In one of the great chains of fate, five of my very closest friends beyond family are connected in direct, personal linear succession: missysedai introduced me to silmaril, who introduced me to Jesse, who introduced me to aelkiss, who introduced me to niquerio. Five special friends in a life richly blessed with friendship, all connected one after the other in a narrative of coincidences that no man could possibly be luckier to recieve.

And as I've had the privelege of saying a little about missysedai, silmaril, aelkiss and niquerio in years past on each of their birthdays, so today I do as well for Jesse. :-)








Years ago, I captured the moment I first met Jesse in a LJ entry. Capturing such moments for all time -- for myself, if noone else -- is one of the primary reasons I write (and take photographs). At the time, I wrote:

After rehersal broke up, silmaril and Breno...stayed behind to work out a few more melodies, while I had the chance to chat merrily with Silmaril's good friend Jesse, a woman every bit as multi-talented as silmaril herself. Jesse belly dances. And ball-room dances. And plays a whole raft of percussion instruments. And packs eight folks worth of energy into one vivacious woman. silmaril had introduced me to [Jesse] specifically, as [Jesse] happens to be graduating from U. Md and beginning her PhD. in the fall up in Wolverine Country, and most certainly, Markland's loss will be [our] gain.

Oh, I had *no* idea how true that was going to become. :-)














There was the first night, after the first Cynnabar Revel, when we retreated afterwards and told stories and laughed until it hurt to breathe. There was the time after our first Michigan RenFaire when she started dancing and made traffic slow to a crawl. There was the fungus milkshakes and ladybugs and cookie books and bakes and sharing together in the grand Michigan Theatre a triumphant departure from the Grey Havens. There is every story which each thumbnail above links to. And countless more.

Jesse's coming to Cynnabar did mean the coming of many, many adventures shared with so many friends. But it also meant many moments we shared together, just the two of us, on the way to a friendship that has been one treasure among many. I had predicted that first night that we were going to be very lucky to have Jesse join us. I simply had no idea how much so that would be true. And one of the constellation of joys that has come from that first introduction has been the chance to introduce Jesse in turn to so many of the rest of you, from missysedai herself to this most recent merry dinner in Berkeley and dscotton and scifantasy and dawntreader42.

Like for so many others, the journey continues, and will continue, all things willing, for years to come. The past is but prologue, to the adventures that yet lie ahead. And on this day, I'd like to take a moment, to celebrate and cheer a special day for a special lady: Happy Birthday, dear Jesse. And many happy returns. :-)

Twice today, our clocks will read 12:34:56, on 07/08/09.

That's neato. :-)

Following up yesterday's entry about caves full of wine, today, another story from the "end of second year of residency" California adventures. Enjoy. :-)





We chased the setting sun as far as we could go.






We drove west until the trees gave way to the moors. Until the summer heat gave way to ocean wind. We drove until we could drive no further, then hiked until the path came to an end. And there at land's end, at the furthest west-most point of land from San Francisco, we watched the sun turn the Pacific sky into brilliant orange fire.




As always, click thumbnails for full sized images



Point Reyes was one of dawntreader42's many brilliant ideas. In five previous trips to San Francisco on medical and scientific business, I had been to many points throughout the San Francisco Bay area. But I had never been north of the Golden Gate; and I didn't even realize the beautiful Point Reyes National Seashore area even existed. And so it was we decided to go north along the spectacularly beautiful Calfornia Highway One.

prophetkristy and I had enjoyed immensely the breathtaking beauty of California Highway One when we went south to Monterrey and the great aquarium there almost two years before. Now dawntreader42 and I took our rental car north across the Golden Gate on the same coast-hugging road. The car's engine was more than powerful enough to go up the inclines. The tiny turning radius of our compact car made navigating the twisty highway a breeze. And armed with a battery of navigational devices and dawntreader42's extensive pre-trip notes, we wound our way up the coastline, from Muir to Stinson Beach and into the heart of the Point Reyes peninsula, sharing merry conversation the whole way. No schedule, no demands, no pressure, just two good friends going wherever road and beauty led.

(As a side note, dawntreader42 and I discovered we make marvelous travelling partners. We're both by personality extremely adaptable people. We both deal very calmly and cheerfully with glitches and changes in plans. We both don't let setbacks bother us. We're both people who believe in meticulous preparation beforehand, so that we know enough and are armed with enough contingency plans, that we can quickly shift gears depending on what comes up. And we both manage to have a great time, no matter what does come up. Plus, she's smart, witty, imaginative, geeky, and funny. Of course we had a wonderful time. :-) )





Click above for panorama


Driving up California One torwards Point Reyes, we saw a sign which pointed off the highway for a "scenic overlook". That seemed neat, so we pulled off, and thus discovered the spectacular Muir Beach Overlook. Even in fog the views were breathtaking, especially at the cliff-point overlook, sheer rocky cliffs plunging down on three sides to a spectacular near-270 degree view of the Pacific Ocean.





One could easily see why the Army had chosen prior to WWII to fortify that overlook with a series of bunkers which remain to this day. Warships attempting to breach San Francisco Bay would have been caught between the fortified observers at Muir Beach Overlook to the north, and Half Moon Bay to the south. Using the distance data provided by those spotters, the exact position of approaching warships could be triangulated -- and the battleship-class guns of Fortress San Francisco brought to bear. The same sheer cliffs would have made any attempt to take out said outpost by direct assault a harrowing enterprise. A facinating bit of history admist beautiful surroundings.







The cool afternoon fog had lifted by the time we reached the tiny coastal enclave of Stinson Beach further up the highway, where we decided to pull off the highway again. A long, glorious strip of ocean beach revealed itself, and after duly noting dire warning signs we kicked off our shoes, got silly in the surf and sand, and watched the surfers tackle the waves.







Our ultimate goal was to reach the Point Reyes Lighthouse in time for a lazy sunset gourmet picnic dinner (courtesy of a Whole Foods in Mill Valley on the way up from the Golden Gate). dawntreader42 had picked out vegetarian spring rolls and risotto cake, goat cheese and hummus and hard-crust San Francisco sourdough -- the makings of a fine repast. We had worked out the timing backwards from sunset, and using her pre-researched directions, cross-confirmed with the ranger station at the gate of Point Reyes, her iPhone, and our GPS, the whole plan came together beautifully.

The Point Reyes peninsula is actually geologically distinct from the rest of San Francisco. It is actually a tiny bit of land slowly sliding up the western side of the San Andreas fault past San Francisco. And so as we drove from the wooded valley of Olema, onto the highway of the peninsula itself, the scenery once again changed dramatically, into rolling, windswept coastal moors. By that point in the day, there was no crowding. There were, in fact, virtually no other cars on the road; we had the whole whole vastness of Point Reyes virtually to ourselves.






Led on unerringly by our GPS navigator, we rolled across the plains up onto the high bluffs at the tip of Point Reyes, until we ran out of road. At that last parking lot, we left the car behind and hiked down the paved trail, past wind-blasted trees and spectacular overlooks, until the trail too came to an end. And there, at the very tip of the peninsula, we finally reached our picnic table at the end of the world.







We had already long before chosen to revise our dinner plans. With amusement, we both noted that we hadn't quite thought of *everything*: specifically, we hadn't taken the ocean wind into account. This far out west from the mainland, this high up atop Point Reyes, the powerful ocean winds had sculpted plants and rock into spectacular formations. The powerful ocean wind would also threaten to blow away any picnic we tried to set down on a table. And so we had already decided to defer actually eating our picnic until we reached the comfort of our hotel later that evening, and instead just enjoy the roar of the waves, the fanfare of the sky, the company of a dear friend.

We watched as great ocean sea-birds wheeled over the beaches. Watched the magic of sun and sea and horizon. Watched with delight as a group of fearless deer quietly came out of nowhere to graze on the cliffside meadows. And just as it was three years ago with prophetkristy at Yaquina Point (Between Sea and Sky), we quietly watched together for the legendary green flash of sunset, as the stars of evenfall began to twinkle in the high overhead sky.




But beauty seen is never lost,
God's colors all are fast;
The glory of this sunset heaven
Into my soul has passed.

- John Greenleaf Whittier (1807 - 1892),
"Sunset on the Bearcamp"

From the "end-of-second year of residency" California adventures

Among the lucky accidents of our adventures in northern San Francisco was stumbling across the Benziger Winery. Because a winery trying to make better wine by throwing ecology and entomology at it is Made of Win. And this entry is about sharing our neat science and wine tour in Sonoma / Glen Ellen...











Now, those of you who know me might be asking what I was doing on a wine tour, since, after all, I don't drink alcohol. And it's true, at wild medical activism receptions (Reza's, anyone?), campfire SCAdian revels or Socials, I take a pass on the booze. I've never chosen to have beer or spirits or cocktails, and my friends graciously accept that as part of who I am. There are three counter-notes, tho --

• Wine *is* the only alcohol I've ever had, and continue to have -- as part of the Eucharist. The bread and wine taken in my churches in Evanston and Ann Arbor and at Breno's church in College Park, at which silmaril sings. (I never did find a church in St. Louis, and given I only have another 12 months here, I'll probably wait until I reach Baltimore/DC to find another.)
  
  
• I may not drink wine recreationally, but I enjoy eating a lot of things that have wine in them, either as an ingredient in fancy restaurants or home cooked meals, or as the origin of fine wine vinegars, which I am also a big fan of. Good wine-based food comes from good wine, and hence an interest in good wine.
  
  
• I am a geek of How Things Work and How Things Get Made. Any process of complexity I can sink my head into or around -- especially a biological process -- fires up the "Ooo, Shiny!" curiousity centers. I'm the geek who sits at heavily scientific Grand Rounds and puzzles over the error bars on figures while my more clinically minded colleagues snore. So the Making of Wine certainly falls into that category; added to my own culinary interest in things that come from wine, and the obvious joy my friends and family take in wine, and a tour to see how wine is made is certainly going to be interesting, even if I don't actually drink the product.
  

And anyway, dawntreader42 wanted very much to visit a winery during our adventures -- actually came up with the idea, which I had never previously considered -- and that would have been reason enough. :-)







So we knew we intended to go visit *a* winery. In fact, dawntreader42 had a different winery in mind at first. But at our previous stop at the Olive Oil press (that entry to come), they had mentioned the Benziger Winery as a good tour, and then driving back into Glen Elen we happened to see a small street sign pointing at the turn torwards the Benziger Winery, and since we weren't really all that set on which specific winery to visit, we said, hey, why not?

By lucky accident, the Benziger Winery happens to be part of the off-the-beaten path movement in winemaking. The Benzigers sat down to think about how to solve agricultural challenges without resorting to industrial chemicals or automated machines, and along the way brought aboard various biologists to help them do it. They aren't just trying to make wine, they're trying to use biology to make better wine. Which is a whole level of extra neatness for the trained scientists dawntreader42 and I are.

Originally popularized in the wine growing world by many of the most senior wine estates in France, the organic farming philosophy adopted by the Benziger winery has its roots in a 19th century compilation of agricultural techniques which in many cases border on mysticism. Rudolf Steiner's Biodynamic agriculture embodies a lot of frankly scientifically untestable philosophy, with some resulting practices of the "weird but harmless" variety. Then again, the eight special herbal preparations Rudolph Steiner prescribed to be sprayed on vines at specific intervals of the year isn't any more mystic than asking the local priest to bless the vines; and the Benzigers added a whole lot of practical 21th century ecology, hydrology and biology to the 19th century Biodynamic model.

The Benzigers didn't set out in the beginning to be organic vintners. The Benziger family originally made their fortune as New York City-based importers and distributors of wine and spirits. They then came out west in the late 1970's and made a second fortune by creating one of the first wineries to fill the niche between cheap blended wines and the wallet-breaking exclusive vintages. They came out of the gate with a series of award-winning wines that cost only a fraction as much as wines from other medal-winning estates, and soon the wine was flying off their estate as fast as it could be made. By the late 1980s, the Benzigers had the most valuable wine production effort in Sonoma, which they sold in 1993 for just shy of a hundred million dollars in today's money.

Having made their fortune twice over, the Benzigers decided to reinvent themselves once again, this time to make the best wines possible without carpet-bombing their land with industrial chemicals and machines. As it happened -- and as mentioned above -- many famous wineries in Europe had long been doing so, using the Biodynamic approach of Rudolph Steiner, with it's combination of scientifically untestable mysticism and practical techniques drawn from centuries of horticultural experience and modern ecological understanding. Rather than trying to do organic wines from scratch, the Benzigers could start with what already worked -- spectacularly -- in some of the most famous wine making country in the Western world. They brought in botanists and entomologists and ecologists to take stock of what they had, mapped the varieties of earth and sunlight exposure and microclimate in their little corner of Sonoma, and got to work.





