basil, but wanted to use up what was in the Fridge--so I decided to use that with the crabs. After I dredged them with flour and ground pepper, and a sprinkle of kosher salt, I fried them in virgin olive oil and a couple tablespoons of the clarified butter.
I just got my US Medical Licensing Exam Step 2 score...a Pass. I confess to a few disquieting dreams over the last month involving other interns co-signing my orders. Being in lab for several years + 9 days of desultory studying did not add up to much certainty when I walked out of the testing facility.
The report also shows the range of your performance in different subject areas. No surprise, the bands exhibiting less than scintillating performance were Psychiatry and OB/GYN. I suppose as someone who touched on Freud in his senior thesis, I should have done better in Psych, but the modern practice of psych is more about properly sticking the patient in the right diagnostic category, e.g. patient A must have symptom X for six months, plus 2 out of 3 symptoms in category Y, unless she has symptom Z, which allows us to reduce the six months for symptom X to 3.5 months depending on whether the phase of the Moon agrees with the traverse of Venus.
The nuances that differentiate "Schizoid" from "Antisocial" personalities just don't hold my interest.
As for OB/GYN, my performance is mildly surprising because I actually did the best on those questions on practice tests.
On the other hand, I have no idea what a gynecoid pelvis is.
In the end I'm glad that there are others who know and love this field.
What discipline did I do best in? Surgery. I also seem to have the strongest affinity for Immunologic Disorders as well as Diseases of Blood & Blood Forming Organs.
Interesting that going into the test I held that Step 2 represents the last time that OB/GYN and Psych can get their claws in the tens of thousands of medical students like me who will never again have to deal with OB/GYN and Psych other than calling a consult. It was exactly those two disciplines that got me--even left a scratch or two.
But I'm free now.
I should cackle diabolically, but it's hard to do in text.
David Edelstein's review of Matrix Reloaded seems to confirm my fears about the Wachowskis' ability to follow-up. Of course it's a review and its subjective, but it's nicely written and very witty (had to chuckle at the references to Jayson Blair and Cornel West). Not that I've been waiting, bereft, for the return of Neo, but I harbor the simple hope that it will be good entertainment. From Edelstein's review, it sounds like a technical masterwork without the ontologic mysteries of the original.
I was/am hoping that the Wachowski's would come up with something clever and mind-blowing, which Edelstein suggests they haven't.
I harbor the subversive opinion that Groundhog Day actually beat the original Matrix to the punch. How does the acne-scarred, sarcastic Bill Murray measure up to the smooth-planed Keanu? Punxatawney was no less an inhabited video game than the Matrix. By the second third of Groundhog Day, Bill Murray is a super hero. Since he knows exactly how the game works, he can subvert fate by being in the right place in the right time (and even impress Andi MacDowell by quoting Baudelaire). For a dingy little town in Pennsylvania, Bill Murray might as well be "The One".
The dramatic tension in The Matrix came from Neo not being aware of his potential and our slowly realizing that those hours playing CounterStrike on the internet weren't very far from Neo's reality. After that, we could start wrapping our minds around the geek fantasy that facility with CounterStrike or Quake might equate with our abilities in some social universe. So how do you restore that sense of revelation when Neo can do everything already? Bill Murray got so bored with the process that he spent part of the movie thinking of creative ways to off himself.
I guess I'll have to see for myself.
I'm listening to it right now. Since accompanying this with the HRO many years back, I probably haven't heard it more than a couple of times. I don't think I differ from many in preferring Chopin's solo piano compositions. His orchestration isn't innovative in any way--it feels like a concerto plain and simple. In spite of its lacking compositional innovation, there's still that feel of a concerto.
It's hard to convey what I mean. For me there's a sense of drama with a concerto that's probably very much tied up in my identifying with the soloist: the subdiaphragmatic whir of butterfly wings as you stand in the wings after the orchestra has finished tuning; how the heavy velvet drapes bow outwards as you walk briskly onto the stage, the hardness of your soles against the wooden stage, eyes and the expectations of the audience and orchestra focused on you; the conductor turns to you, baton poised, eyebrow raised--a silent "ready?" A stray cough echoes through the concert hall; an indrawn breath, and the orchestra starts...
This from US News & World Report. This writer really gets what we're striking for with the paper. He prefaces his piece with the dilemma clinicians face when they have an effective, but toxic drug that works for a few patients, but they don't know which patients. So they have to just go at it trial-and-error, exposing some patients to toxicity without benefit in the process.
What we hope our method will help people do in the future is to help patients and physicians understand the "which?" question.
