Learning to ingest the less than palatable

At some point in my formative years, having been brought up on traditional Pennsylvania Dutch cuisine, I was introduced to pudding. As I recall, I didn’t care much for the texture or the taste.

I quickly learned that to ingest pudding, you had to add a generous coating of pungent mustard and a saltine cracker to make it semi-palatable. To this day I do not seek it out, preferring ring bologna or souse instead.

These days I am fully grown. Far from being force fed, I can comfortably pick and choose those substances that I care to ingest — for the most part.

Which brings me to the electronic medical record, a concoction which I am forced to swallow and digest daily. more»

Interested readers can examine my thoughts on this issue in my latest Musings blog post newly published in the Journal of the American Academy of Physician Assistants.

Presents and presence — Good gifts

This past Wednesday evening, the day after Christmas, I sat at my desk, staring intently at the monitor of the computer. There, amidst frozen swirling splotches of green, yellow, purple and blue, rested a stationary icon — a tiny orange airplane with a pink line emanating from the tail. All of this was superimposed on a map of the eastern United States. The software was tracking American Airlines flight 1581, en route from Bradley International Airport to Dallas, Texas.

I had a special interest in this flight, because my eldest son was on board. He had come home for Christmas. As always, the time was short; and so we made the best of the three days we had together. After a final meal of smoked ham and sweet potatoes, I drove him to the airport to catch his flight. Because of the impending storm, it was delayed nearly two hours; but unlike many other flights that evening, it was not canceled.

After I returned home from the airport, my youngest daughter went out to get gas in her car. Meantime, the snow had begun to fall.

My other daughter, sick with a nagging cough for the past two weeks, telephoned in a panic. She couldn’t stop coughing — she could barely get out the words over the phone — and she wanted to know what to do.

In the midst of this hubbub I had opened another browser window on the computer. Intermittently, I read Maureen Dowd’s NY Times column “Why, God?” In view of the recent spate of violence in Newtown and elsewhere, Dowd had asked a special guest to offer some thoughts on the holiday season.

Father Kevin O’Neil has shown himself to be especially understanding at the bedside of the dying. This is particularly poignant, because by his own admission Father Kevin feels woefully inadequate at such times. Indeed, he relates the story of how, early on in his career, he was called to minister to a family who had just lost their 3-year-old daughter to a sudden illness. The family was from Peru; they spoke little English, and Father Kevin spoke little Spanish. Nonetheless, he came and sat with these parents, offered what words of comfort he could muster, and stayed with them in the hospital over the course of the night. In the end the young couple seemed grateful for his presence.

Father Kevin writes that in his opinion, God manifests his presence through his people. In a very real sense God works through individual human beings to minister to a broken world.

I found some solace in Father Kevin’s words that night as I stared at the updated progress of my son’s flight on the computer monitor, as I first listened to and then advised my sick daughter what to do, as I watched the snow descend outside the window, knowing that my youngest daughter was out there somewhere on the road in the darkness.

One hour later I called my sick daughter to find that her cough had settled. My youngest daughter texted that she was driving home, taking it slow because of the snow. By then the tiny orange airplane icon on the computer monitor had passed beyond the borders of the green-yellow-purple-blue cloud.

I breathed a sigh of relief. On the map there was no discernible weather from Louisville to Dallas.

I picked up the cellphone and drafted a text message. “Tracking your flight online. Looks like the worst weather is behind you now. Should be all clear to Dallas. Safe home.”

It was.

In irons

Being ‘caught in irons’ refers to a boat sitting at, or very nearly, head to wind with sails luffing and no forward motion. Left alone any boat will eventually drift out of irons with a 50-50 chance of coming out on a desired tack.

It had been a rough week in the wake of the Newtown shootings. Each morning I read the news reports before heading into the office to see my daily panel of pediatric patients — kids of all shapes and sizes, in sickness and in health. As is the case every year, those in sickness succeeded in passing some form of their ailment along to me.

General body aches and a sore throat kept me out of the pool most of the week. By the time Saturday rolled around, I sorely needed some sustained exercise to ease my battered body. I grabbed my duffel and headed to the gym.

Not many had ventured forth that afternoon. The sky was overcast; the wind was up. A few drops of rain pelted the windshield. I pulled into the parking lot and struggled to push the door open against the heavy wind.

Inside the locker room I changed into my suit, grabbed my goggles and strolled out onto the pool deck. I chose one of the vacant far lanes and immersed myself in the water.

It was a bit rough going at first, but I soon stretched out and concentrated on snapping my forearms down through the water, alternatively sweeping them back along my thighs as I slowly crawled down the length of the pool and back.

Forty laps I counted, each 25 yards in length. After a brief pause at the wall I resumed swimming, now with a pull buoy tucked between my legs. This time I swam 36 laps, or 900 yards.

I resolved to continue the trend, successively completing 800, 700, 600 yards, alternating swims and pulls. Eventually, at a quickened pace I tooled the last swim of the set — 100 yards — before calling it an afternoon. All told, I managed to log 5,500 yards; just over 3 miles in the water.

I finished up the workout with 50 push-ups and retreated to the showers.

As I sauntered down the hallway past the front desk to the exit, I felt as though I were walking on air; my body was so light, my mind so clear. All of the mental cobwebs from the past week had been brushed aside.

Outside, the intermittent rain had given way to gusts of snow flurries. It was the day after the solstice; winter had arrived.

Stepping out into the cold, I raised my eyes to the pole in the circle at the front of the facility and froze in my tracks, caught up in the moment.

The flag stood at half mast, luffing sharply in the winter wind.

Humane Medicine — Horse sense

There is an old adage in medical practice: when you hear hoof beats, think of horses, not zebras. In other words, any given clinical presentation will more than likely turn out to be a common disorder. In primary care medicine, esoteric diagnoses are relatively rare.

