Coding ET

[I tried to embed scenes from the movie from YouTube. Of course these have been removed due to copyright violation. But probably if you look it up, someone else will have posted it.]

I was at home on my own, watching TV post-call after an ICU shift. Nothing was on, and I landed on the middle of "ET: The Extra-Terrestrial". Before you know it, government agents are surrounding the family home; soon, as ET gets sicker and sicker, a medical team starts coding ET.

When I watched this movie as a kid, I saw it through the child's eyes, and the government agents were totally terrifying. Now I see the physicians among them as basically benign, though surely misguided: in trying to save ET's life; they're running a by-the-book Advanced Cardiac Life Support code algorithm.

Apparently, there were real emergency medicine physicians involved in this scene, and although some things have changed in the way we run the same algorithm now (betrylium? huh?; and what is with those lousy chest compressions?), much is the same. You could argue with the technique: a light-hearted series of letters in an emergency medicine journal at the time went over the code. One pointed out, for instance, that ET had 6 beers earlier in the movie, and this might have induced hypoglycemia given his small size; another pointed out that perhaps an overdose of endorphins related to ET's abandonment on earth meant that he could have benefited from naloxone.

A letter in Annals of Emergency Medicine defended the scene: "As one of the physicians responsible for resuscitating ET in Steven Spielberg's movie, ET, The Extra-Terrestrial, I read with great interest the letter in your August 1983 issue entitled, "Use of Naloxone in CPR" (August 1983;12: 519-520). In that letter Drs Wasserberger and Ordog suggested that the resuscitation effort of ET might have benefited from the use of 'high-dose opiate antagonists.' I would like to inform my colleagues in emergency medicine that ET received every drug known to our specialty in our resuscitation attempt. Unfortunately, many of the drugs used, the correct dosages administered, and the procedures performed on ET were destined for the cutting-room floor of the editing department...

"I am pleased that our efforts did not go unnoticed by those with knowledge to judge and evaluate the scene. Although the process of editing changed the details and order of the events in the scene, we hope the flavor of the management of a true cardiac arrest came through on the screen." (A. Lampone, Ann Emerg Med 2 February 1984)


The emotional punch of the scene of ED being coded comes because the scene does look like a real code. Because it looks like a real code, it also looks like a form of madness in the emotional context of the children's relationship to ET. Nearby, (not shown in the excerpt above) little Elliott, who feels what ET feels, shouts, "You're killing him! You're killing him!" And poor little Drew Barrymore, then a small child, is flinching and crying as she watches the code team apply shocks to ET's chest.

Elliott is not upset because they're not giving Narcan to ET, or because the chest compressions are too weak and too slow by today's standards. He's upset because the process of coding ET seems barbaric; and totally beside the point. Most of the audience, I'm sure, identifies with Elliott. I can't help but identify with the doctors; and yet, I also recognize the emotional resonance of the scene from the Elliott point of view. There are plenty of times when we start moving forward with some high-intensity intervention, coding someone because that's our job, putting a line inside someone, whatever it is--and at the same time inside of us, some little Elliott is screaming, "Stop! Stop! Please stop!"

The marching bands of the radical left

At a bit after noon today, I heard some kind of big drum beat outside, and remembered--today was the day of the Honk! festival in which a bunch of radical leftist marching bands march down Massachusetts Avenue. They go from Somerville to Cambridge's Oktoberfest, a street festival with no particular political approach. Our apartment, near Mass Ave, is equidistant between the two points, and therefore ideally suited to notice the arrival of the Honk! parade.

What the Honk! festival lacks in polish--one band's website earnestly stated that it did not discriminate on the basis of musical ability, bless their hearts--it makes up for in enthusiasm and anarchic charm. As someone who grew up on the left, I was always viscerally bothered when people decided to go to protests and behave like a bunch of wierdos. But for all my normalcy since then, what have I accomplished politically? And despite recognizing that I have accomplished little in political terms, I am not a member of a ragged marching band with a dance troupe of slacker girls and gay boys doing cheerleader moves in front. So, in the end, I've had the worst of both worlds: I do not get to hang around and dance in the streets with a bunch of radical wierdos, because I'm not radical enough politically or culturally; but yet, I also do not get to enter the halls of power and really get things done, because, well, because of a lot of reasons.