One interesting component of the work I'm doing is that it exposes me to the process of thinking about how academia and the commercial arena interact. If anything we're doing is going to impact people, it has to be "out there". And to be "out there" means engaging the hurly-burly of commerce.
During the dot.com boom, still being in school, I felt sidelined (and even thought about blowing it all off and exploring working in VC). Sitting on the margin was a blessing in disguise. All of the era's hubris, overstating/overreaching, are lessons learned from afar.
So now we're working slowly and methodically to build what we have into something that's good for patients, that we can be proud of, and that we can put before the public in a manner that treats all partners/collaborators equitably. I'm sure we'll make mistakes and stumble along the way, but as a lifelong student, I'm willing to treat all experience as learning experience.
Academics tend to look askance at business, but the gears and levers for getting things done and truly impacting society are--for better or for worse--commercial.
Snagged my MD diploma this afternoon. In the last week I've gotten two Duke blue binders to put in the safe. I'm not the kind to hang my diplomas on the wall, but I wish they'd make them bigger. My undergraduate one is an elegant and big affair. These specimens are 8.5" by 11". Can't they splurge a bit on the lambskin? I could run-off something like this on my printer! While I robed up for the Hippocratic Oath ceremony, I couldn't abide the thought of donning that polyester extravaganza today. Probably didn't get my money's worth for the rental. Oh well.
Last night was the Hippocratic Oath ceremony. A moist May evening. As we walked from the South Clinics out to Davison Quad, the Chapel bells were ringing most academically. My polyester PhD robe was a puffy, hot, and Duke blue affair. I tried to wear it as little as possible with the heat until our pre-ceremony Class Photo session forced us to line up on the Old Chem steps for our digital firing squad. Several years ago, the class that I felt the most emotionally connected to, my entering class, graduated. As a late appendage, I couldn't feel the commonality of shared experience. The class photo I have in my room is that one.
The actual ceremony is a formal affair where the graduating seniors line up alphabetically to file into the Chapel, its organ precessing, in something akin to a marriage ceremony. The Chapel was quite full and there was David, Pearl, and Nathan on the right, Tyler and Jake hollering for my attention, Mme. Rosse waving from up front on the right. On these occasions Duke was so smart to have built a "Chapel", though as Dr. Halperin pointed out in his excellent address, it really is a Cathedral aside from its lacking a bishop.
They had us seated in rows in the front, and Dr. Halperin thundered away on the millenia-old tradition of medicine, the etymological origins of our hallowed tradition, even a close reading of the actual Hebrew of Exodus 3, and that what it means to stand on sacred ground. His interpretation was that the intent of the passage was that the ground under your feet is sacred wherever you go; thus, standing before a patient in the clinic, we must understand our sacred role. The address was a good one.
We recited the Hippocratic Oath (of course one of its modern versions) and each went up to the altar to be hooded and receive a scroll inscribed with his name and the Oath. I felt sorry for the audience having to sweat through 87 of these. And now I'm wedded to my calling.
After the recessional (more traditional wedding music, Vierne), we emerged into the soft night. I found my father and spoke with Nancy Major, easily the most warm-hearted attending in the hospital, Jake and Tyler gave me a picture frame Jake made with their photos, insisting that I come babysit them soon. Tyler comically donned my cap.
Joe and Mike were there and much appreciated for their attendance, and the Rosses where there to witness the remarkable occasion that their neighbor had actually done with school.
Here are some newslinks related to the Lancet Paper:
Our group's paper is released for publication today. The associated commentary by Sridhar Ramaswamy and Chuck Perou is cogent.
My initial response to their commentary
They query the use of metagenes (they call them "highly abstracted structures") to summarize the impact of multiple genes, suggesting that treating genes individually is enough, and that deconvoluting the roles of individual genes from metagene data is difficult--I'd venture that (1) metagenes reduce noise; (2) more importantly, they reduce this noise in the context of discrete biological functions, i.e. all analytical techniques aggregate genes in some manner, what we do is distill and heighten the signal/noise ratio for genes that share functional associations; (3) metagenes actually simplify the process of understanding how individual genes interact within functional roles because they allow us to prioritize and estimate the impact of individual genes.
They also ask what the point of predicting lymph node status is if it's an "imperfect surrogate", but the point is that lymph node status is currently the single best clinical prognostic indicator, so (1) shouldn't we try understand genomic data in this context? (2) isn't there pure scientific interest in understanding the metagenes and biology involved in lymph node status? and (3) what about those patients who within a narrow window of time at workup are lymph node negative, but are about to convert to lymph node positive? Isn't it of use to be able to identify these patients?