Click above for panorama of the Benziger Winery valley

It's a fascinating series of ecological solutions to agricultural problems. For example, instead of spraying pesticides to get rid of pests, one figures out what eats said pests, then figures out what kind of habitat said natural predators require. The Benziger vines are thus intermingled with flowerbeds and selected grasses and towers of bird-boxes for varying species. Other patches grow plants selected for their nutritional contribution to compost. They have sheep and cattle which wander through the vineyard, keeping the ground growing plants in check, fertilizing the soil with their manure, and aerating it with their hooves. The bowl of their estate drains down to a collecting wetland they installed, which serves as a natural filter and breaks down organic runoff, leaving clean water to seep into a collecting pond for reuse on the estate. Steiner's biodynamics involves a good heaping dose of mysticism -- hard to test whether timing certain herbal sprays for certain moon cycles really makes a difference -- but all in all, the Benzigers have used the natural ecology of northern California to help them grow their vines.

The organic farming approach comes at a number of costs, of course. The product yield is far less efficient than industrial methods. A vineyard aggressively farmed with chemicals and machines would grow three times as many tons of grapes per acre of vines as the current Benziger organic vineyards do. Much of the Benziger estate *isn't* growing grapes, instead being used for things like the previously mentioned wetlands and flower gardens and support crops. And the Benziger organic approach, with it's coordinated jigsaw of native plants and animals, is far more costly in manpower than a highly automated, industrialized vineyard. Even with the award-winning wines that come out of their winery, the financial yield is far lower than a comparable industrialized vineyard. But the Benzigers aren't interested in maximizing profit margin -- they *already* made their fortune twice over. In the current incarnation of the Benziger winery, they're just trying to make as great a wine as they can with as minimal an enviromental impact as possible. And by all accounts, they appear to be succeeding.

Despite the emphasis on low-enviromental-impact winemaking, there is a substantial role for science and technology on the Benziger estate, however. As noted earlier, substantial amounts of ecology and entymology are employed to intelligently use the region's flora and fauna to accomplish what others would do with chemicals and machines. Exhaustive ground mapping and meterological sensor technology has also come into play in allowing the Benzigers to maped every corner of their valley, identifying distinct regions of the valley with distinct growing characteristics. The soils differ from location to location. The amount of total sun exposure differs between the east and west facing slopes. The amount of water and mist and rain. Over two decades has resulted in a vast amount of data which, together with their trained noses, has allowed them, in their own minds, to intelligently divide their property and the grapes grown on it into different "flavors", rather than lumping together the entire valley's production into an anonymous mass. Together with other partner organic vineyards, they then mix and match the products of these microregions like paints on a artist' palette, seeking the flavors they're going for.







It turns out the most gentle way to get juice out of grapes is with several tons of precision-machined, computer controlled steel (as seen in the thumbnail at left). After having gone through all the trouble of growing grapes as naturally as humanly possible, subdividing them into microregions, and then hand-harvesting them in the cool early morning hours, it would be silly to then lose much of that hard-won flavor by over-rough handling. The gigantic juicers enable exacting control of pressure, friction and temperatures, enabling the juice to be removed from tons of grapes with a minimum of trauma. The vast networks of sterile, chemical resistant connectors and pipes mean the only yeast and bacteria which get into the juice are the yeasts and bacteria which originally naturally occured *on* the grapes, not whatever cross contamination happens to be sitting on the equipment or a crusher's hand. The separate lots of juice from separate lots of land are then stored in fermentation tanks until the Benziger vinters determine by taste and smell that they're ready for wooden barrels.








The ancient Mediterranean societies who in Europe first invented wine primarily used ceramic amphorae for the transport of liquids, including wine. Owing to the perishability of barrels, the origin of the wooden barrel can only be conjectured (Herodotus noted the use of palm barrels for the transport of wine) but they come into signficant use by the Roman Empire after their encounters with the Gauls and other tribes. While barrels hold liquid as well as a ceramic amphorae, winemakers soon discovered that *unlike* the generally chemically unreactive ceramic amphorae were made of, a wooden barrel does several things to the wine within it.

The organics in the wood will over time interact with the organics in the wine, modifying and imparting flavor. Also, unlike ceramic amphorae, wooden barrels allow the evaporation of vapors, further changing the character of the contents. Winemakers over the centuries have come to use these actions of wood on wine to their own advantage, deliberately putting wine into specific types of wooden barrels treated in specific ways in an effort to achieve specific flavors. (For example, many modern wine barrels are deliberately and carefully cooked, or "toasted", in order to change the flavor of the wood interacting with the wine.) And so, in that tradition, the Bezingers take the additional step of aging their wines in wood, in caves they themselves built.






Click above for panorama of Benziger caves




The Benzigers some years ago drove a large network of caves into the rock of their valley, in which to age their wines. While the cost of burrowing giant galleries into the rock is extremely high, a properly sited, properly built cave requires vastly less electricity to cool and humidify, decreasing the carbon footprint and ultimately decreasing costs. And so the next step of our tour was to walk the long galleries under the foothills of Mount Sonoma, admist thousands of wooden barrels of carefully aged wine.

While it was bordering on 100 F in the sunshine, deep within the caves the temperatures was a cool, moist 65. Pallets of barrels, each with their own computerized bar code, marched down the length of each gallery deep into the darkness. The air within in the caves was rich with the "angel's share" -- the portion of the wine which evaporates out through the wood of each barrel and fills the air of the cave with its vapor. Here the barrels will remain, periodically gently recasked as the sediment settles to the bottom, until they have completed their years of aging and are ready to be put into bottles.








The tour of course ended with a wine tasting. Actually, they just handed out wine glasses and started uncorking a whole menu of wines, and invited folks to come up for glass after glass. This would normally pose a slight problem, as the next item on our agenda was to drive into the mountains, something that would be slightly less than advisable after a generous wine tasting. Happily, and conveniently, as noted previously: I don't drink. This left us free to assign me to do the driving and dawntreader42, the wine afficando, to do the drinking. I love it when everything fits together perfectly. :-)

(In fact, the Bezingers were so generous with the quantity of wines offered for wine tasting we never actually had to invoke the "she's drinking my share" bit.)

For my own family, I leave the wine picking to my vastly more competent General Surgeon cousins, and trust that they can pick appropriate wines for our family gatherings; if I were to try to take a wine home, I'd pretty much be doing it at random. But dawntreader42 had developed a substantial wine knowledge through her years of travel as part of the Peace Corps in Russia and other journeys. Even though I don't drink, her fascinating commentary was enjoyable and enlightening, as were the stories she told associated with the wine as she went through the selection offered. We were able to pick out one dawntreader42 could share with folks back in Boston.

Even though I never and don't drink, it was a wonderful, warm time of stories and laughter shared over old wines with an old friend. And that, more than any wine, is a treasure worth savoring. :-)

...age appears to be best in four things: old wood best to burn, old authors to read, old wine to drink, and old friends to trust.


- Francis Bacon (1561 - 1626), of Alonso of Aragon

Road trips!

I've always been profoundly lucky to have a loving family and home to come home to, no matter how far afield my work took me. Grateful also to have been gifted with visits from countless friends whom I had the honor of hosting; and the privelege of being hosted by countless friends in return.

And I've been very, very lucky, over these many years; that on the rare occasions I have the freedom to hit the road and travel somewhere, that there have always been many, many eager friends willing to hit the road with me. :-)








Every picture a memorable story. (Every thumbnail can be clicked to go to it.) Every story just one of many more. Countless happy memories over many miles of happy travel shared with merry friends, be it a short jaunt just over the hills to a journey measured in thousands of miles. I've always been a very easy-going traveller, never one to let the inevitable glitches of travel put a damper on an otherwise delightful journey. And I've been very lucky to have found many fellow travel companions of similar spirit, and with them shared the road.

And so it was again this June, at the end of my 2nd year of residency, on a merry five day journey with the delightful dawntreader42 and many other friends all across the Bay Area.











dawntreader42 and I had a rental car with which we could drive anywhere. A GPS that could map for us the road on the fly. And her iPhone with it's on-demand internet access, with which we could look up anything, about anything, from anywhere. Together, we were equipped to go and do anything as our whim dictated. And so we did, and had a glorious time.

Some photos you've already seen. Some more you see here. And the happy stories -- from Point Reyes, from Mount Tamalpais, from the Muir Woods and Alcatraz and the Exploratorium and the Mission/Castro and a wedding on Treasure Island -- those stories will yet come, as my time allows to tell them.

One more set of road trip stories, to go with so many others. One more set of happy memories, to be treasured in years to come. One more set of bright happy days, shared with so many friends, to become part of the Invincible Summer. And my deepest gratitude for it all.

In even more happy news; at the same time I was in San Francisco celebrating the wedding of one of my closest and oldest friends, another pair of my oldest and closest friends brought a beautiful baby girl into the world.

They, being busy, have announced on Facebook but not yet on LiveJournal, and so I defer further details. But a special day it is for them, and for all who care for them. For me; a journey which began more than a half-lifetime ago on the other side of the world; a journey which led to their wedding day; and now this. Sincerest congratulations, old friends. And welcome, little one. :-)

Today, friends from throughout the Knowne World set forth for Ealdormere (Ontario) for the Seventh Known World Dance Symposium, the great bi-annual gathering of medieval dance and music enthusiasts from every corner of the SCA. Four days of dancing and music and song, with hundreds of fellow enthusiasts in all their finery.

I couldn't make the sixth in Seattle. And I can't make this coming one. Heck, I might not even be able to make this weekend's day-long celebration in the Barony of Three Rivers, depending on whether the Chief Residents call me in. But the next Known World Dance Symposium -- the Eighth, whose location isn't even (to my knowledge) chosen yet; by that time, in the summer of 2011, I will have finished my third year of residency and my first year of fellowship. And *that* one...

That first year of fellowship at Hopkins is widely regarded as the hardest year of a Pediatric Hematologist/Oncologist's life. Far harder than even internship. Far harder than even this most recent neonatal ICU / Pediatric ICU / ED-Trauma run I just completed. But I will learn a tremendous amount in that year. And at the end of that academic year, for the first time since I returned to wards in October of 2005, in July 2011 I will get control over my life back. Largely get back the chance to schedule things without horse-trading, begging, and bribing my colleagues to trade around jigsawing 80 hr/wk schedules. There will still be tremendously hard work -- there will never be anything less, for this will never be an easy road. But at least the freedom to rearrange that work will be mine to an extent I have not known for more than four years.

I've truly been fortunate. Just one generation ago, our predecessors in medicine worked 120 hr wks and had four days off a year. Had I not taken the PhD diversion, I would have been one of them. Thanks to the work hour changes, I have been able to sneak in an incredible series of adventures, happily recorded here in this journal, shared with so many of you. And by the time the next Known World Dance Symposium comes around, my life will have gotten even better. I can't make this KWDS. But I might very well make the next one. And mighty Pennsic, and so much more.

So Huzzah! for my friends headed to the glory of Known World Dance Symposium. Huzzah for my friends who are *running* it. Huzzah and hurrah and safe travels, and come the summer of 2011, when once again the musicians and dancers of the Knowne World gather again in celebration, I might yet join you there. :-)

My attending hands to me a headset that looks like something a Mission Impossible or Metal Gear operative would wear rapelling into a laser-gridded secure space.

I put it on and drop the head-mounted optics down into place in front of my eyes. My attending powers up the headset and begins to explain the options available to me. A whole battery of selector switches on either side of my forehead allows me to cycle through multiple magnification modes, light amplification options, tight beam, narrow beam, polarized, flourescent. I have my choice of lenses, light sources, focal lengths. Five thousand dollars worth of head-mounted surgical microscope that looks like a piece of cyberpunk hacking gear on my head and I'm thinking, Dude, sometimes my job is made of Win and Awesome.

And now I'm ready to hunt the moth.




He was part of a hard-played touch/tackle football game near dusk when suddenly an insect came out of nowhere and flew straight into his ear canal.

Into his ear canal. *All* the way into his ear canal. His whole head rang with the furious buzzing of the now-trapped insect and his world became excruciating pain. I mean, think about having a large insect banging on your eardrum as fast as it's wings can beat. His buddies had to carry him back to his parent's house, the pain was so intense, and then he was brought into the Wash U / Children's ED.

He was quickly brought back from the triage area, given heavy doses of pain medication, and then his ear was examined with a standard otoscope, whereupon it was immediately obvious some large and angry insect was, in fact, banging it's way around the interior of our deeply unfortunate young man's ear. That problem was quickly solved with a quantity of mineral oil poured into the canal; within a few seconds, mercifully, the insect was drowned and his pain eased. (If you *know* you have a live insect in your ear, this is the first aid treatment to stop the insect. The problem is that, if the excruciating pain in your ear is instead a ruptured eardrum, you've just poured mineral oil into your middle ear.) This still, however, left a large insect inside of his ear canal. Which begs the question of how it was going to come out.