The Honk! festival is a great community event, though, uniting Cambridge and Somerville in a Somerville confluence of radical leftist marching bands and a random Cambridge street festival. This allows the radical leftist marching bands to gather and play in different little pockets of fans and casual onlookers throughout Harvard Square; and also, presumably, allows the radical leftist marching bands to eat jerk chicken, vegetarian samosas, pad thai, caramel apples, and the other things that are served at the booths of any street fair in a big city.

Relevant to medicine? Well, there was a group called the "Pink Puffers"--a medical slang phrase indicating people with emphysema-predominant chronic obstructive lung disease, as opposed to bronchitis-predominant "blue bloaters".

By the looks of the Honk! festival, radical leftist marching bands can be found in many different places in the world; the Pink Puffers are from Italy.

Here, on YouTube already! are the Pink Puffers rocking Somerville in preparation for the festival, showing off their radical leftist marching band ways:





Representative videos from last year (we randomly bumped into the Honk! festival last year, too--it's in the neighborhood, and hard to miss once you hear it): here we have New York's Rude Mechanical Orchestra. This year they were standouts, playing this same song, "Matador", by Los Fabulosos Cadillacs, as they marched down the street.



Apparently "Push It" is also a favorite:


This does make me think that just as this emerging tradition among the radical left is doubtlessly fuelled by the many former marching band nerds who went on to read Gramsci and Emma Goldman in college, surely too the medical community also contains many former marching band nerds. The medical community's events would doubtlessly be more entertaining with medical marching bands as part of our professional and cultural tradition. I suspect the psychiatrists would blow everyone else out of the water, but I bet that infectious diseases has a lot of closet marching band geeks, and they could be contenders. And I'm sure surgical specialties, if combined, could roust up a fair number of brass players.

No, I don't see it coming any time soon. But, you never know.

Our farmer

A member of our CSA, on our farm's Facebook page, laying out a week's small share on the counter, and sharing the photo with the world.

Today was the last day of the year to pick up produce from our farmer. Our farmer is an old punk rocker, now a single dad and farmer. His son (who is maybe 6?) was enthusiastically shilling the hen-of-the-woods mushrooms that our farmer was selling as an extra if we wanted to add it to our regular farm share: "It's fifteen dollars! You have to buy them!" No thank you, I said, bemused.

This last couple of pick-ups are extras beyond what we originally expected. We'd negotiated which of our two-out-of-three bonus sessions we'd attend, because we're going off on vacation soon, and getting married. He remembered this, and cut me off a hunk of hen-of-the-woods mushroom and said, "You're getting married, right?" Yep. "It's a gift." His son, still in salesman mode, shouted, "Fifteen dollars!" No, our farmer told him, it's a gift.

Our farmer has been frustrated and disappointed all season. Earlier this summer, the weather was so lousy that even our NPR station had started doing lengthy stories about the fact that it was raining; and we heard him on the radio talking about how the rainy weather had flooded out his corn. That was how we knew we were able to prepare ourselves for the disappointment of not getting any corn from our farmer later in the summer. We did get lots of good greens, though, and turnips, and radishes, and green beans, and cilantro, and kale, and some green tomatoes and some red ones. It was a tough year for our farmer. He was a little bitter, a little sad-seeming, and a lot apologetic at the end of the season.

But we were happy. It was our first season with a community supported agriculture program, and although it was apparently a bad year for our farmer, it made a tough summer a little sweeter to go get our produce from our farmer every week. Every Thursday we'd go to a corner about six blocks from our house, where he'd have a truck pulled into someone's driveway, handing out produce, often with some other guy who looked like he was probably an old punk rocker too. (Old punk rockers don't wear punk clothes any more. I'm not sure why old punk rockers look like they were once punk rockers, but there's a look. I think there are a lot of people in Narcotics Anonymous who look like that.)

"Large or small?" he'd ask when we approached--the two categories of shares. We had a small share for the two of us, so we'd hear instructions something like "One each of each of these, then a pound of the beans, and three peppers." We'd fill one of those reusable grocery bags with our loot for the week, and come home and have farm dinner--this year, very often roasted root vegetables and a salad, and then from the big store, maybe some turkey sausage or some chicken. Everything tasted great, and it was pleasing too: it was from our farmer.

There is no particular reason that all kinds of people couldn't have a farmer. Back in my hometown in California, there were Hmong families taking spots of empty land in poor neighborhoods, and farming the hell out of those little spots, suddenly bursting with green. They fed their own families, I'm sure; but with just a bit more land--knock down a couple foreclosed homes that aren't getting sold, till the land, and make a neighborhood farm--you could imagine these folks becoming neighborhood farmers, so that people would amble down the street and pick up the week's produce from their farmer.