Finally, they off handedly say that out-of-sample cross-validation "generally overestimates" accuracy. I'm not so sure this is a proper generalization to make. If we "locked" our predictive model and just cross-validated the samples, perhaps. But we cross-validate not only the samples, but the model. This is about as stringent as one can get. Naturally we are actively augmenting our sample size and hope to be working with thousands of samples in the near future.
Reasonable questions. Perou and Ramaswamy do find common ground in that gene expression data all point to the fact that metastatic potential is present in primary tumors.
The NYTimes has this article on Elizabeth Dole's first few months in office. Apparently she has spent all of her time engaged in serving her state rather than parlaying her connections and position to maintain a high profile in the Senate. It seems that many opponents are befuddled and even disappointed by her going to ground. The accusations of Dole being a carpetbagger hardly apply when she has turned down interviews in every major print and TV outlet and spent all of her freshman time visiting tiny obscure hamlets throughout the state. She only consented to her NYTimes interview because it would take place in Camp Lejeune.
After her bravura performance at her husband's nomination for the Republican ticket, I confess that I thought her a bit slick, and calculating; but her doing the seemingly mundane gruntwork of taking care of her constituency seems to force a reevaluation. A political consultant was left saying, "She hasn't done anything that Democrats could much attack here, much as we'd like to." Another disappointedly wondered if Dole was "ever going to move out her husband's shadow?" People forget that Bob Dole was respected on both sides of the aisle because he was an excellent Majority Leader who got the job done rather than cultivating political division, helmet hair and inserting both feet in his mouth. Apparently, his advice to his wife has been to do the same: do the job you are paid to do--that means getting Federal recognition of the Lumbee Indian tribe, working on a buyout of tobacco farmers... None of this the heady stuff of national politics for someone whom many considered the front runner for the Republican presidential nomination until W. came to prominence.
Several years ago, Henry Louis Gates wrote a glowing, even hagiographic profile of Dole in the New Yorker. to the point that it looked like she had his vote if she ever made it to a national election. There's probably more than meets the eye.
Dean Williams, Ralph Snyderman, & Huntington Willard published this editorial in Science. The leadership in the Medical Center has chosen the concept of "individualized" medicine as a rallying point for research. From the angle of genomics, I published this editorial in the Chronicle, December 2001. I think such an approach will be the important next step in medical care. Everyone is very aware that assigning a patient to one prognostic bin versus another can be arbitrary. A woman with breast cancer and 0 positive lymph nodes is treated differently than a woman with 1 lymph node. These sorts of tools are very "low resolution"--on average they work, but there is significant room for improvement. And because these bins are large, a patient isn't treated as a distinct entity, but as an undifferentiated member of a bin. What we're harnessing genomic information for is to get away from discontinuous categories and move into a continuous space that allows us to predict a woman's individual prognosis as a point estimate for her, not as a member of a group.
Ultimately, this sort of individualization will revolutionize how we prescribe drugs, how we determine cancer treatment protocols. It will even allow us to "recover" drugs that had been shelved because on average they failed to work for large population, but we will now be able to tell specifically for whom that drug is actually efficacious.
Patients instinctively recoil from being treated as merely being a part of a population, they want to be addressed as a singular person with singular health characteristics...thus the wackiness of plying Whole Foods' herbal remedy aisles, which is symptomatic of Big Medicine's failure to answer personal needs.
Next week, our paper which demonstrates some first steps in this direction for High- and Low-Risk breast cancer patients as well as for predicting lymph node status will be appearing in The Lancet.
I've ridden in one of these. Our college orchestra's Eastern European tour included a sojourn in the soon-to-be Czech Republic. I remember my host family arriving in this clattering, plastic car, considerably noisier than my neighbor's John Deere rider mower. Now, according to The Guardian, a company wants to perpertrate this conveyance on Africa, formerly known as the Trabant, and dub it the "AfriCar". Its chalky, slightly fibrous and sun-bleached red finish left an impression, but I didn't realize that its body is made from "a blend of phenol [carbolic acid] and compressed cotton named Duroplast", or that its rubber insulation is "prone to melting and 'leaking like a sieve'". The advantage is that it's "unbreakable", and, assuming the impossible happens, "the car was designed for 'any roadside mechanic to fix'".
Who needs a Hummer?