Like most problems in life, it's a matter of having the right tools. I ordered and the tech brought me a pair of appropriately lengthed alligator forceps to gently grasp the insect by a leg or wing. The next question was how I was supposed to *see* said insect that I was going to try to get. After all, the usual way to see things in the ear canal is an otoscope, except if the otoscope was in the ear, how was I supposed to get the forceps in, too, to actually pull the insect out? I'd seen the otolaryngologists (the Ear/Nose/Throat surgeons) use big surgical microscopes in the operating theatre, but I wasn't sure what we used in the ED. And the answer, happily, turned out to be a matte-black, future-tech, bad-ass set of headgear which my attending with a big grin handed to me with the admonition, Have fun.

With the headgear mounted, I sat down at my patient's bedside and began cycling through the selector switches. I brought the white beam down, focused it to light up the ear, then adjusted the zoom and focus until suddenly the deep interior of the ear canal was the size of a dinner plate in my field of vision -- and the now-dead insect's every detail was obvious. I inched the crocodile forceps down the ear canal, very gently closed the jaw around a wing, and gently eased the insect back up and out.

It did turn out to be a large moth-like insect -- thank heavens it wasn't a wasp or a bee -- and needless to say, the young gentleman and his parents were very, very happy.






As always, click thumbnail to enlarge



Operating with surgical robots (Concerto). Zapping tumors with particle accelerators (Swords of Curie). Airborne medicine. Sometimes, this job is just geek Awesome. :-)

Alcatraz Island, 10:00 AM



:-)





Back in St. Louis. Back on shift in a few hours. Might miss weekend with SCA friends because of being called into work.

But for a few brief days, an escape. And deepest gratitude to all the friends -- especially dawntreader42, my fellow wanderer all these happy days -- who made it so.

Family and friends make lighter a long journey.

The previous evening's shift began with getting repeatly kicked in the gut and ribs by an out-of-control teen patient and went downhill from there.

This morning, I woke up in my apartment near Wash U / St. Louis Children's and got going for the day.

Happily, today, I do not actually have to report to work; I get the day off.

And tonight, I get to share a merry dinner with many old friends.

In San Francisco.

(I'm writing from Denver right now.)





I'll be having dinner with dscotton.

And scifantasy, who is normally in New York City but is spending the summer in San Francisco.

And dawntreader42, who started this morning in Boston.

And Jesse, who started this morning in Ann Arbor.

(The three of us will be landing in the Bay Area within about an hour of each other.)




Since I can't make it to the Social in Toledo (alas), we'll have one instead by the Bay. We'll raise some sushi in y'all's honor. :-)

College days, mid-1990's

Cosmin was a local, from the Chicagoland area. Alvin hailed from out west in California. And I had just brought my two allowed suitcases with me from Japan. The three of us began at Northwestern University together in the last day of the summer of 1994, in dorm rooms right next to each other. Cosmin was in Rm 403, I was in Rm 404, and Alvin was right across from Cos in 407. We met on our mutual very first day of college, almost fifteen years ago...

And Cosmin and I were extremely lucky that Alvin didn't decide to hate our guts the moment we first met him.




The mid-1990's had some of the worst odds of entry into medical school anyone had seen in twenty years -- and the worst ever seen in the years since. At it's worst, during some years in that period only two out of every five pre-meds would get *any* seat in medical school. In that enviroment of extraordinary uncertainty -- when you could fight and labor and work for four years and had an almost 60% of having nothing to show for it at the end -- Cosmin and I were one of the extremely lucky few with a get-out-of-pre-med-hell card, as part of Northwestern's Honors Program in Medical Education (HPME).

The two major BS/MD programs at that time -- Northwestern's HPME and iliana_sedai's PLME at Brown -- had among the fiercest application processes in all of college admissions. One's odds of admission to any other college in America -- *any* other college -- were better than one's odds of getting into one of the 80 slots in HPME or PLME. The average HPME entering SAT and GPA was (and remains) higher than the entire Ivy League -- or anywhere else. And the reason was simple: for the lucky few who won a seat, HPME in those days offered a practically iron-clad guarantee of a medical school seat, straight out of high school.

Once in, no further application required. No MCAT required. In fact, at that time, Cosmin or I could finish Northwestern with a straight C- average and *still* in three years time join Northwestern's first year medical class. Not only that, we still retained the right, if we chose, to apply like anyone else to other medical schools without jeapordizing the seat we already held at Northwestern -- in my case, for example, to make the attempt to go home to in-state U. Michigan. Instead of going to Harvard or Stanford or Yale for undergrad, working bitterly hard, and still ending up with nothing; us lucky few could come to Northwestern, be guaranteed a top-twenty medical school seat from day one, and still, if we chose, fight to go even higher. In an age where more than half of our pre-med classmates nationwide would never make it to medical school, we had the pre-med's dream. Which is why members of the HPME program were among the most hated people on the whole of the Northwestern campus, bitterly resented by the vast throngs of pre-meds around us living with the nerve-wracking uncertainty we ridiculously lucky few escaped.

Alvin was an aspiring pre-med, from a small town in California. He had never had the same kinds of chances growing up Cosmin or I had. Alvin's high school never offered the Advanced Placement classes, the well-stocked science labs, the summer opportunities that Cosmin and I both were lucky enough to get; and so Alvin had never had a shot at a program like HPME. If Alvin had gone to my high school at the American School in Japan, he surely would have been the valedictorian, instead of me. Instead, Alvin had been stuck at a high school where there were more pregnancies than calculus students. It was to his extraordinary credit that Alvin, despite the paucity of opportunity available, had managed to fight his way into Northwestern anyway, with the scholarships needed to make his attendance possible. And to his still further credit he never showed any sign of resentment torwards Cosmin or I, despite having every reason in the world to. Indeed, Alvin and Cosmin and I became fast friends, fellow geeks going through the ups and downs of our first year away from home.

We were pre-meds together, Alvin and Cosmin and I. We slogged through Organic Chemistry and General Biology and Physics, lecture and lab and fratricidal curve-based grading. We labored away in our research labs, mine in computation, Alvin in biomechanics, Cosmin in neuroscience, keeping company with a bajillion rats. With our housemates, we got ourselves into legendary pranks like the time we flooded the house and deafened the Quad and epic Doom Deathmatches on the house ethernet networks. We drove Alvin throughly insane as he tried to lead our incompetent, bumbling selves through preparing the annual Thanksgiving banquet, Alvin's consummate talent in the kitchen trying to ringlead walking culinary disasters like us. Through all-nighters and long weekends and all else, we shared the freshman college experience together. And in late-evening hanging out in the hallway between our rooms, we'd idly wonder what the future would have in store for us.

That was fifteen years ago.




2009


Fifteen years. Fifteen years. Almost half a lifetime. Gauss and I made it from kindergarden to medical school in less time than that. (He skipped 2nd grade, I skipped 7th, and we both finished college in three years.) For Alvin and Cosmin and I, as college freshmen, fifteen years into the future was as remote as the dark side of the moon. And yet, here we are.

Once upon a time, we were wanna-be pre-meds, fretting our way through Orgo problem sets and Bio exam curves. Faces among the vast crowds hoping for a future in the profession of medicine. And here we each are, still linked by friendship after journeys we each could never have imagined. Alvin went on to medical school at UCSF, crown jewel of the University of California medical system; on to residency in Orthopedics at Stanford; fellowship at Harvard/MGH; and now an attending orthopedic surgeon's position in Silicon Valley. Cosmin went on to Northwestern Med; residency in General Surgery at Wisconsin and Baylor, when the late legendary DeBakey still operated; and fellowship in Cardiothoracic Surgery at Michigan, under the tutelage of some of the world's greatest heart surgeons. And my own road, from Northwestern to U. Michigan to Wash U to Hopkins/NIH and beyond.

Long ago we shared together the trials and joys of freshman year. We endured together the common indignities of the neurotic pre-med life. We each embarked on the experiences common to all who follow the physician's road, from 1st-year anatomy to running services as a senior resident and fellow, encyclopedic exams, thirty-hour shifts, miracles and madness and terror and everything else. And here we are, fifteen years later, having found success we could have never dared for.

We celebrate each other's success -- success much less about the honors or the Big Names, and much more about the lives we've each been priveleged to have been a part of in our service. Alvin helps the lamed and the broken walk. Cosmin strives to fix the tiniest of sick hearts. Of my own road and chosen work, you all know. And along the way, Cosmin fell in love and married just two years ago. Alvin's wedding I will have the privelege of attending in just a few day's time, by the waters of San Francisco Bay. And I still hold out hope that I too will win the honor of being a special Lady's husband, if I should so earn; if I am worthy, my time too will come. In the meantime, in their joy I too rejoice, and remain priveleged with the gift of their friendship.

The chance to make a difference, each and every day. The chance to share richly in the blessings of family and friends. In our wildest imaginings we could not have dared to hope for more when we were aspiring pre-meds, as newbie college students in adjoining dorm rooms, so long ago. And while the future is uncertain, as it always is; there is more than enough to be thankful and grateful for where we have come, and those who kindly have come with us; including the three of us, still a part of each other's journeys from beginnings in a pink-halled college house, long ago.

While I'm trying very hard not to think about health care policy while escaping from the medical center -- as the state of health care and the politics surrounding it is an intensely frustrating and depressing subject -- I was reminded that a lot of folks haven't read the following recent column, which is a pretty good (IMO) viewpoint on the issue...

The article's author is (IMO) one of the better health care opinion writers active today. Which might have something to do with his background. Dr. Atul Gawande writes about medicine as someone who has ascended to the very highest heights of achievemnt in medicine -- Rhodes Scholar, Harvard Medical School MD graduate, professor of oncologic surgery, Brigham Women's / Harvard. He writes about medicine -- and health policy -- not as an outsider looking in, but from the inside looking around. His books are well worth reading. As is his recent article: The Cost Conundrum..

The kid sprayed with oven cleaner. And bleach. And Windex. The kid who had the back of his head ripped open after an ATV accident, with flaps of loose scalp hanging off the back. The kid with nausea and vomiting and dizziness and a funny crick in his neck, which ultimately got rushed into emergency brain surgery for the massive tumor we found. Just another night, like every other night at work, these past many days and weeks and months.

It has not been the easiest run, from the Neonatal ICU to the Pediatric ICU to the trauma/ED service I am on now.

But thanks to the kindness of friends and the love of family, there have been bright moments. Silver Jubilee. Terpscichore. Memorial Day Weekend. And after this one last trauma shift, to head out to the airport once again, this time to meet good friends on the edge of the Pacific Ocean, for the longest period away from work I have had since going home in December to my family over New Year's, and prior adventures with prophetkristy among southern sands.

After one more trauma shift, heading out to the airport for a long weekend in San Francisco with dscotton and scifantasy and Jesse and travelling all over the beautiful northern Bay Area seacoast with dawntreader42, and the wedding of a mutual old, close friend on the shores of San Francisco Bay. And when I return, the great, grand Three Rivers celebration known as Birthday Bash, music and dance with wonderful Calontiri friends whom I have not been able to escape work to see in far too long.

Friends and family make lighter a long journey.

Today is Father's Day, as already noted.

Today is also fortuna_juvat/inked_caduceus's birthday. Having recently just celebrated in this Journal her wedding and her hooding, not much more really to say. :-)








Happy Birthday, dear Kat. :-)

As events unfold in Iran, I remember another nation, another story, and my friend Alexandra: Alexandra's Choice.

One of the very best entries I've ever written, for the holiday coming up: Strength of my Fathers.



To all fathers out there: Happy Father's Day.

Why the fuck would someone gut-shoot a baby? Why?

Fucking motherfuckers!

My very last morning – the very end of my thirty hour shift – we got The Call.

A little infant with an isolated lung problem, all she needed were new lungs and he might have the chance at a full, long, normal life. Without new lungs, it was only a matter of time before her self-destructing lungs killed her. From clear across the country she and her whole family had come to Wash U / Children’s, for the chance at a lung transplant which was her final hope. For weeks we had fought to keep her alive in the Pediatric ICU here at Children’s, fought to keep her stable enough to survive a lung transplant if one arrived. And my very last morning, word came through UNOS that a pair of suitable, type-matching lungs had become available.

For weeks the transplant team had been ready, updating and reupdating the standby sets of orders that waited on the 7th floor CICU central office, the gameplan that would activate the moment the UNOS call arrived. And within minutes of the call, a furious storm of activity lit to life. Pulmonary, CT surgery, anesthesiology, Perfusion, blood bank, the HLA typing lab – personel from all the related teams were summoned from home or call rooms and converged on the PICU. A laundry list of labs were drawn. Pre-medications were given. Operating room schedules were rearranged. The harvest team raced off the helicopter pad on the roof of Children’s even as the implantation team dusted off chest x-rays and CT scans and went over the surgical plan one final time. And a few hours after the call came in, our young patient was wheeled off the floor, a huge gathering of family trailing behind, off to the operating rooms and her date with destiny.