I know from my dad--who's spent his life thinking about stuff like this, and in many ways dreaming of the day that ordinary people would be talking about going to their farmer like they talk about going to their doctor or their hair cutter--that there are all kinds of reasons this is harder than it sounds. Still, I'm kind of incredulous and pleased that by paying a sum up front that is almost certainly less than what we spent on produce last year over the same amount of time, we got great produce every week, from an old punk rocker who we can call our farmer.

Our farmer: there is something about these kinds of relationships that is different than the more fragmented retail marketplace, something that is important and good. It is how I want people to feel about having me as their doctor; I want them to see me in good times and bad. And even when they see that I'm frustrated with the insurance system, or apologetic that I'm running late, I want them to feel that I am their doctor, like I feel that my farmer is my farmer; and to feel like, at the end of the summer, they got a decent deal even in a bum year.

Joe Wilson's war

For all the fuss about Joe Wilson disrespecting Obama by shouting "You lie!" (to which, it can only be said, he never would have said that to a white president)--

the biggest crime is not disrespecting the president, but that he was doing so in the cause of trying to make sure some Guatemalan girl can't deliver her baby, and some Chinese guy can't get treatment for HIV infection, and some old Mexican lady is going to die for reasons regular medical care could have prevented.

And now, politicians are bending over backwards to say, Joe Wilson is disrespectful, but to his larger point, they only respond, please, fellow Americans, be assured, we won't be taking this love your neighbor thing too far.

Night float

Our department chair decided at some point that the people on night float shifts--interns who cover the medicine patients overnight, and residents who admit new patients coming in after the regular teams have stopped admitting--should have a teaching session. And so we met this morning, all the night float residents and interns. I've been doing a pinch hitter sort of job, in which I do overnight medicine consults and also support the night float interns; next week I'll be doing admissions. The relationship among all of these people is an odd one. Except for me (because I spend a reasonable amount of time checking in with my early-in-the-year interns and backing them up in various medical crises), we are mostly working alone. But we see each other through the night, crossing paths in the hallways or sharing a workroom for an hour here or an hour there.

In our conference this morning, we started talking about a patient. It turned out she'd been admitted two days prior by one of the admitting residents. An ICU resident on call overnight came down to evaluate her when we thought she might go to the ICU, and spent a good long time afterwards thinking about the patient's situation. In a workroom, thinking aloud, getting excited about some ideas about the patient's situation, the ICU resident talked to another nightfloat resident, and had pitched her theory to a couple of us. One of the interns had been called a couple of times to go see her overnight, and I'd gone to back him up for some of the hairier calls, and I had helped arrange the patient's possible transfer to the ICU before we decided she was OK to stay on the regular medical floor.

In conference, then, the admitting resident presented the case, but the group started talking about it in an engaged and interested way, because so many of us had thought about the patient, cared for the patient, or heard about the patient already. I'd seen the admitting resident a couple of nights before and had talked about this patient even then, because the resident was excited about the admission. She wasn't too busy and with an interesting case to think about and read about, she got the chance to do real medicine instead of setting up a holding pattern to be handed off to the day team. I'd spent a long time thinking about the patient when I was trying to figure out whether she should go to the ICU. And the nightfloat intern had spent a lot of time seeing the patient because of multiple problems over several nights, trying to figure out which of the calls represented real crises and which ones didn't.


I was reminded of another time I was in the ICU and a patient came in with an unusual problem; within a couple of hours, cardiologists, pulmonologists, and oncologists had mobilized for procedures and studies, teams were passing the chart back and forth as they worked on plans and notes and recommendations, and people kept buzzing in and out of our MICU team rounds to give updates on the latest detail of the plan. A cardiology fellow showed up and so did an echo tech, and within an hour of us asking for the study, there was a detailed echocardiogram and an attending reading it. Someone else was planning for a biopsy. One consult team was calling another consult team to help work out details.

"This is when I love being at a teaching hospital," I said quietly to one of my fellow residents, as our intern was presenting data and we were watching out of the sides of our eyes as one of the consult teams was bustling about nearby. "These moments of this massive mobilization of expertise, all of these people with this insane amount of training, coming together for one sick person. It's beautiful."