I had read the novel a couple of times in Middle and Upper School. Filtered through those adolescent impressions, in spite of its undoubted importance as a critique of totalitarianism, 1984 had always felt like science fiction to me. It's suffused with cold, and inhabited by the Byzantine apparati of oppression. This always requires erecting contraptions for the sake of atmosphere and plot that just feel elaborate and busy to me. I wonder if going back to it as an adult might affect my perceptions of the book, whether the vision of a prole singing would impact me more than its steel and concrete drabness.
Interestingly, in his introduction Pynchon calls the internet "a development that promises social control on a scale those quaint old 20th-century tyrants with their goofy moustaches could only dream about." I find this odd and paranoid, not because of the accepted wisdom that the internet is a democratizing influence--that is a cliche perhaps--but because Pynchon's predilection for rooting out secrets and subversiveness should have him reveling in a hurtling etherworld where hackers deface government and corporate websites, war-chalkers root out wireless networks, bloggers aggregate and debate. The WASTE symbols that Sixties college students used to scrawl in university bathroom stalls reminds me of the chalk iconography of war-chalkers. Thomas should get out on his computer a bit more.
It's ironic that the late 20th Century dystopian vision of a dehumanized police state with its accoutrements of technology is entirely wrong about the challenges that confront us now in the 21st. Rather than Progress running roughshod over basic human rights, it's reversion to Medievalism that threatens individual freedom. I wonder whether we are philosophically equipped to handle this challenge when for the last 80 years our energies were bent on critiquing and opposing Fascism/Stalinism/Maoism. This ideology of stentorian music, posters and statuary of musclebound mechanics and industrial production wrapped up in the trappings of Science and Progress is taking its last paradoxial and asphyxiated breaths in North Korea. If anything, science and progress have helped rather than hurt us. It's the wild-eyed fundamentalist plotting by firelight in a shack or a cave (whether he's in Afghanistan or Montana) with antiquated visions of what will buy him a place in heaven that frightens me more than the spider-like probes of Minority Report. I can opt out of registering my email address; I can turn off my cell phone. I can't prevent a 767 from colliding with my workplace. Not that we should be lazy about the issues of privacy that the wireless and internet world have spawned. But I think we have a vocal and vociferous enough group of technophiles defending the privacy border.
There are those that would argue that we shouldn't stop short with Medievalism being the greatest threat to modern society because the response to that threat entails aspects of that technological police state. And I'd be forced to agree up to a point. The biggest difference is that we have mechanisms for self-examination and public debate about whether we overstep in our desire to protect ourselves. For those captive in the Middle Ages, there is absolutely no legitimate and protected manner to make this critique.
Though Orwell pitched his story 40 years into the future, what he was really responding to was the here and now; i.e. what he'd seen as an disillusioned Republican in the Spanish Civil War, the brutalism of Hitler and Stalin. There is nothing really prescient about 1984. And, as Pynchon points out, he missed the boat on fundamentalism....to be continued...
The Washington Post has an excellent report on how the CDC is responding to SARS here. The Post seems to be publishing more articles that are straight reportage without much of a polemical bent. There were some very well-written and atmospheric reports from their embedded reporters during the Iraq conflict, and this article seems to be more of the same.
I really enjoy pieces that give you a feeling for the texture of life in a milieu you haven't been exposed to, whether it's a firefight on a road in Iraq or the aroma of new "furniture carpets, and paneling...off-gassing their heady hydrocarbons" in the new Emergency Operations Center at the CDC.
As someone who's seen both sides of the Pacific, one thing I see Americans do well in comparison is respond to crises. There's a deep vein of pragmatism in this country that results in competent specialists like Virginia's Fairfax County Urban Search & Rescue Team that's been designated by USAID as a response team for disasters across the world. Indeed, when Taiwan had its earthquakes a couple of years ago, the VATF were the ones to show up and help them deal with search and rescue. Same with the CDC. I'm sure they're not perfect, but if I had to choose between China's and ours, the choice is easy. Walk into a Home Depot and you'll instantly find dozens of people who know how to do a job right.
Chinese culture tends to emphasize getting something to just work by any means, whether that entails doing it the right way, or doing it in a way held together by bubble gum and rubber bands. There's also a tendency to sweep things under the rug that cannot be handled ad hoc, as has been the case with SARS.
China clamors to be accepted on an equal basis in the international community, but continually undermines itself with amateurishness. Their holding the plane and crew after their incompetent fighter pilot collided with a US military observation aircraft, their hesistancy to engage North Korea in discussion (until recently) with the US, and their failure to report and respond to the initial stages of the SARS outbreak are not actions of a modern nation aware of its obligations to the international community. If they want to be a WTO state, they ought to act like one. Ironically, their actions have probably cost them more economically than if they'd openly acknowledged this new disease from the beginning. They're a superpower only by virtue of their being a nuclear power and their massive population.