She is reportedly doing extremely well in the Cardiac ICU, where she went after the transplant. Only time will tell how she does; but we’ve given her a shot, and that’s the best anyone can do.





Our patient in the Pediatric ICU was one of two young infants waiting for lungs. The other was a young infant who I also had the privelege of taking care of, a patient I had admitted early the month before during my Neonatal ICU rotation – the young patient of the story Piglet.

The Call came in time for one infant. Time ran out for our other. A second pair of lungs did not arrive before Piglet’s young lady deteriorated beyond the point of no return.




Despite all of our skill, all of our knowledge, all of our technology and our effort, in the end, so much rests on fortune and fate.

We do our best.

The entire hospital cares sees nearly five thousand inpatients and ten times as many outpatients for a total budget of approximately a million dollars. Sees over fifty thousand patient visits on a budget no bigger than the lifetime costs of a single transplant or cystic fibrosis or AIDS patient here in America. The available selection of drugs is tiny; the power supporting the medical equipment often flickers; the nearest CT scanner is three hundred miles away in the capitol. But the most important things are the same. Whether a remote hospital high in tropical mountains, or a biomedical fortress on the farthest edge of human knowledge: what it means to be a doctor remains the same, skill and service, compassion and courage.

Her family was quietly dignified about their grief; I wrote a code note and they sobbed but did not wail. One of the other patients - apparently a relative; remember, this all took place in a ward of beds only a few feet apart - came over to cry with them. And I prayed, and I took my bag, and walked out into the night feeling painfully inadequate.

I don't know what happened; I think if I knew then it might make things a little better... but I'm going to have to put this one on the list of things to know at the end of things. And that's hard for me, so very hard.


- ayradyss, Thursday, June 11th

In the United States, a city of that size would have a hospital capacity of 300 beds, a dozen surgeons, dozens of other physicians. The jungle community of Kudjip in Paupua New Guinea has almost a hundred thousand people but only just over a hundred beds, served by less than ten doctors. This month, ayradyss is one of them, serving together with her husband and her toddler daughter over eight thousand miles from home. And just as she did while she was stateside, she writes movingly of her experiences in her overseas blog she shares with her husband: the blog here, with Livejournal feed at mnpng.

Two birthdays today, an Aussie and a Calontiri...







She's the merry music Mistress of Three Rivers, our ringleader (so much as our happy anarchic band of musicians has a leader) and organizer. Cheerful organizer of the dance orchestra at Crystal Ball; co-organizer of the music at Lillies, Calontir's great weeklong summer tournament; organizer of the music in the gallery at Calontir's Silver Jubilee. Mistress of the Order of the Laurel by right of skill in the arts, the Knighthood-level SCAdian artistry rank; Court Baroness by the love so many in this Kingdom have for the ever-smilling cantigajoy. Beekeeper and gracious host and woman of deep faith, for over a decade she has brightened our Kingdom with her artistry, her music, and above all, her kind and generous heart.

She was one of many who so kindly welcomed me to Three Rivers and made this place a SCAdian home for me. She had her own apprentice personally ink the magnificently beautiful scroll I recieved in the story Silver and Swan. She made welcome too my musician friends who traveled all the way from Cynnabar to play in the band. Her friendship and freely shared joy, her support and her kindness has been a deeply humbling gift. And today is her birthday.

Happy birthday, dear Mistress cantigajoy. Benedicat tibi Dominus, et custodiat te.










A long time ago a gent from England introduced me to a Pub on the border of a hundred worlds; and many were the warm and welcoming folks I met there. Including a group from Australia, two of which I had the privelege of finally meeting in person (all too briefly) one fine afternoon in the Windy City.

The years since have brought many changes. The Brit is now a Calontiri. For that matter, so now am I. The Pub has long ago faded into the mists. But the friendships still burn bright. Happy surprises in brown paper packages, kind words on e-mail and LiveJournal; even text messages of encouragement from all the way Down Under. And today happens to be the birthday of one of the wonderful Ladies from Down Under whom I had the privelege of sharing the journey...




Happy Birthday, dear reynardo. And many happy returns. *hug*

A hundred and fifty miles.

It's just over the distance between Los Angeles and San Diego. It's just about the distance between Seattle and Portland. It's the distance from Washington DC to Philadephia. A hundred and fifty miles. It's a long way.

Especially on a bike.

Especially in the middle of summer.

And that's what missysedai's Bubba and Maus are going to do, at the end of June.

For the third year in a row.






The National Multiple Sclerosis Society's Northrup Memorial Bike to the Bay is a two-day rambling course across the back country between Toledo and Put-in-Bay. The roads aren't any good. The sun-heated asphalt in summer bakes everything on it like a frying pan. The temperature flirts with a hundred degrees fahrenheit. The humidity pegs at a hundred percent. You sweat like a shower, but it doesn't do you any good. A hundred and fifty miles on bike would be a strenuous go in cool, ideal weather. In the very heart of a Midwest summer, it's brutal in the extreme. And that doesn't even count the long miles and weeks of training, the hours and hours in the seat, on the road, it takes to get ready for an event of this class. This will be the third year missysedai's husband and eldest son will do it. That's pretty damn awesome.









If the work of the National MS Society rings a bell for the readers of this journal, it should -- we've seen them before in my journal, in the work of Team Wench and my wonderful friend faireraven, the merry fiddler of Cat and the Fiddle Morris. Bringing her magic and her brilliant smile to RenFaires across the country, she herself has been a tireless supporter of the work of the National MS Society. Work that, as she has told many times in harrowing detail, saved her own life. Fifteen years ago this past January, in a matter of days faireraven went from the prime of health to near-total loss of muscle control, a journey she recounts here.

It is technically true that Multiple Sclerosis does not kill you. It's the complications that actually do you in. And even in "milder" cases, for too many people, Mutiple Sclerosis is a lifetime sentence in a prison of their own flesh, a thief which robs a person of the ability to walk, to dance, to use their hands for work or art, to kiss, to hug. As faireraven notes, she was one of the lucky ones; modern drugs developed to combat MS helped her recover, have so far kept the disease at bay. She has been a tireless fighter for funds to support MS research, determined to advance research to help others less fortunate than she was; the same research missysedai's Maus and Bubba are going riding a hundred fifty miles in the heat-blasted heart of summer to support. The same organization, the same cause: to defeat the dread disease, once and for all, once and forever.

The biology and the science, the research and the hope -- just a few months ago, prior to faireraven's last fundraiser, the entry Heather and Cyd introduced those things. Discussed the laboratory efforts supporting the work of clinicans like the teams on the 12th floor here at Wash U / Children's with whom I have had the privelge of serving. Every mile Maus and Bubba put in on the road is a mile closer to a world without Multiple Sclerosis, a world where beautiful people like faireraven never have to feel the terrifying loss of the disease. missysedai is proud of her boys. And we're proud to support them -- their team donation pages here and here.

This fight -- the fight against disease and death -- is a whole panopoly of long slogs. There's trying to stay awake for 24 straight hours of fundraising for Blogathon, like missysedai has done in the past. There's the brutal thirty-hour-awake workdays that all of us in medicine know. There's the tens of miles in fund-raising walks like silmaril and faireraven have done. There's the hundreds of miles on bike-back that Maus and Bubba have done over and over again. There's the long march of years and decades that the so many biomedical scientists amongst our fellowship have travelled. And above all, there is the terrible, harrowing road that the patients and they who love them must endure, a journey of grief and loss which too often ends years too early. For the friends and family who were saved -- for the friends and family we have lost; to cancer and to Alport's and to MS and to everything else: each of us, in what ways we can, do what we can. The price is one we will gladly pay, because the prize was always damn well worth the price.

Together, we'll fight. And together, we'll win.

A long shift in the Emergency Department which was supposed to end past midnight instead hurtled along until the sun started coming up.

The day fell behind in part because of spending a lot of time as part of a team helping put back together a little boy whose face got mauled by a pit bull.

And while I was in the middle of that, the young lady volyball player I wrote about in Ribbons of Grey, who I had admitted near the end of my ICU rotation and signed over to the next month's ICU team just a few days ago; after the shift was done I recieved a note letting me know that, just that afternoon, she had suddenly had a catastrophic -- and final -- deterioration.

The medical team was at least able to get her parents and her boyfriend in the room before the very last.

She never got to go home. She never even got to leave her ICU room.

She was twenty years old.






Lunch, and then back to work.

The vast majority of phone calls I make on my cell phone are to my parents. In fact, my parents are the only people I call on a regular basis, and thus the vast bulk of my cell phone time.

My parents recommended the other day that I install Skype, which enables computers to make free computer-to-computer calls and cheap computer-to-cell phone calls. The cost savings for international calls -- between us and our family in Taiwan -- are dramatic; and for me, taking the calls to home off my cell phone bill would remove most of my cell phone bill. So I set out to set it up.

I had no idea my laptop had a built in microphone. A microphone? Really?

It apparently does, a fact I stumbled over while looking up wireless microphones compatible with my laptop. I had no idea. I still have no idea where the microphone is actually physically located -- there are a few recesses and projections which might be where the microphone is hiding. But the quality of the audio pickup is more than good enough for phone calls, and so now I have free phone calls home.

Most surprises in my life are unpleasant ones ("Surprise! Code Blue!"). It's nice to have a pleasant surprise once in a while. :-)





So, if you have Skype, drop me a comment or an e-mail -- would love to have your contact info. :-)

I was humbly priveleged to be a tiny part of the defense of the University of Michigan's efforts to preserve same-sex marriage benefits (as a member of the University Senate's Civil Liberties Board) after Michigan passed it's own same-sex banning ammendment years ago. My own position on the subject of same sex marriage has been pretty explicitly stated before. So it would be fair to say I have more than a little passing interest, put mildly, in this subject. And having recieved at least a rudimentary training in the knife-fighting of politics during the course of my own medical activist career, several things certainly stick out about today's extrordinarily explosive Defense of Marriage Act (DOMA) filing by the Department of Justice...

W. Scott Simpson is a Senior Trial Counsel for the Department of Justice. Since at least 2004, Counselor Simpson has authored a number of briefs on behalf of the Federal Goverment relating to the so-called Defense of Marriage Act (link 1, link 2, link 3). He wrote DOMA briefs for the Department of Justice under the Bush era, and was part of a team that won an internal DOJ award from former AG Alberto Gonzales for their work defending the Partial Birth Abortion Ban Act (link). And today, another brief written by Counselor Simpson in support of the Defense of Marriage Act was filed in court. Of course, *this* time, the Department of Justice Counselor Simpson filed his brief under the authority of was the Obama Administration...

Today's brief is first notable for the... vigor... with which it defends DOMA. It has been pointed out that the Obama Administration is obligated to defend DOMA until such time as it ceases to be federal law (more on that in a moment). But there are degrees to which that defense can be launched -- and as has been pointed out by many (appropriately) enraged commentators, today's brief by the DOJ defends DOMA -- and attacks same-sex marriage -- with a ferocity that the most hard-core anti-sex-marriage advocate could hardly better. It was a brief almost designed to flip off the LGBT community. It was a brief that basically explicitly stated every possible angle in defense of DOMA in a way that would -- appropriately -- piss off the LGBT community and it's supporters. Given the obligation (again, more in a moment) to defend DOMA, having the option to go on the volume of that defense from one to ten, this brief cranks things up to eleven and then turns on the nuclear-powered subwoofers. Whomever wrote this brief certainly did that on purpose. The question is why.

Which leads to the next key question. There are *three* authors on today's explosive DOMA brief. One is Counselor Simpson, which as previously noted has been writing DOMA briefs for almost half a decade now, who worked for Bush before he worked for Obama. The second is James J Gilligan, who has been with the Justice Department at least as far back as Bush's attorney General Ashcroft (link). But the third name -- the Assistant Attorney General under whose authority and whose name the brief was also filed is very much a Obama appointee -- Tony West, a San Francisco attorney who was one of Obama's major campaign leads in the Bay Area, and a supporter of liberal judicial efforts including The Equal Justice Society. In other words, an Obama DOJ appointee who was formerly heavily active in liberal judician causes in San Francisco -- repeat and emphasize that, a San Francisco attorney -- attaches his name to one of the singularly most inflammatory, insulting and explosive possible legal briefs against same-sex marriage imaginable.

I mean, for crying out loud -- San Fran-f**king-cisco. If there's one city in all of America -- one city in the entire world -- in which LGBT causes and activism could not possibly be stronger, it would be San Francisco. There is no way anyone operating in legal circles in San Francisco could not possibly understand just how explosive today's document would be. There is no -- repeat, *no* -- possible way Attorney General West *couldn't* realize just how violent a reaction today's brief would engender. Reemphasize this point one final time: a San Francisco attorney prominently involved in progressive and liberal judicial causes authorizes under his own name a legal brief practically *designed* to touch off an absolute -- and absolutely justified -- firestorm amongst the LGBT community and it's supporters. Given the option to defend DOMA as narrowly as possible, Attorney General West instead authorizes and signs what is nearly the most full-throated, high-volume, ferocious defense possible.