Overnight, the hospital often seems like it's in a holding pattern. We try to keep people alive until care can be advanced during the day. So it was a surprise to me to find myself in conference with a little bit of that teaching hospital feeling: the feeling that there were all of these smart and engaged and caring people watching the progress of one sick patient and sometimes being a part of her care, wondering how it would turn out, wondering whether she would come to the unit or stay on the floor, wondering whether she'd get sicker or better, hoping for the best.

The senior admitting resident had come up with a long set of possibilities for what might explain the patient's symptoms, and ordered a bunch of tests right away to start sorting them out. The ICU resident was pitching an obscure diagnosis but one with some credibility; though I wasn't buying it, I had to give her props for zeroing in on a particularly striking lab value which I had skimmed over. I was pitching another theory, but at the same time telling the intern to cover for gram-negative infection, which was actually a counter-move to anticipate what could happen if I was wrong. The attending, writing a note in the morning when we emerged back onto the floor from our conference, thought we were all wrong, was stopping the antibiotics I'd told the intern to start, and had another theory entirely. But we all had opinions without certainty, which meant that we really listened to each other, and we all had a sense of suspense:

"Poor lady," said the attending, "I haven't seen a case like this for a while";

"I really think the team should start treating now, even without knowing everything!" opined the department chair;

"I know what you mean, but they could get in trouble with that in other ways," said the chief resident, deferential but firm;

and the intern, new to it all, was listening to the primary attending with eyes much brighter than his fatigue should have permitted, truly a part of this thing that we all had spent so much time working towards, and which he had finally just joined a few weeks before.

We felt ourselves to be a part of a community of highly trained people, late at night when others are asleep, part of the world of doctors as doctors themselves hope for and imagine it should be. A team of experts and people becoming experts, mobilizing, caring, theorizing, arguing; and at the same time, perhaps above all, walking briskly down the hall towards the patient's room after getting a page from the nurse about low blood pressure.

Becoming the Fat Man.

Sleep-deprived and worried for my interns, I start spouting half-true or all-wrong or kind of right aphorisms as if I was aspiring to be the new Fat Man:

"All patients lie. All patients are crazy. And it is our job to love them anyway."

(Said to an intern who is tempted to believe everything his patients tell him, to his patients' potential detriment.)

A pair of nurses, overhearing this, do a double take and tighten up as they hear me start this, then visibly relax as I finish. One says, "You saved yourself with the last part there." I try to save myself a bit more: "Well, we all lie sometimes, even when we don't realize it, and we're all a little bit crazy, right?"

Still, I thought, Am I really the resident who blurts out cheap half-truths as if they were wisdom?


It is an inevitable temptation of power--even the minor power of a senior resident at the beginning of an intern's year--to start spouting bullshit. On reflection, I think I succumbed.


At the same time, I don't think it does any favors to patients to subscribe to a false humanism, some kind of big happy medical friendship bracelet of co-dependence between needy doctor and needy patient.

I got at what I was trying to say a little better a couple of days later, with the help of talking to Dr. Ms. Hemodynamics, who had more clear things to say about this problem, which I then said to an intern, with words something like this:

"It is inevitable that when we are feeling doubtful about ourselves as doctors, we want our patients to like us, because that makes us feel like we are good people. But it's not the point of being a doctor to have your patients like you. Your patients should come to trust you, and to respect your counsel, and value your role in their life. But liking you is beside the point, and it's dangerous to them for you to need that from them."

This I do believe.

To boil it down to a Fat Man-style law:

"It's not your job to have your patients like you. It's your job to love your patients enough not to care."

100% true dialogue from the wards

The attending, the senior resident, and the intern are sitting in the work area, discussing a patient. The senior resident, a bespectacled and bearded graduate of Harvard Medical School, is cautioning the intern on jumping to conclusions:

"I understand that you're taking the evidence and trying to see if it matches your theory. But actually, you want to do the opposite. You don't want to try to prove yourself right. In the philosophy of science, Karl Popper wrote about 'falsification'--the idea that you take your hypothesis and try to prove it wrong, until, failing to prove it wrong, you decide that it's the best theory for now."

The intern: "OK, yeah, I see your point."

The attending: "Karl Popper, huh? You've read Karl Popper?"

The resident: "No. But I've read about Karl Popper on Wikipedia."


Attending: Falls out laughing; retells the incident for laughs to another attending on rounds a couple of days later.

Resident: Laughs too; retells the incident on his blog a couple of days later.