At least they're letting the WHO go to Taipei (which has been a major politcal bone for a long time).
Give me the Poles or Czechs any day.
Columbian Mesa de los Santos, ed to setting 6.5, well into the second crack. A wisp darker than a Full City . I'll drink some after dinner.
Whenever I ran into an attending or anyone medical-related, they'd ask me "so what are you doing before residency starts?" Lacking a strong response to that question, I began thinking about what I might do. Should I brush the dust off Tyler2, my trusty sea kayak? (American history geeks will understand the reference). Perhaps take it, filled with a week's worth of food, to the Outer Banks and explore salt marshes and haunt Portsmouth Island? Maybe if I wanted a more low key break, rent a house in Corolla, or perhaps Bald Head Island, and just read and write. Then there is the Offshore Sailing School class in Tortola, BVI. Bora-Bora even flitted briefly across my mind.
In the end I decided to do what 80% of honeymooners decide to do: go to Hawaii. Since I'm newly-wed to the life of a surgical intern, why not? So I've appropriately drained my parents' Frequent Flyer fund (United Airlines' Premier Executive Elite Gold Member Special Private-Line-Only reservationist was rather surly in spite the rigmarole of a special treatment and a special 1-800 number), pre-paid the hotel and car rentals, and am on my way to Kauai and Maui. I plan to be surrounded by nubile hula dancers necklacing me with fragrant orchid leis and plying me with umbrella drinks and Kona coffee (I'll probably arrange a day trip to the Big Island).
Don't let me down Hawaii.
I tripped across William Gibson's blog and found an interesting comment here. I haven't wrapped myself in the blog universe, but agree with Neuromancer's author that the relaxed, colloquial nature of blog writing doesn't meet the stringency of what we traditionally call good writing. People tend to be conversational and self-conciously irreverent. But then when I want eloquence I don't go fishing for it on the internet. I wonder if Shakespeare would have kept a weblog.
For instance, I see the F-bomb dropped a lot. I've nothing against the F-bomb, and often find some amusement in its employment. I think I'm still subliminally shocked by its appearance in print and get that thrill of taboo blaring out from my laptop screen, but it's a cheap thrill.
Since Saturday I've been spasmodically fiddling around with utrinque paratus. Evidently, this site has been neglected for a long time, but here I was with time on my hands, the realization that I was 0.63 versions behind with Movable Type, an obsessive desire to figure out a way to post on utrinque paratus what I'm listening to on iTunes currently. Amazing how a day can skulk silently away while you're hacking on the computer. I can see his bald head rounding the corner.
It's fun. Bizarre how I can take a photo, manipulate it, create a new banner and have it posted on a server based...where?--I don't even know where my host is based--and have it lighting pixels on the internet in 10 minutes.
What a different world internet publishing has wrought.
This is oriented to Movable Type users who have the TrackBack function built-in. Normally this is a cool way for weblogs to easily refer to one another by pinging to a .cgi script. The latest version of Kung-Tunes takes advantage of this by using the "HTTP POST" method to ping iTunes info to the mt-tb.cgi in your Movable Type installation.
So, once you've downloaded the app, go to your Movable Type website's control panel and select the appropriate blog (assuming you have a couple). In the sidebar on the left, select "Manage/Categories" and create a new Category called "nowplaying". Click on the "Save" button and wait for the screen to refresh. Now "nowplaying" is added to the list of Categories you already have running. Click on the "Edit category attributes" link next to the "nowplaying" field. Here you can add a description of "nowplaying", but the key is to scroll down to the section "Incoming Pings" and click the "On" radio button for "Accept incoming TrackBack pings?" Click the "Save" button. The screen will refresh and you'll see below the "Incoming Pings" section a new section headed "Trackback URL for this category". In the box below will be an URL that looks something like:
http://www.yourfavoritewebsite.com/mt/mt-tb.cgi/4This will vary depending on how you installed Movable Type, and the numeral after mt-tb.cgi will vary (I think). Copy this URL into your clipboard.
Now go back to your blog's management sidebar and click "Templates" and select "Main Index". At this point, for prudence's sake I'd copy the original "Main Index" template to TextEdit in case you goof. Now Kung-Tunes's author doesn't recommend just cutting and pasting the HTML that inserts your iTunes track info directly into your template, but assuming your template HTML is straightforward (e.g. the standard column layouts), this is quite doable. I have a heavily modified version of one of the templates that come standard with Movable Type and knew exactly where in the right hand column I wanted to insert my "Now Playing" section. Here's how it looks for me:
So the "MTPings category" is the new "nowplaying" category we created where "lastn" refers to the number of most recent tracks you've listened to.