Something is certainly the Hell up. The question is what.




It is obvious to anyone with half a brain that President Obama does not think LGBT issues are the highest priority of his adminstration. From the threat of collapsing banks to the cratering economy, from his speech in Cairo to the Muslim world to his efforts to shine a light on the torture question, it's pretty obvious President Obama and his administration have chosen to initially spend their political capital on other issues, other priorities, rather than immediately tackling the explosive issue of same-sex marriage -- especially when a growing momentum is spreading among *States* to fix the inequality. LGBT issues have very clearly taken a back seat to salvaging the economy, the financial sector, the health care system, foreign relations, etc. It's fairly obvious the Obama administration would rather focus public attention on those things rather than a fight about LGBT issues, and that the Obama Administration was content for now to let a growing number of states take care of the issue on their own. If that was the Obama administration's intent -- and it's pretty obvious that was their intent -- this latest bombshell of a brief is going to make that damn well near impossible.

The very virulence of the DOMA brief -- filed by his DOJ, for which he ultimately bears buck-stops-here responsibility -- is going to *demand* White House action, one way or the other. Even if Obama's own position opposing the Defense of Marriage act is explicit and clear -- explicitly stated here -- he and his White House haven't done it *yet*, and DOMA currently remains the law of the land to which his DOJ is obligated to defend until such time as President Obama moves to attempt to change it. It's been extremely obvious President Obama and his administration have chosen not to take up that fight up to this point -- it's pretty obvious President Obama considers the task of ramming through economic reform, health care reform, torture, etc. etc. an earlier priority. But if the Obama administration would rather defer tackling the third rail of actually *acting* on LGBT rights, this extremely explosive brief pretty much makes that impossible. LGBT activists are going to demand -- and legitimately so -- that the Obama White House explain itself. This single brief forces the issue to front and center. Even as President Obama prepares to address the American Medical Association House of Delegates on Monday regarding health care reform, the press -- the progressive press -- is going to be up in arms about Defense of Marriage, all thanks to this extremely inflammatory and explosive brief.

If the Obama adminstration wanted to defer dealing with the Defense of Marriage Act -- and the electrified third rail it represents, because very little else would fire up the Right Wing culture warriors than this issue -- then what *should* have happened was that the DOMA brief filed today should have been written as narrowly -- and as half-heartedly -- as possible. Instead, the DOMA brief was written in such a way as to crank the volume up to eleven -- written in such a way as to provoke the *maximum* amount of outrage among LGBT activists and their supporters. Done so by a Assistant Attorney General from San Fran-fricking-cisco. Assistant Attorney General West and Counselor Simpson *had* to know just what would happen when they put that document on file. The authors of this brief must have known the violent reaction the brief would trigger in the LGBt community, and known it would force President Obama and his administration to confront, once and for all, right now, the gulf between President Obama's explicit, documented committment to repeal DOMA and the fact DOMA currently remains the law of the land.

This was clearly no accident. So the question is: why?

I can brainstorm all kinds of possible explanations, based on the tactics of political knife-fighting; all kinds of assumptions based on how far up the ladder one assumes the decision was vetted and made. While buck-stops-here responsibility does ultimately go to President Obama, was he even aware of the brief before it was filed? Was Attorney General Holder? Is it possible that even Asst. Attorney General West had no idea what his Bush-era holdover subordinates were about to pull? (And on that last point, wouldn't that be, you know, his *job*?) Multiple possible explanations, many of them mutually contradictory, depending on what who you're assuming is pulling the strings vs. getting blindsided, and depending on what you assume the puppet-master's motives are. I very strongly suspect someone's gotten and is getting played, and played badly. The primary question is who.

It should be *very* interesting to see how this plays out.

She once was a Queen. Yesterday, she defended her PhD thesis and became a doctor. And just two years from now, she'll march across stage to accept the green velvet hood that is a physician's right, and be made a doctor again.

Of her Grace I have written a tale before, one of my favorites (A Note from the Cleftlands). And from a SCAdian born of the Midrealm to one of its former reigning nobility; from one physician-scientist to another: sincerest congratulations to HG Noelle, now *Dr* Gallogly. :-)

As the question of health care reform kicks into high gear, the news spotlight this week shifts to the House of Delegates of the American Medical Association and it's Annual Meeting. A week of intense debate amongst thousands of medical activists; a world in which culfinriel, mdrnprometheus, resonance42 and I have in our time been heavily involved. It is, in fact, on the floor of the House of Delegates of the American Medical Association that we all first met.

Five years ago I wrote an entry talking about the internal dynamics of the American Medical Association in particular, and of medicine and medical activism in general. I think what I wrote then is even more true now. And if one wants to understand just what is going on behind the curtain, that entry from five years ago remains the best summary I could possibly come up with: the entry A House of Medicine Divided.

As medicine has found increasing success curing cancer in general, the lack of success treating brain cancer becomes more and more prominent. While cure rates for other tumors have skyrocketed -- mortality rates for leukemia, the most common tumor in children, have gone from 90% death in five years to 90% survival -- cure rates for many major classes of brain tumors has remain virtually unchanged despite nearly forty years of effort. Brain tumors today are the leading killer among pediatric solid tumors. The 2nd most common killer among all tumors in men under 40. In 2009, nearly a quarter of a million Americans will be diagnosed with a brain tumor. Many of them, especially the young, will not live to see 2011.

About a year ago, a consortium of charities and memorial funds supporting brain cancer research joined together to form the Grey Ribbon campaign. Modeled on the more famous pink ribbon for breast cancer and the red ribbon of AIDS, the Grey Ribbon effort is uniting a growing number of smaller awareness and fundraising campaigns to help support the fight against brain tumors.

Which is why the young college gentleman standing in the pediatric ICU hallway was wearing the t-shirt with the large print grey ribbon on it, and the text: I'm Wearing Grey for my Girlfriend.




She still bore tan lines from the tropical holiday she had just returned from with her family and her boyfriend. She looked remarkably well, considering all that she had been through. Just a year ago she had been living up the college life with her friends, as captured in the many photographs on the website her family put up to keep everyone updated on her progress. A young woman living away from home for the first time, going through all the adventures of college life, up until the moment a bad headache became a living nightmare of surgery, radiation, and chemotherapy.

She had detailed her struggle, her hopes, her fears on her website, as she underwent round after round of treatment. Her family, her friends, her entire town rallied behind her and her family, hoping against hope to beat the odds. The entire arsenal of medicine was thrown against her tumor -- guided stereotactic surgery, gamma knife radiation therapy, whole classes of chemotheraputic agents that didn't even exist fifteen years ago. A generation back, her survival time might have been measured in weeks. She's done a lot better than that -- not just surviving, but managing to travel all over with her family and close friends in between rounds of treatment, including the recent holiday on the beach during which she got her tan. In contrast to the stick-figure skeletons or bloated Cushingoid habiti that marked cancer patients in the past, she still looked very much the vibrant young volleyball player she was before the brain cancer took hold. Still looked to be in the prime of the life she was fighting desperately to hang on to.

And losing.

We had bought her time; but time was all we had bought her. Her family's website detailed the heartbreaking progression of bad news, as serial scans revealed invasion, spread, metastasis. Despite how well she felt between rounds of treatment and how well she looked, her tumor continued to quietly progress. Continued down the course all too familiar from so many other young patients like her. Despite the hopeful, defiant note she and her family struck in their public online blogging, we knew it was only a matter of time. At some point, the tumor would finally cripple some critical brain function; as we ran out of our last treatment options, time too would run out. And so we came to that recent early morning, with her family and her boyfriend anxiously gathered outside of her ICU room, while we fought to control the seizures that had just that day for the first time suddenly exploded in her brain.

Just a few weeks before she was hamming it up on the beach. Now she was wired and tubed and sedated and silent. And even if she wakes up from this -- which she very well may not; the time will soon come when she will wake no more.









Above is a excerpt from a group photograph from the K lab, my first research lab in medical school, the group with which I did much of my early work and began my research sabbatical with. At left is my friend W, who was an undergraduate biology student I had the privilege of working beside when I was a med student researcher. W. was an extremely hard-working, talented, and driven young man. His work in the K. lab led to a paper with him as first author. His brilliant undergraduate record led to a seat at Johns Hopkins as a medical student; and ultimately to a place as a resident at Hopkins' neurosurgery training program.

The field of neurosurgery was born at Johns Hopkins. Cushing's Diease and Cushing's Triad -- the trio every medical student recognizes as the cardinal signs of potentially lethal brain swelling -- are named for Harvey Cushing, the surgeon who at Hopkins first developed the techniques which made brain surgery possible. Dandy-Walker malformations -- the syndrome where children are born with the brain pushed and squeezed abnormally down out of the cranium and down into the spinal cord space -- is named for Walter Dandy and Arthur Walker, two of Cushing's successors at Hopkins. For over a century, Hopkins neurosurgeons have progressively redefined the meaning of the word "inoperable". And together with their neuro-oncology partners, have pushed hard to find answers to the intractable problem of brain cancer.

It is research with implications far beyond just brain tumors; after all, what makes brain tumors so deadly is the one thing they do that normal brain tissue *doesn't* (largely) do: grow. The uncontrolled replication of neural tissue which forms a tumor somewhere at it's heart potentially carries the secret of how to make *normal* brain tissue grow -- or repair -- itself. Physicians and scientists worldwide have brought the weapons of the molecular biology revolution to bear on trying to better understand what makes brain cells go rogue, what makes brain tumors so resistant to therapy, what makes those tumors grow out of control -- and perhaps what can make *normal* brain tissue grow again. And much of the last few weeks has been spent talking with investigators and reserachers at Hopkins and at NIH about their extremely exciting work. Work recent graduating and current fellows in the Hopkins/NIH Pediatric Heme/Onc fellowship program have been involved in, have published in the most senior scientific journals; and which I could perhaps earn the chance to be a part of, following in their footsteps.

I am not yet sure if I want to specialize in Neuro-oncology, to dedicate my career to working side-by-side with neurosurgeons like my friend W. There are many clinically important and scientifically interesting areas throughout Hematology and Oncology, a whole wealth of ground-breaking research throughout Hopkins and the Bethesda campus of the NIH I could be a part of. Much of the next few months will be spent corresponding with potential research mentors and reading papers, leading up to a planned week in October travelling around the Hopkins and NIH campuses interviewing with laboratory groups, in an effort to find the laboratory which will become the starting point of the rest of my scientific career. There are many equally important questions, many areas of extraordinary strength at Hopkins/NIH. But the fight against brain cancer certainly qualifies on both counts. And it would not be a bad way to go, to spend the rest of my life trying to help patients like our young lady. Trying to bring hope to people like her faithful boyfriend and loving family. And tying a grey ribbon around my white coat sleeve and taking the fight to the devastating enemy which has so long resisted all that science and medicine can do.

Postscript.

Every few years, the window reopens; and as vvalkyri announced, it has reopened again. The window to help save a life -- for free.

Many of us have already joined. Many of you joined the last time. But if you missed the last window, your chance has come again.

For the next few days, the National Marrow Donor Program will be waiving the cost to join the registry. For the next few days, you could help save a life -- for free.




Every year thousands of patients world-wide become critically ill and require a bone marrow transplant for survival. Their only hope is to find a genetic match from the international registries. In the past, volunteering to join the registry cost money -- but for the next few days, the fees will be waived.

One of my first stories told explained the science, the biology, the medicine underlying the need for bone marrow transplants, why we need matches, how matching works, what a volunteer actually does; all of that as told in To Juliet, and to Victory. But a few years later, vickita said it all far more eloquently:

Some years ago, the husband of a friend had leukemia, and he needed a marrow transplant, but no one in his family was a match, and nobody in the current registry was a match, so they went looking. They got everyone they knew, and lots of people they didn't, to get tested and sign up with the Bone Marrow Donor Registry. I was one of the ones that signed up.

They never found a match for David. He's gone now. *sigh*

One day, a few months after I signed up, the Registry called me to tell me that I was a potential match for someone, and they asked me for permission to do further testing on my samples to see if I would be a match. I said, "Of course!" and I got all excited, because OMG, how often do we get the chance to save somebody's life for real? But I wasn't a good enough match, so that was that. They've never called me again.

Think about that.

Think about how there wasn't one single match for David, anywhere in the world, among the millions of people who are signed up with the Registry. (There was one person who was close, in Scandinavia, but nope.)

Think about how many, many, many people are looking for donors, and not a single one of them has been a close enough match to me that I have gotten another call.

Think about how it would be if it was someone that you loved who was looking. Or you. Would there be a match out there?