But sometimes when the sound of hoof beats returns in rapid succession, the clinician would do well to consider the possibility of a zebra in the forest. more»

Interested readers can now access my latest Humane Medicine columnHorse sense: Recognizing a rare diagnosis in primary care — recently published in the Journal of the American Academy of Physician Assistants.

Humane Medicine December 2012

For whom the bells toll

Governor Dannel P. Malloy has requested that all Connecticut churches toll their bells on the morning of Friday, December 21, 2012, in remembrance of those who died in the Sandy Hook Elementary School shootings in Newtown last week.

On that day in our village church, scripture lessons appointed for the Feast of the Holy Innocents (normally celebrated on December 28) will be read. At the close of the service, at 9:30 AM, the church bell will toll 26 times as the names of the deceased are read out.

Traditionally, church bells are rung to mark the passing of the departed. We think of John Donne’s meditation No Man is an Island, which carries the final lines: “And therefore never send to know for whom the bell tolls; it tolls for thee.”

A. E. Housman‘s poem Bredon Hill comes to mind as well. Here the poet mourns the death of his beloved at Christmastide.

But when the snows at Christmas
On Bredon top were strown,
My love rose up so early
And stole out unbeknown
And went to church alone.

They tolled the one bell only,
Groom there was none to see,
The mourners followed after,
And so to church went she,
And would not wait for me.

The bells they sound on Bredon
And still the steeples hum.
`Come all to church, good people,’ —
Oh, noisy bells, be dumb;
I hear you, I will come.

Incidentally, the Feast of the Holy Innocents or Childermas — the Fourth Day of Christmas — commemorates the slaughter of those boys in Bethlehem two years old and younger, who were put to the sword under Herod’s orders. As Bethlehem was a small town, the number of those children was probably no more than 25.

In Newtown there were 20.

Coventry Carol

Lully, lulla, thou little tiny child,
By by, lully lullay, thou little tiny child,
By by, lully lullay.

O sisters too, How may we do
For to preserve this day
This poor youngling,
For whom we do sing,
By by, lully lullay?

Lully, lulla, thou little tiny child,
By by, lully lullay, thou little tiny child,
By by, lully lullay.

Herod, the King, In his raging,
Charged he hath this day
His men of might,
In his own sight,
All young children to slay.

Lully, lulla, thou little tiny child,
By by, lully lullay, thou little tiny child,
By by, lully lullay.

That woe is me, Poor child for thee!
And ever morn and day,
For thy parting
Nor say nor sing
By by, lully lullay!

At sixes and sevens

To be “at sixes and sevens” is a British English idiom used to describe a state of confusion or disarray. The phrase probably derives from a complicated dice game called “hazard.” It is thought that the expression was originally “to set on cinq and six” (from the French numerals for five and six). These are the riskiest numbers to shoot for (to “set on”), and anyone who tried for them was considered careless or confused.

The first two of the 20 children gunned down at Sandy Hook Elementary School were buried in Newtown, Connecticut, today. Last evening at a town wide interfaith memorial service President Obama read the names of those who had died in the massacre.

Yesterday’s New York Times website carried the names and ages of the victims posted in stark white letters on a black rectangular background. The post was reminiscent of the black wall of the Vietnam War Memorial in Washington, D.C. All of the murdered Newtown children were either 6 or 7 years of age.

A Hemingway quote from A Farewell to Arms came to mind:

“The sacrifices were like the stockyards of Chicago if nothing was done with the meat except to bury it. There were many words that you could not stand to hear and finally only the names of places had dignity. Certain numbers were the same way and certain dates and these with the names of the places were all you could say and have them mean anything.”

And then this:

“If people bring so much courage to this world the world has to kill them to break them, so of course it kills them. The world breaks every one and afterward many are strong at the broken places. But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these you can be sure it will kill you too but there will be no special hurry.”

Today we were busy at the office. Of the 34 kids I saw, several were 6 or 7 years old. Some were blonde, some brunette; one was a redhead. Several were missing one or two front teeth. Many were sick; a few had come in for their yearly well-child exams. Without exception, all possessed the air of childhood innocence.

After a full morning, nearly exhausted, I retired to my desk. The afternoon schedule was packed. I wondered how I would make it through the rest of the day.

I pushed my chair back, rested my head atop my folded arms on my desk and closed my eyes for a short nap.

It was almost like being back in first grade again.

Despite the myriad words

On the morning of Friday, December 14, 2012, a lone gunman entered Sandy Hook Elementary School in Newtown, Connecticut. Among the 27 victims that died at his hand that day, 20 were young children.  As yet no motive for the slaughter has been identified.

Despite the myriad words, there are no words — no words to describe the loss or the grief.

How does one small community shoulder 20 small caskets at one time?

How do 5- and 6-year-olds step over and around the bleeding bodies of their playmates as they are marched out from a place they never considered to be anything but safe? The media reported that the children were told to close their eyes as they were led out; but which is the greater horror: the copper-penny smell of newly-spilled blood in sightless nostrils; or seeing the small corpses strewn about, helter-skelter?

While seated around the table near the fireplace at our holiday office party, co-workers stroked their smartphone screens, searching for updates. One of the women received text messages from her husband, who had been deployed to the scene. Periodically, someone would rise and momentarily disappear, only to return with the latest news from the big-screen TV above the bar. We consumed our food and drink without appetite. “Don’t think about it,” someone said.

We sang a few songs, a couple of the old favorites. I struggled to recall the words; somehow the notes failed me. After dessert I rose to take my leave. Already it was dark outside.

That evening we watched the news camera footage. Only the images spoke. Many words were uttered, but they made no sense. Only the pictures spoke, and they left us dumb.