Below are the tracks I'm currently listening to on iTunes 4:
Now open Kung-Tunes and select the "Preferences" panel from the Kung-Tunes Menu. Make sure the "Upload" tab is selected and that the "Upload Method" is HTTP. Paste in the TrackBack URL into the "URL:" field. Make sure you delete the "http://" from that URL. Kung-Tunes automatically inserts this and otherwise you'll be left scratching your head why you keep on getting "Type 6 Errors" whenever you try to upload iTunes data to your blog. It took me an hour to find this boneheaded error. Click the "Save" button. As is advisable with any program, if a "Console" is available, open it if you're having trouble; it's much easier to spot silly syntax errors if you can see what the application is telling the server.
Otherwise, the defaults in this panel are fine. Next, select the "Formats" panel from the menu and delete everything from each of the fields and paste
into the "Format for currently playing track" field. You can play around with the tags later if you want to customize how the tracks are formatted. Also make sure to enter your own blog's name where you see "blog_name" above. It's the name you specified in the Movable Type control panel. Click the "Save" button.
title=itunes&url=foo&blog_name=myblogname&excerpt=^t by ^p (^a)
You should be set now. Fire up iTunes. Kung-Tunes should show your track info. Click the "Upload" button and a small bit of text with your track info that's saved in your /Library/Preferences directory should be sent to your Movable Type installation's "mt-tb.cgi" and published on your website.
This primer isn't radically different than the author's own directions, it just clarifies some points.
Since it took me a bit of time to get it to work (more out of my own dunderheadedness) I thought I'd add a brief tutorial here.
A week from today I'm done. It only began to sink in when I finally tracked down my AWOL PhD diploma, and picked up my robes, hat and hood. Up to this point as I've finally kicked past the last few milestones, I've tended to view them with some sense of anticlimax. Last August I didn't make any real effort to bring my family to my PhD defense and it was Joe who encouraged them to come. For next week's MD activities, I really would have been happy to sneak through the whole process, but alas, they're here.
Walking across the Quad, my diploma in one hand, a hanger-full of academic regalia in the other was the first intimation that I've actually done something. These are all symbols, but it's finally palpable that I've finally laid down the foundation, and now it's time to get to work and build upon it.
March 20th was a rain-spattered Match Day. I'd scrubbed out of a breast reconstruction case, put on my white coat and tie and wandered down to the Searle Center as thousands of Duke seniors have done on the third Thursday of March. There were only a few people yet. Most were in street clothes having had the day off. I suppose I should have asked for the same, but sitting at home, bored didn't appeal to me. Having been only a late appendage to this class made the day less momentous I think. I only knew the few people I shared rotations with and a few holdovers from the class I had TA'd in Medical Genetics. I ate a lot of chicken tenders.
Within ten minutes the room was milling with nervous 4th years. It does seem that everything about medical education encourages high sphincter tone. We're either apprehensive about our grades, which medical school accepts us, whether we survive medical school, then the Match, then residency, the fellowship, the Boards, on and on. There was Suzette in a Burberry hat, there was Patty saying that she felt like projectile vomiting, Daniel waiting for Emily to show up, Sheleika looking far more relaxed than she had in the SICU, Shy to witness the proceedings and provide moral support. They had these really huge chocolate covered strawberries. I had about five--they were in front of me; I couldn't help it.
And then here I was, putting a dollar in the pot, shaking random hands and collecting the envelope that would tell me where I would spend the next at least five years. After the 87th person had been called was the signal to open our envelopes: "Contratulations, you have matched!" in bold on a laser-printed page from the NRMP, "General Surgery, Duke Univ Med Ctr--NC". What I'd wanted.
It all begins soon. I confess that I'd rather live and work in San Francisco or Boston, but work in the CODEx Project is so promising, and I'm to have some sort of faculty position in the Computational & Applied Genomics Program of the Institute for Genome Sciences and Policy, that leaving seemed counter-productive. Anyhow, I actually don't mind the infamous White Pants of the Duke surgical Intern and Junior Resident. We may indeed be the last to require them, but aside from having to find white boxer shorts, I like the idea of minimizing early morning decision making.
You did everything just about right. This doesnít mean everything is absolutely perfect (impossible so long as we are human), but there is nothing I look back on with regret or see as a vast, uncorrectable error. Iím not scarred, I can advance through life without thinking Iíve been hobbled; others have told me that my parents ďraised me rightĒ, and I suppose thatís as good a validation as one can find.