Go. Do this thing. It's easy (they don't even require a blood sample anymore; they'll send you a cheek swab kit through the mail and you can send it back to them), and being a donor is a very low-risk, low-discomfort thing to do, considering that you're saving someone's life. You could give them back their health. You could give a loved one back to a family. And you might literally be the only one in the world who could do it.

During my time serving on Peds Heme/Onc, on Peds ICU, I've had the privelege of helping many brave patients and their families waiting for a bone marrow match. Too many of them never found one. All of our science, all of our medical knowledge, all of the resources and research, all of our years of training and experience, *none* of that matters, without a Match. Nothing we do -- nothing we *can* do -- as scientists or as physicians is enough to save their lives. But maybe *you* can. And all you have to do is sign up.

It's painless to register -- we mostly don't even draw blood anymore, we just type the DNA from a home kit that collects loose flakes of skin from the inside of your mouth. It's increasingly painless to donate, with advancing technology making the actual giving of stem cells less and less of an issue. These days -- like for my fellow resident who just got The Call -- it's no more complicated than a blood donation. And for the next week or so, the usual cost of registration is being waived.

If you've registered with the National Marrow Donor Program before, if you have been in a bone marrow drive before, confirm your registration and make sure they have your correct contact information. If you don't remember your details, you can call 1 (800) MARROW2 (1-800-627-7692), and they can track your information just with your name and birthdate. And thank you.

If you've never registered before but want to volunteer during this free period, go here to start the process and see if you are eligible. It's quick. It's simple. It's free. And you could, literally, someday, save someone's life. Maybe even many lives.




For all of our brave patients and their families, all their love isn't enough. Not without people like you. For all of us who have dedicated our lives to the fight to help people -- help kids -- with cancer, our best isn't enough. Not without you. All of our science, all of our skill, all of our training and our expertise, we can't do it -- not without you. But with your help -- with the help of all of you who have registered -- we'll save thousands of lives. All thanks to you.

With your help, we'll find more matches. We'll save more lives. We'll save more kids. We'll work on wards and in our labs and you'll register. Together we'll fight. And together, we'll win.

Just one more call night, one more weekend on duty, before handing over. And then this.

Like many of the patients in the Pediatric ICU, he has been waiting for the organ transplant which could save his life. For weeks, we have fought to keep him alive, managing to keep all of his failing organ systems clawing along, desperately battling to stave off collapse in hopes the phone would ring. Fearing the day that overtaxed, overstretched, overwhelmed body systems would finally be pushed past that last tiny bit of reserve and the whole house of cards would come tumbling down.

The phone hasn’t rung. And his time may finally be running out.

It is that pit of ice that forms in your stomach as you realize that everything truly is falling apart, as you recognize the signs of total, final collapse. The sudden deterioration after weeks of fragile balance, the sudden escalation rapidly torwards the very limit of medical technology. A limit we can meet – a limit we can deliver; the entire arsenal of medicine is here and we will use it all. But there comes a point where the collapse is so total that the patient no longer has the strength left to survive a transplant even if the organ arrives. That is how too many of our valiant patients meet their last. And so it may appear to be now for him.




The three of us residents on duty this weekend – this last weekend before we hand off to the next team -- we all have the same unspoken realization as the latest set of lab values sinks in. After fighting all month to keep him alive, we know what this latest turn likely heralds. We know where this will go, barring one more miracle – a miracle we will fight to the hilt to win, if it can be won. But we know what are the odds against. And know that there is a good chance one of us will be summoned for the final duty that is the physician’s and the physician’s alone.

It is a terrible thing, one that frightens many of my fellow residents – as well it should. It *is* terrifying. Terrifying even more for someone who has never been there at the end, never been taught, never been shown by someone else how to help a family, help parents, facing the single most crushing tragedy they will ever face. Many residents never get that education; for it is a situation even most attending pediatricians never face.

I was luckier, in a sense. Long ago, in my very first clinical duty, fresh-off-the-Step I; long ago, in the year I spent on duty in the Heme/Onc clinic as part of the first year of my research sabbatical; kind mentors sat down and talked me through, walked me through, let me watch and learn as they helped families through the moment of a child’s loss. I am in no way “good” at it – I don’t think *anyone* can ever be “good” at it – but at least I have the kind of training most residents aren’t lucky enough to ever recieve. And in the years since, perhaps because of that training, many times I have been at bedside to the very last when perhaps other residents would have shied away. Trying to live up to the standard my mentors set for me by their example. Trying to help with what little comfort, what tiny bits of humanity, are possible in the blackest of all possible moments.




One of the three of us on duty on successive nights this coming weekend will probably be called to the last duty. I hope against hope that I am wrong. But if it must be one of us, as it probably must be: let it be me. Let that burden be mine.

Tomorrow marks the ten-year anniversary of what would turn out to be one of the most pivotal turning points of my life: the date of my very first post to rec.arts.sf.written.robert-jordan (link).

Because, of all of you reading this now, either you met me first in person as a schoolmate or as a medical activist... or you met me because of events which began on that day, ten years ago now. rafwr-j, the Wolves Glen Pub, Cynnabar, Three Rivers, the RenFaire life, LiveJournal -- all of it, my entire life outside of family, school, work, activist service and church; everything else and all else, began here.

The full story detailed in A Memory of Light.

It's been a truly wonderful ten years. :-)

Flying cars! How come nobody mentioned we now have real, for-sale, flying cars?




When I was a little boy, twenty-five years ago, among many books I enjoyed reading were those speculating about what the future would hold for our daily lives. What the world of our future would be like. Of course, twenty five years into the future from when I was a little boy would be right now.

In many ways, we have, in fact, arrived in the future. Back in the early eighties, portable phones were huge briefcase sized things, and home computers had green-and-black screens and used cassette tapes for memory. Imagine being a kid back then and getting shown an iPhone. Being told that, when we grew up, we could, say, be cruising on Boston Harbor, be curious what the island off the port bow was, fire up a little handheld device, get a GPS-aided map fix to identify the island, look up information on the Internet about said island, take a movie as the island passed buy, send that movie to friends all over the world, then look up restaurant ratings for the evening meal and making an online dinner reservation. Again, all with a hand-held device. For someone who grew up with Commodore PET computers and Atari game consoles, Hell Yes we've arrived in the future, and it is Awesome.

I remember playing NetHack-like clones, with ASCII-character monsters, when that literally was the state of the art of computer entertainment technology. Imagine showing my five-year old self in 1981 today's World of Warcraft, or EVE Online. Dude, I hear my alternate-reality little five-year-old self squeeing. ;-)

Or how about drawing up an object on a computer, hitting "print", and having a machine fabricate that object from scratch in 3D? Check. Genetically engineering staple crops to better feed starving underresourced populations? Check. Cashing in your frequent flyer miles for a trip into (suborbital) outer space? Sign up now. In a lot of ways, we *are* in the future.

Of course, there's always the running joke: if this is the future, where the $%#!! are the flying cars?

Well, here the $%#!! are the flying cars:






Over the past few weeks, a small company led by a wife-and-husband team of MIT aeronatuical engineers have been flight-testing the Terrafugia Transition. It's a small two-person ultralight airplane which, after you land, you can hit a dashboard button, the wings fold up, and you can then drive home at highway speeds and park the plane in the garage.

Runs on auto gasoline. Gets 27 mph in the air, 30 on the ground. I could drive this thing out of my apartment garage after lunch, onto the highway, out to Spirit of St. Louis airfield where our medivac planes are staged, punch the "configure wings" button, wait for my car to unfold its wings, take off, fly the nine-hours-by-car journey home in half that time (and no traffic jams), land at Linden Price airfield, hit the "configure wings" button again to tuck the wings in, and then drive the rest of the four miles home to my parent's house for dinner and park the plane on our family driveway.

As they point out, most Americans already live within 30 miles of a small airstrip from which the Transition could take off. Especially out here in the lower Midwest, where beyond St. Louis it's all tiny little towns admist vast flat plains, tiny litlte towns with tiny little airstrips -- or long stretches of straight highway. Instead of crawling around long detours along backcountry roads, just fly from point to point. It's surprising just how much extra mileage you have to tack on simply because there's no direct road: for example, to drive from St. Louis Lambert International Airport to Detroit Metro is 542 miles by car -- but only 439 by air, almost a 25% difference. Stack that together with the obvious speed advantage of being in an airplane, plus avoiding traffic jams and road construction, and you're talking some serious time savings in a vehicle you can literally drive/fly/drive from door to door.

There are all kinds of limitations with this first model -- most notably, it's an ultralight airplane, not a full airplane, and so isn't rated for weather or night flying, for example. But the real point is that if we can do this now with *today's* technology, imagine what'll happen as composites get cheaper, as engines get more powerful and compact and fuel efficient. If we're already at the point where a freaking flying car (or, more accurately, drivable airplane) is in the same cost range as a 40-foot sailboat, just imagine where we'll be with another ten or fifteen years -- or twenty-five years -- of technological development. We don't drive around routinely in flying cars, but my children -- or my grandchildren -- really just might.

More about the Terrafugia Transition here.

The Future is Here, and it is indeed Made of Awesome. :-)

The teen gunned down at such point blank range the plastic shell casing is jammed deep in the dinner-plate sized entry wound. The high school boys with limbs nearly shredded off by gaping ballistic wounds. The ones who flatline -- are Code Blued back -- flatline -- multiple times before they even get out of the trauma bay, and then multiple times more in the OR, as surgeons feverishly try to tie off everything that's gushing blood. Pints and pints of packed red blood cells and platlets and cryro and FFP that you pour into a patient in a frenzied effort to keep their circulating blood volume up, pouring products into them at just slightly faster than the blood oozes -- or gushes -- back out of them.

A stunning number of these kids actually survive it all, at least long enough to be hauled into the Pediatric ICU, where the fight to keep them alive will rage on for hours and days. Where the team waits for "demarcation" -- the sanitized word for waiting to see what parts of the body, what fingers, what feet, turn black and die because the bullets destroyed their blood supplies. Sharp edges between living and rotting tissue, which tell the surgeons where to cut and cleave.

Long enough to hear the inhuman sound of anguish one a young teenage basketball player makes when they wake up for the first time days after the shooting and finally realize what's missing. The bottomless terror of loss expressed as he wildly swings the stump of a limb no longer there.

Those are the ones who make it. There are also those who do not. When the code gets called long after all hope is gone, and a family of moms and grandmas and siblings and cousins are escorted into a conference room, where we have to tell them that their son, their daughter, is dead. Family members who often had literally no idea just what their children were up to before it got them killed -- or children who did everything "right" except for being in the wrong place at the wrong time. A child carried in the womb, raised every day from birth -- dead. Gone.

And then there was the young teen dumped -- literally dumped -- in the ambulance pathway the other evening.





The car sped into the drive -- slowed barely a moment -- a heavy thump -- and then the squeal of wheels racing away into the darkness. On the concrete a young teen lies crumpled, shot repeatedly, bleeding out onto the pavement. A desperate fight to keep the flagging heartbeat alive while blood pours out of too many holes, a fight the trauma team eventually loses. A young life gone -- without a single clue who that life once belonged to.

No identity. No names. No information. The young shooting victim arrived and expired with nothing more than the hospital default identity tag used for such situations -- "TRAUMA A####" -- in place of a name. The trauma staff have no idea who even to contact, no idea where to even begin. And as the day goes on and noone reports in, the possibility begins to rise that we might never find out.

Perhaps there is a worried family, not even realizing their child is already dead. Perhaps there is no family at all, the teen having run away or left behind roots and origins. Perhaps there *is* noone who will even notice, noone who will even note, noone who will even care. Fingerprinting, dental records, DNA typing -- those only work if you have something to match the evidence from the body *to*. The Wash U staff will make a valiant attempt -- but the odds are dramatically against success, especially with the young, who are less likely to show up in databases of such information.

The staff carefully clean and wrap the body, transport it to the morgue once seen in the entry A Voice From Cardiff. But it cannot stay there indefinately, for we do not have room to keep it there so. When noone claims it within a few days, the body will be handed over to the St. Louis City medical examiner; and from there, eventually, an anonymous grave in a potter's field. A young life disappearing without a trace.




This week is my last week on the Pediatric ICU service. Next week, I begin nights on duty in the Emergency Department and the trauma bay.

Old friends and new friends, "borrowed" friends and Blue (and Gold) friends -- it was my first two-day weekend off in two months, the first since Terpscichore (Kazoos and Swedes), and thanks to so many friends, it was a wonderful one. A post, in celebration. :-)





Part I: Port Huron

Just as texas_tiger had done just two years before, fortuna_juvat found a way to get me to the church in time. :-)

I'd brought my garment bag with me to the hospital to the beginning of my thirty-hour shift on the Pediatric ICU. My attending was generous enough to allow me to round on my patients first. I was able to change to my suit in the callroom, with the geeky tie malada and deor had so kindly given me long ago. And so I signed out to my colleagues in suit and tie at noon - raced out by taxi to the airport by 12:45 - airborne by 1:30 - landed at 4:00 where one of fortuna_juvat's kind friends was waiting at curbside - and pulled into the parking lot at the church just in time. :-)





fortuna_juvat looked radiant in her dress. And very, very happy. And had incredible dance moves. :-) I spent the car ride getting to know many of her medical friends from Wayne. And she seated me at the reception with a whole group of her geek friends, with which I had a marvelous, silly, geeky evening. From both groups, many newly met merry folk on a wonderful afternoon marking a joyous milestone...




2006, 2007, 2009



I don't remember the exact details of how silmaril "introduced" fortuna_juvat/inked_caduceus and I over LiveJournal -- I don't remember if silmaril pointed me to fortuna_juvat or vice versa; and I have no idea how silmaril first "met" fortuna_juvat over LiveJournal in the first place. But I was lucky enough to have had the introduction made, to have gotten to know fortuna_juvat over her parallel LiveJournals during her first two years in medical school. Of the medical side of the shared journey I wrote a happy celebratory entry yesterday. And like her parallel LiveJournals, a friendship which began online turned into a merry, marvelous in-person friendship to match, which is how I ended up, thanks to her kindness and the kindness of her friends, dancing the Time Warp with her and her friends one late May Friday evening. :-)






We first met us in person in the story she captured in Super-fabulous awesome day. Met a whole gaggle of rasfwr-jians at a grand shindig at missysedai's place (A Lazy Sunday at Missy's). Michigan Renfests (Dancers and Pirates and Then You Go to Jail, Postcards from Hollygrove) and SCA Dances (To Drive the Cold Winter Away, Fi de tristesse!). Many merry adventures over many happy years, as she fulfilled her childhood dream of becoming a physician and found happiness in love. Very, very lucky once again I have been to have been so kindly befriended by a geekette such as she; and very honored I was to share in her special day. And in one final incredible stroke of luck, once the dust settles from her next move and mine, we'll end up being *closer* to each other than we are now, just up and down a stretch of I95 between Mercer and Hopkins/NIH.

Sincerest congratulations one last time, fortuna_juvat/inked_caduceus, and best of luck. And here's a toast to the adventures to come. :-)







Part II: Pickney

Months earlier, aelkiss and niquerio, learning that I was going to be back in town, had decided to organize a weekend of camping and music and song in the same beautiful country we had explored a year earlier (The Beaches of Hell Livingston County). And so it was many old Cynnabar friends and many new Cynnabar folk who had joined the music and song community since I had left Cynnabar gathered for a afternoon and night of singing and outdoor feasting and geekery. Even two of the geeky folks whom I had just spent the previous evening at the reception with joined us as well. And it was all great fun.




The food cooked around campfire was excellent. Song after song was sung, in four-part harmony and musical tunes we all knew. A long lazy afternoon turned into a sunset-painted evening and then a fire-lit glow below and the brilliant stars high above, old friends and new friends and memories more.

Sincerest thanks to all the folks who came out into the woods to share the day with me. And sincerest thanks of all to aelkiss and niquerio, who organized the whole event really in large part just because I was going to be there. Vive le compangnie. :-)









Part III: Livonia

I had actually been there the night before. fortuna_juvat's friend generously dropped me off in Livonia at annewashere's home. The rasfwr-jians had left the door open and the light on for me. And so after an evening spent meeting many new friends, coming in past midnight with friends first met almost a decade ago.

A long lazy morning catching up, then a taxi to the airport to rent a car to head out to Pickney. The morning after, I was originally supposed to have breakfast with a cardiothroasic surgery friend early the next morning, but then after those plans got sidelined by his ward duty, some quick reshuffling of plans and I was able to swing by, pick up Jesse (and recieve the wonderful gift of her doctoral thesis), and head back to Livonia with Jesse and visit many old friends yet again.

annewashere shared homemade yummy waffles with real maple syrup. silmaril and Jesse and I played badminton (with two rackets and a paper plate in lieu of a third -- twang twang *THWOCK*) and much conversation was had with old friends not seen in far too long. A house full of old friends and good food -- almost thirty Socials I have been a part of since the first almost ten years ago. And a wonderful yet all-too-short time it was, once again.









Part IV: Ann Arbor

One of the major advantages of having rented a car was the ability to revise and rearrange plans on a drop of a hat. And so it was when my old friend C. had to cancel the original early morning breakfast plans I could quickly reshuffle to spend the morning in Livonia; and then, when his ward duty just as suddenly opened up again, be able to swing back to Ann Arbor to catch up with him; of which another separate entry will be written. And then to end the weekend with a Memorial Day barbeque with my parents, aunts, uncles, and family; and congratulate littleholly in person for the first time since on her hand she recieved the gift of a ring. To end a wonderful weekend surrounded by loving family -- the best way to end a weekend of all.









The thirty-hour shift from which I left ended with a young patient shot in the head.

The thirty-hour shift I immediately returned to began with the death of one of our patients and that room immediately being reoccupied by a little girl horribly burned by battery acid.

But in between, a weekend's respite, with friends old and new, borrowed and True Blue; and family, loving and beloved.

Well, that was the most brutal 34-hr shift I've ever had. I've slept nearly continuously since coming off yesterday afternoon and I *still* feel like I've been run over by the Calon Shield Wall. And in no physical shape to hang out with friends at St. Louis Renfest today, alas.

But to happier news. :-)






Today is the Hooding. Tuesday, at Detroit's famed Fox Theatre, the graduates will cross the stage one last time.

Sincerest congratulations to *Doctor* fortuna_juvat/inked_caduceus MD, *Doctor* spartanmd MD, and *Doctor* legeix MD, members of the Wayne State University School of Medicine Class of 2009. And warmest welcome to the ranks of the profession of medicine. :-)









I'd like to take a moment to make a particular shout-out to Kat. :-)

A lego hospital at age 8. The "When I grown up" speech in year 4. Dressing as Florence Nightengale for Halloween. Medicine has been a part of me for as long as I can remember. I don't know if I could separate the rest of my identity from my desire to be a doctor; I've never been without it.


-fortuna_juvat, in The road to med school

Kat's a Geek. A proud geek. Book-loving, roleplaying, Con-going, Con-presenting, Team-Fortress-playing, corset-wearing red-headed Geekette with capital G. She's witty and funny and passionate, enthusiastic and brilliant and as many have tagged her, "Penguicon's official Hot MD". And she's wanted to be a doctor since she was a little girl.

She captured the pre-med journey in her own primary journal, at fortuna_juvat, along with her adventures in Geekdom and study abroad in Australia and all else. And when she won her seat in medicine, she began a second, parallel LiveJournal at inked_caduceus, to chronicle her story from literally the very first day of medical school.. Through basic science bookstacks and USMLE Step I and days in the life on wards, she's shared that road with us.

One of many physicians among my LiveJournal friends, she stands out as one of *the* most enthusiastic med people I know. Her twin journals capture not just the determination but the excitement with which she has tackled her medical work; for Kat, medicine has been not just a calling but a passion. More than almost any other young physician I know -- on or off LiveJournal -- life in medicine makes her happy, a life she shares with her family and friends and all kinds of geeky adventures.

I've always been in awe of her spirit and deeply admired her joie de vivre in the midst of the brutal cadence which is life in medicine. A life she has not just accepted, but pursued almost her entire life. And now today she accepts the traditional forest green velvet Hood; the robe with the triple black velvet chevrons on it's sleeves; the long white coat; the title before and the initials after the name; all the symbols of the physician which are now hers by right of achievement and conquest. She has shared with us all the entire journey from first day onto last. Today, we her readers -- we, her friends -- share in her richly-earned celebration.











She's brilliant, she's funny, she's passionate and beautiful: and today, she's a doctor. Once again, once more: heartfelt congratulations, dear *Doctor* Kat. :-)

A post for this past Memorial Day

To the southwest is Fort Leonard Wood, one of the US Army's primary Basic Training bases. To the southeast is Fort Campbell, headquarters of the 101st Airborne. To the east is Scott Air Force Base, headquarters of the 18th Air Force and the Air Mobility Command, center of the US Military's airborne transport fleet. St. Louis is the nearest major city for a substantial number of military personnel here in mid-America. Troops of olive-grey-green digi-cam fatigue clad soldiers are a common sight snaking their way through the terminals at St. Louis' Lambert International Airport. And their children are a common presence here at Wash U / St. Louis Children's Hospital.

For many children whose mother or father is based at one of the region's many facilities, Wash U / St. Louis is the nearest lung transplant center, nearest Phase I oncology center, nearest pediatric neurosurgery center. And many more are the children whose parents are based elsewhere or have been deployed to the frontlines of Iraq or Afganistan, and so the children stay with spouses or families living in the vast region that Wash U is the primary final referal center for. To the sands of Anbar and the mountains of Kandahar America has sent her sons and daughters. And *their* sons and daughters are among those we routinely serve here at Wash U.

Say what you will about the decisions the previous Commander in Chief and his administration made. Say what you will about the previous Commander in Chief and his administration, with regards to their planning, to their decision making, to their prioritization and their heed of evidence or history. Say what you will about the current Commander in Chief's handling of what he has inherited from his predecessor. History will certainly have much to say on all those accounts. But history is for the future, and that will take care of itself. For now, our duty and our privelege is to care for the soldier and the veteran sent off to fight, a story told in The Lights at the VAMC, from service as a medical student on Internal Medicine and Psychiatry. And now as a pediatrician, our duty and privelege is to care each day for the children those soldiers left behind.

We set aside particular days on the calendar to remember and honor our soldiers and our veterans, and this is appropriate and good. But far more important is what we do on all the rest of the days of the year to support those who we let our government send off to war. We owe each day our best to all the children we are priveleged to serve; but we have a special debt to the children of the soldiers, sailors, and airmen sent abroad. On our cancer services, our surgery services, our intensive care units, we fight for the children of those who our country ordered into battle. They who serve left their children to our keeping. And in this trust, we shall not fail them.

Sincerest congratulations

to Dr. fortuna_juvat / inked_caduceus

on the occasion

of her wedding day

and deepest gratitude

for her kind invitation

to share in the celebration.

:-)







Now in a house in Livonia full of old friends; before heading out to Ann Arbor tomorrow afternoon, to make revel with yet more old friends; and then to end Sunday with family. More to come. :-)




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It has been a very hard day. It will be an even harder, sleepless night. But in between, a moment to catch a breath and a bite.

Through the west-facing windows of the Pediatric Intensive Care unit, I can watch the sun set into the arbors of Forest Park while waiting for our next patients to arrive, halfway through another ferocious thirty-hour shift.

By the time the sun sets again, I will be in Port Huron. And then Livonia. And then Ann Arbor. And literally dozens of friends, many I have not seen in far too long, await.

Packed in my garment bag stashed in the call room, I have my special Geek tie, the sky-blue tie imprinted with the secret message in binary ASCII on it, the one malada and deor gifted me with so long ago. The perfect tie for the suit for the wedding I will be at, this time tomorrow. And then a Social, and then music and dancing and song until the stars soar high into the sky.

I have not had two days off of work in a row in nearly two months. One last long, hard night lies ahead. Beyond that, the wild rumpus awaits. :-)

Trauma pagers went off.

Another little kid. Shot in the back of the head. Should be here shortly.



There are no words.

So in my previous pizza-centric entry, my dear friend dawntreader42 (background) invited me up to her kitchen in Boston, for baking merriment. :-)

I like cooking. I enjoy cooking. Born with my family's metabolism like a furnace and a home where my mother was an excellent cook, cooking is something I got an interest in very early. And my mother involved Gauss and I all the time in cooking and baking, from which my earliest lessons come.

Many friends of mine have real genius in cooking, that instinct and artistry that can do amazing things in the kitchen. I have none of that natural talent, alas. I'm merely someone who after eight years of molecular biology training and three years of clinical medicine training have learned to be decent at using my hands to accomplish precise tasks and following instructions. I can't create food like art; but I can at least do food with the same competence as a cell culture experiment or a lumbar puncture. :-)

My mother began my cooking education growing up; and many kind friends have generously advanced it. I have many fond memories of puttering around missysedai's kitchen, and silmaril's, and aelkiss', and Jesse's, and ladybird97's. Happy stories like Cookie Book Stories and Swinging in the Sunshine. Or cooking in public, like the stories Dishes at Delonis, In the Eagle's Kitchen, or To Serve it Forth. Cooking is wonderful. Cooking with dear friends even more so.