Lucy thinks so too.
I fondly remember your making the costumes for the Hobbit. I fondly remember you bursting into our room one morning with the smell of blueberry muffins wafting in, singing the Muffin Man, or making a papier-m‚chť relief map of Great Britain with me.
You designed a beautiful environment for us to grow up in; literally, and figuratively. Thatís why I continue to chase beauty now. I donít necessarily mean in a girl, but in life; finding those moments in life and work where things fit together just right, and are balanced, and elegant.
I donít pretend to say that this inculcated characteristic makes things easyóI want the esthetically pleasing situation where most will settle for the mundane, but thatís the point, isnít it? If you donít give a damn, itís pretty easy to be content and settled, but drabness and complacency arenít our lot.
The only thing I can think of that we can hear more of is what is worrying you or stressing you. And you shouldnít worry too much about our significant others. That issue will take care of itself.
And perhaps you should take more time off? Traveling? Visiting me or Eugenie?
I spent the Thanksgiving holiday with Dax and Kelly and their girls Abigale & Lily. When I'm a houseguest, I try to leave a light footprint and attempted to help out as much as possible keeping the girls (2.5 and 8 mos) occupied. Now I've spent a lot of time with friends and their kids, and gosh it's hard work. I'm not sure I'd be up for it, especially looking down the gaping maw of residency.
Above, more pictures of my library. My shelter. I've gotten some new chairs for itóMeda chairs (much handsomer than Aerons). It's enamored me so much the other rooms in the house are neglected.
Sick today. I suspect that Small-Head Dave shed some malignant little viruses when he invited himself over for the Sopranos last week, and they've had a nice few days to incubate, deposit themselves in my tonsils and precipitated a prostaglandin storm. Bastard. Constitutionally, I deal with illness rather poorly. I think my system overreacts to infections and sets off a torrent of cytokines and prostaglandins that render me a creaky, achy, sweaty wreck of a person.
Today I've taken 650 mg Aspirin, 600 mg Celebrex, and 400 mg Ibuprofen. Who wants to bet that I've burned a hole in my stomach? There probably isn't a single functional cyclooxygenase molecule in my body. And I still feel flu-y.
Surg Path is boring the crap out of me. I really like pathologists, but could never be one.
I missed the Leonid meteor shower. I heard that this was supposed to be the best it will be for the next century. Slept through it. Wasn't even aware of it. A once in a century event passed in the early morning hours. Wonder what other momentous events I've missed because I was either never informed, or lacked the perception to remark them.
One thing I've also learned over the last few months is that my ability to read people is really rather limited. My intuitive IQ is probably 50 or so. Matters are worse because I've always thought it was 150. Worse to overestimate your acuity than to be stumbling around myopically thinking you're the one-eyed among the blind.
Over the last couple of weeks, I've finally "moved into" my library. Nothing could be better. Surrounded by my books with my computers close at hand.
This is my space.
Huguenot Cemetary, Dublin, May 2002.
A picture taken on my trip to the Oncogenomics 2002 meeting.
The first time I see Mr. Rawlins is in the operating room. He is already asleep. You can tell that he used to be a big man, but he is sick, and there is a pruned thinness in his limbs. He has advanced stage IV lung cancer, and his right lung is bound in a tight capsule of inflamed tissue. He cant breathe and we are going in to free his lung up to make him more comfortable. The procedure, in its sanitized way, is called a right video-assisted thoracoscopic decortication, which means that we make 3 small incisions in Mr. Rawlinss side, inserting a small fiberoptic camera in one, long, tweezer like instruments through the others, and clean up the mess. The attending surgeon Im working with is a virtuoso at this sort of thing.
Mr. Rawlinss right chest is filled with bloody fluid and debris. I drive the camera as the attending and cardiothoracic resident clear it out, and dexterously strip off the suffocating binding cancer has wrapped around his lung. And were out again.
Later, in his room, his daughter is sitting on his right next to a window that looks out onto the concrete span of the parking garage.
How are you feeling Mr. Rawlins? He opens his eyes. Their blue is a startling contrast to his pallid skin and tousled white hair.
Tell him how youre doing Daddy,
All right, he looks surprised and closes his eyes.
Can you cough for me, Mr. Rawlins? I have to check for an air leak. As I inspect his chest tubes, I describe to her what we saw in the operating room. She wants to know. People like to know more, even if the attending has already spoken to them. Its comforting for family that other people know whats going on.