It's not that I'm looking forward to leaving St. Louis -- I am deeply grateful to Wash U for all it has given me and all that I have learned here. And I am just as grateful to my wonderful friends here, and am sad to leave them behind. But it will be wonderful to be able, once I am out there, to be able to hop up easily to dawntreader42's kitchen in Boston. Or for her to come down to Baltimore/DC and play around in mine, and for her to meet all of my wonderful friends in the Baltimore/DC area just as she introduced me to hers in Boston. Or for that matter, to return to NYC for more omelets and biscuits with ladybird97 and host in return. Or to finally try Jesse's father's famous cheesecake. And with so many other friends, so much more.

The story is just beginning. And there will be many pies -- and cakes, and cookies, and all else -- to come. :-)

And so, inspired by the unplanned outdoor dining experience at a local pizzeria courtesy of an exploding power transformer (see previous entry), time to talk about something important: pizza.





Growing up, I have many fond memories of making pizza at home with my parents and Gauss. We used to make pizza dough from scratch in the rice cookpot, set it by the floor vents to gently rise (with a lid with a see-through window so we could come by every so often and see how far it grew), stretch it out on a cookie sheet and then top if off with a riot of toppings.

And then I went to the BS/MD program at Northwestern, in Chicago.

Now, my family already knew what "Chicago-style" pizza was. My older cousin Paul had done his MD work at Northwestern a few years before I came, had raved about Chicago style, had even brought stuffed spinach pizzas home to Ann Arbor for us all to try. My parents and Gauss and I had first eaten at a chain Pizzeria Uno's in Rochester, NY, and had immediately fallen in love with deep dish pizza.

What I hadn't realized was that the chain Uno's was simply an *imitation* of True Chicago Pizza. The *original* Uno's in Chicago's River North -- which I ate at my first weekend at Northwestern -- serves a substantially different -- and far better -- deep dish pizza. In addition, Uno's is just one of many competing Chicago Style pizza places, which Chicago residents debate the merits of with the fury usually reserved for religious conflicts and Big Ten sports rivalries. Gino's has it's partisans. Giordano's -- with it's branch just easy walking distance to Northwestern's campus -- was a favorite "get-away" lunch spot during summers otherwise spent eating ramen in rented roach-infested fraternity housing. Lou Malnati's - founded by the chef who actually created Pizzeria Uno's first deep dish pizza -- is Gauss and I's current favorite, and a Must Order every time I come up to Chicago to visit. Although, recently, I have heard rumors of a deep dish pizza place even *better* than Malnati's...

My family is a family of huge eaters, born of ridiculous metabolisms constantly requiring food for fuel. (Yesterday's breakfast before call was four cups of oatmeal. Dinner the day before was two quarts of rice and vegetables and fish.) Deep dish pizza, with it's thick, crunchy crusts, nearly a literal-inch thick deep layer of pure mozzarella and piles upon piles of toppings, thick tomato sauce rich with chunks of tomato -- *this* is the kind of food perfect for eaters like my family. This is food that's too heavy for regular paper plates. This is the kind of food which makes diet gurus whimper and cardiologists start thinking about the upholstery in their next Rolls Royce. This is the kind of food which makes a sixty-four ounce steak -- another Chicago favorite -- look positively lean and healthy. I've had the privilege, over my years of scientific and activist work, to eat in some of America's finest restaurants, from New Orleans to Waikiki. But if I got to pick one meal to eat before the Vogons demolish the Earth to make way for a hyperspace bypass, I'd have one more deep dish pizza from Lou Malnati's.

And then, I moved to St. Louis.




Now, St. Louis has many wonderful things. It has Wash U, one of the nation's top five NIH funded medical centers. It has the marvelous Barony of Three Rivers. It has the City Museum, as told in this happy story. It has Music Folk, as told in this happy tale.

But not all is good in St. Louis. There is, after all, St. Louis pizza.

Now, I understand many of my Calontiri friends actually enjoy St. Louis pizza. I treasure my friendship with these dear friends. But they are, with all due respect and great affection, clinically batshit fucking insane.

I have my own opinion regarding St. Louis style pizza. In my opinion, St. Louis style pizza is not good. It is the exact opposite of good. St. Louis style pizza is not just not good, it is an atrocity. It is a crime. It is a crime against pizza, a crime against food, a crime against all that is Right and Good. If Chicago Style Pizza is what they serve in heaven, St. Louis style pizza is what they serve in Hell, except Lucifer wouldn't want that shit a thousand leagues near Hell.

What's wrong with St. Louis pizza? St. Louis style pizza is like the Star Trek Dark Mirror version of Chicago Style Pizza. It is everything good about Chicago Style Pizza, but inverted and passed through a cosmic colon. Whereas Chicago style pizza is thick and hearty and could be used as a blunt trauma weapon, St. Louis style is paper thin and flimsy and an entire "pizza" could be rolled up into a single blob not that much larger than a single slice of properly done Chicago Style. Whereas Chicago Style has thick, crunchy crusts around the rim, St. Louis pizza doesn't even *have* crusts. Whereas Chicago style pizza can have more meat topping than an average sized steak, more vegetable toppings than your average salad, and a rich tomato sauce that still has chunks of honest-to-god tomato in it, St. Louis pizza has a smear of runny tomato "sauce" and a pathetic scattering of toppings.

And while Chicago Pizza has pounds of pure mozzarella cheese in chewy layers, with the occasional other pure cheese component, St. Louis pizza has -- okay, what the fuck is Provel, over? Provel? You literally can't even legally sell Provel as "cheese". You cannot legally call Provel on food packaging "cheese", since Provel fails to meet the official FDA standard for cheese. Provel is a "processed cheese", in the same category as American "cheese" and Velveta. Provel is not only an adulterated, factory processed and pasturized cheese food product, Provel doesn't even bother to contain mozzarella even as a component. Provel is a stewed, melted, and processed collection of provolone, swiss, cheddar, and other non-cheese ingredients. Putting cheddar and swiss on a pizza is already seriously suspect, although tolerable, had it been actual real cheese. No, Provel is a *processed* aglomeration, the end result of food factory manipulations leading to a plastic-wrapped off-white blob which St. Louis residents actually voluntarily put on food.

Provel is the sort of thing that makes cheese afficianados reach for a gun, either to shoot the Provel makers or shoot themselves. If you tried to give a Chicago resident Provel, they would first club you senseless with the rubbery brick of pseudo-cheese, and then throw you and the Provel into the Chicago River, except no Chicago resident would want to pollute their river and even if they did, the River would probably throw the shit back. The wikipedia article on Provel notes: "Although popular in the St. Louis area, Provel is rarely used elsewhere." If the entire rest of the fucking human race won't touch your food product, You're Doing It Wrong!

There are Chicago style pizza places in St. Louis. There are no St. Louis style pizza places in Chicago. There are, in fact, no St. Louis style pizza places *anywhere* except St. Louis. This should tell you everything you need to know, if my previous few paragraphs of rant hadn't made the point abundantly clear. Chicago style pizza is something you savor. St. Louis style pizza is something you inflict. People of sanity, when faced with the choice of eating St. Louis style pizza or skipping dinner... get in their cars and drive to Chicago.

That being said, apparently the best Chicago style pizza... is in St. Louis.




My curiosity was recently piqued by a bit of local news. A few years ago, a chef named Chris Sommers opened up a deep dish pizza place called Pi's here in St. Louis' Delmar Loop. Now, Mr. Sommers calls his pizza "San Francisco style", as he borrows the dough from the famous Little Star San Francisco pizzeria. But both the cornmeal containing crust and the deep-dish style directly trace their lineage to Chicago style pizza, and the glowing reviewed of Little Star all universally classify the product as a Chicago Deep Dish. Any way you slice it, good old-fashioned Chicago style deep dish pizza here in the heart of St. Louis; and Pi has shot up the St. Louis favorite lists.

This past fall, a staffer for a visitor coming through town ordered some pizzas from Pi's to be delivered to where they were staying. A few hours later, a surprised Mr. Sommers took a phone call directly from said visitor, who called it the best pizza he'd ever eaten. In fact, said visitor liked the pizza from Pi so much, he later invited Mr. Sommers to come bake some more pizzas this spring at his house.

The White House.

True story -- Barack Obama, while on a campaign swing through St. Louis, first tasted the pizzas from Pi when a staffer ordered them for the team. Senator Obama actually phoned Mr. Sommers that night to say how much he liked the pizzas. So much so that now-President Obama invited Mr. Sommers to come to the White House this past April to bake some more pizzas. (For the record, no taxpayer dollars were involved, as Mr. Sommers reports that he paid for his own airline ticket, paid for the ingredients, and stayed with the family of his girlfriend.)

Keep in mind that President Obama himself didn't just live in Chicago. He met his wife in Chicago, was married in Chicago, his children were born in Chicago. He was an Illinois State Senator from Chicago, a faculty member at the University of Chicago, and lived in Chicago while Senator from Illinois. It is reasonable that, like most Chicago residents, President Obama has had his fair share of Chicago style pizza. Not to mention surely having eaten pizza from coast to coast while on the campaign trail. So when a long-time Chicago resident likes a particular *St. Louis* Chicago-style pizzeria enough to specifically invite the chef to drop by the White House, well... that's got to be some amazing fucking pizza. Certainly worth a shot.

At the very least, it won't be St. Louis style pizza. ;-)

... and of course, leaving the hospital for the first time in thirty-two hours, discover my entire neighborhood outside the medical center has no power.

First clue was the total traffic snarl in front of the north gate of the Wash U med complex and the complete absence of streetlights -- which took me a moment to notice in my post-call state. Then the complete absence of lights in all the restaurants up Euclid -- some shuttered for lack of power, some merrily serving food outdoors. And so on all the way back to my apartment building which, like every other building in a three zip-code radius [1] outside of the Wash U medical center complex, has no power.

Fortunately, I always carry a flashlight with me -- my physician's penlight is a nearly indestructible industrial model manufactured by Energizer that can light up a room [2] -- so I could actually *get* back to my apartment through the now dark hallways and stairwells of my building, lit only by the occasional emergency light. For all the good that does, given I don't dare open the electric freezer and refrigerator; I can't cook with the electric microwave or stove; I can't do my piles of laundry in the electric washer and dryer; I can't get my car out of the electric-powered garage door; and even though I can boot my computer on internal battery power, there's no working wireless node within ten city blocks, except back at the hospital.

Which is where I find myself back again, since there was a phone number I *had* to call this afternoon, and it was, of course, in my e-mail.

See, now, this is where a counter-top Zero Point Energy Generator would have come in *so* handy...






[1] The local power company has a neato widget which maps all power outages in their coverage zone. Of course, the people who most need the information don't have any power to their wireless nodes and cell towers, but it's the thought that counts. :-)

[2] After wearing out or breaking lots of the cheap plastic penlights, I decided to invest the few extra dollars to buy a solid, professional, won't-wear-out model. As an additional plus, the LED light consumes far less power than the usual tiny light bulbs, doesn't shatter, and produces a remarkable amount of light for the tiny bit of energy consumed. Marketed for mechanics and other professionals who need lots of light in tiny places, I figured it would do just fine for my "hey, do those pupils shrink?" and "hello, Mr. Uvula!" needs.

Fortunately, I tested said penlight on myself before I used it on a patient. After a few minutes of blinking away the afterimage from the almost-sun-bright light, I proceeded to tape multiple layers of protective masking tape *over* the end of the LED light so it would avoid frying my patient's retinas. :-)

Post-call again.

I think this is the single most brutal clinical rotation I have ever been on. By far.

By every measure -- by stress, by workload, by hours, by horror -- these few days on the Wash U PICU and the two call nights I've been on are the hardest I've ever done. I can feel the exhaustion in my freaking bones. And the nightmares every time I sleep. There's a reason why the moment I asked my classmates if someone would be willing to trade their 2nd month of PICU with me so I could have a 2nd month instead of them, nearly every person in the class eligible immediately offered.

Yet it's different than my first rotations as a third year medical student. My first rotations in retrospect were less hard -- *everything* I've ever done is hard than this rotation now -- but there's a huge difference.

Back when I was just starting out -- and starting out later than the rest of my class -- I had the same quiet, hidden fear than everyone else that I wouldn't be able to hack it. I wouldn't be able to function on the thirty-hour run. I wouldn't be able to handle the juggling of tasks and the negotiating of clashing, conflicting personalities and everything else. I would break under the strain. That was then. This is now.

As brutal as this rotation is, deep down inside I *know* I can handle it. There's a confidence won after nearly three years of this. This rotation may be the most brutal I've done yet, in every way that counts. But the doubt is gone. Nothing before has broken me. This won't either.

They'll be hard lessons. They'll be moments of sheer terror. They'll be exhaustion beyond words. They'll be Epic ass-kickings. They'll be yet more horrible things I'll see in my sleep for years to come. And surely ahead, in my return to PICU next year, during my coming first year as a fellow, during my service as the buck-stops-here attending someday -- they'll be harder challenges to come. So be it.

Nana korobi / Ya oki


Fall down seven times / Get up eight


Traditional Japanese proverb