Ive just come back to clinical life. After several years pursuing a doctorate in a basic science lab, its back to patients and the daily deluge of morning labs, CT scans, and chest X-rays. Returning for my last year of medical school is a shuddering culture shock. Im older than most of my residents. A third of the drugs they use are new to me, and theres an urgency on the wards that my former laboratory flasks of tissue culture cells just didnt demand on a daily basis. On the other hand, where our goal in lab was to generate knowledge novel enough to merit publication, the sort of knowledge required of me as a medical student, intern, or junior resident is textbook knowledge and clinical pearls shamanistically memorized and regurgitated by generations of trainees. Ive shifted gears, but my clutch work is not perfect, and I can hear the gnashing of the synchros.
A short, polyester blend white coat reminiscent of a ice cream delivery mans marks me as belonging on the bottom rungs of a long ladder of clinical training. The Rawlins family doesnt care though, theyve gotten used to my waking them up at 4:00 every morning, and stopping by every afternoon. Mister Rawlins happily complies when I ask him to cough for me. We talk about his golf scoreshes a scratch golferand his other daughter, the older one, tells me about the farms and hiking trails they have around their place in Virginia. Im supposed to come up and visit them sometime.
One afternoon, I find the medical intern on the floor drawing a blood gas out of Mr. Rawlinss wrist. The intern is cross-coverage, but its clear that Mr. Rawlins is more disoriented, and less responsive to people. They transfer him to the intensive care unit that night. Over the next weeks he is cheerful when I can wake him, but more confused.
Do you know where you are, Mr. Rawlins? We have to ask silly questions like this because they become less straightforward the sicker the patients get. He doesnt remember.
Whats your favorite hospital? No one should have a favorite hospital.
Duke, he says and smiles brightly.
Hes fading. Soon hes transferred back to a regular room. There are dozens of get well cards taped to the walls. Theyve taken away the heart monitor. Theyve stopped drawing labs. He now has to wear an oxygen rebreather mask and his chest retracts as he gasps for air. The older daughter is distraught. More family are in town.
One evening, in a spare moment, I go upstairs to check on him. The room is dark and empty. Theres a gauze wrapper on the floor. Up front, a nurse tells me that hes gone.
The wards are acquiring their evening hush. The elevator whispers open, its empty and I enter slowly. Still in my hand are the stapled index cards on which Ive recorded Mr. Rawlinss vitals, labs, and medications for the last few weeks on the service. I slip his cards into the inside coat pocket where I keep retired index cards. Theres a momentary loss of gravity as the elevator accelerates downwards.
Its bad and good to be back.
There are times where, in the span of a few months, you experience seismic changes in your life. I finished the Ph.D. on 8 August, amidst much turmoil not related to my work. It was a rush to the finish so that I could start the late August-September block of medical school.
One week, I'm waking up at 7.00 in the morning, and going to lab in jeans, now I'm throwing on a tie and arriving at the hospital shortly after 4.00. My SICU rotation was my baptism back into clinical life, and for that month, my life centered around one floor and 16 beds.
The texture of my life is so different now that I'm not quite sure I have a handle on it. Even as an attending, you're able to maintain some distance and perspective about medical science, but at the intern/resident level, it's really life in the trenches. Every moment of your life is devoted to the day-to-day minutiae of managing the patients on the floor. This is the system that stems directly from Osler, you start as an apprentice, and slowly work your way, as years progress to a wide and comprehensive knowledge of how to care for your patients.
I have a lot to learn, not even because I've been away from clinical training for so long, but by the simple fact that I'm just a 4th year med student, many months short of an MD and many years short of Board certification.
Interestingly enough, I remember a great deal. The biggest difference is that knowledge acquision is different in science than it is in clinical medicine. At the med student and resident level, there's no substitute for just knowing. And just knowing is essentially memorizing. When you're confronted with an acute heart attack, you don't have time to logically think through the physiology of thrombus formation, tissue necrosis, and the effect of these things on electrical conduction in the heart. There fifteen things you have to do, and you simply must know them and do them. In an abstract you can lessen the load of clinical knowledge by leavening it with understanding the physiologic/molecular/anatomic features involved. Still, there is no way that you'll know that the half-life of pre-albumin is 3-6 days unless someone's told you so.
In science, however, the mode is knowledge creation, and your time is devoted to rolling back the margins of what we don't know and generating something new (that hopefully the clinicians will have to memorize one day).
Well I'm back. So much can happen in the span of 5 months. I finished my PhD in Genetics on 8 August. What a turmoil-filled couple of weeks that was. Not because of scholastic issues, but the layering of personal/romantic/family problems on top of those.