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Medical Humanities Section Newsletter - March 2008, Vol 4, #2

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circle_arrow From the Editor
Winter’s Weight & Whimsy
circle_arrow From the Chair
Art in the Art of Medicine
circle_arrow Two Lovers
circle_arrow Photo: Winter in Wyoming, Iowa 2008
circle_arrow Can I Get a Soda?
circle_arrow Code Blue,
     code yellow
circle_arrow Kid Midas


Newsletter Index


Medical Humanities Section

 

 

From the Editor
Winter’s Weight & Whimsy

Peter J. Paganussi, MD, FACEP
Fairfax Hospital, Falls Church, VA

In this, the first issue of MUSE (Medical Humanities Section for Emergency Physicians) for 2008, the backdrop is winter, and the talents of the section range from weighty to whimsical, constructing a creative collage of emotion. As I see it, this could be the absolute definition of "the Arts." Comedy and tragedy, yin and yang, introspective and outwardly comical: DaVinci and Degas, TS Eliot and PJ Wodehouse, Laurence Olivier and Martin Lawrence, all represent the breadth of the arts. While our humble little newsletter will never be mistaken for any of the works produced by the aforementioned, it does display a range of emotion (and talent).

We begin with our Chairman, Dr. House, and his discussion of the Emergency Medicine Residency review process at his institution, the University of Iowa. As you will see he has a very unique take on how it should be conducted. I applaud his rather novel approach to finding residents with "the right stuff." As a member of this section I am thrilled to know that medical humanities are being taken seriously at the highest levels of our profession. Take Dr. House’s test yourself as you read his piece. How would you answer, based on what you see in the paintings? This one embodies the weighty and the whimsical.

We are then treated to a beautiful photograph from Dr. Hall-Boyer of a winter scene in Kyrgyzstan. Beautiful framing and incorporating light and shadow make it a peaceful respite, followed by the equally beautiful, and elegant, poetry of Dr. Mitchell. A winter days’ walk on the beach: it flows with contrast and subtle colors that freeze-frame emotion. Enjoy its soft, lyrical beauty.

Dr. Brownell has provided us with a photographic look at winter 2008 in the U.S. heartland…Iowa. Dr. Brownell is one of those poor people that Dr. House tortured with "art in medicine" during his interview at the University of Iowa. His artistic eye prevailed, he completed the residency, survived Dr. House, and he has provided us with some nice photography of the pounding the Midwest has taken this winter. Black, white and grey predominate, but the subtlety of the sign and the lone leaved tree, that lend just a bit of color, make this an intriguing photograph, and in keeping with our weighty/whimsical theme. Enjoy the winter photos from both sides of our little blue planet: from Kyrgyrzstan and Iowa…worlds apart, but both blanketed in the splendor of winter.

Dr. Austin has provided us with a poignant piece of ED pie. It is a moment in time that left a deeply personal impression, which he shares vividly with the reader. It is the type of situation we in emergency medicine often find ourselves in, and it is the little things that swirl in it all that we seem to hold on to. Death has finality, but life goes on. Enjoy it.

We move into a poem by yours truly. One morning, about 15 years ago, I found myself quite literally running between our two major trauma rooms tending to two victims from a motor vehicle crash. I was doing an overnight, and they both hit the door at about 4:30 am. One man was leaving early for a second job so he could support his family, the other was about 6 weeks out from a hip replacement and was driving drunk, returning home from a late night of drinking. As I ran from room to room the juxtaposition, the duality of the situation, struck me deeply. I have never forgotten the event, or the people involved. I tried to create the dichotomy with this piece using both sight and sound. I hope I hit the note.

Finally, we end with the very whimsical piece by Dr. Baehren, a "Steely Dan" look at greed and money. As I write these words, the (ahem!) Honorable Eliot Spitzer, the soon-to-be-former governor of New York State, has been caught in his own web of greed and money to cap off this crazy, snow-laden winter. Could he actually be the real "Kid Midas"? We end with whimsy and leave on an ironic note. Please enjoy this issue, stay warm, and we shall return this summer.

 


 

 

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From the Chair
Art in the Art of Medicine

Hans House, MD, FACEP
University of Iowa, Iowa City, IA

No member of this section would argue with the notion that there is a role for art within the art of medicine. It gives us a medium to express ourselves as well as interpret the experiences of others. The relationship between patient and physician is so intimate, so much more permissive than the interactions we normally allow with any professional. This unique relationship and the struggle of artists to depict it have given rise to many great works. Since last year, I have begun to use these works in my role as Residency Program Director.

Every winter, I have the unenviable task of sorting through 350 applications to find 8 non-psychopathic physicians-to-be. A critical step in this screening process is the residency interview. One of my standard questions to every candidate is their interpretation of a painting. I keep the question as open as possible, "Look at this painting and tell me a story about what you see." Most students simply list all the components of the scene with minimal interpretation. Over the last two years, I have gotten a few brilliant answers and a few really bad flops.

Last year, I showed everyone the classic The Doctor by Sir Luke Fildes (1891). Since it was the first time I have incorporated art interpretation into the residency interview, I didn’t know what to expect or what I was really looking for. The scene in the painting evokes a sense of puzzlement, worry, and compassion. Primarily, I expected the applicants to describe the actions of this compassionate and concerned physician. For the most part, that’s what I got. But a few impressed me by involving the hidden figures of the parents in the background. Or inventing a back story for the characters, including that the physician is the patient’s rich uncle and he is looking after his dying niece. Few candidates were willing to provide a bright prognosis for the patient.

Some, labeling the family as one of limited means, noted the improvisation of placing the child on two chairs. One very clever student noted the position of the tissue on the ground just below her open palm, saying that she is so weak, she has just let the tissue fall from her failing grasp. The only real flop I encountered was the student who said nothing more than "It’s the old days of medicine- there’s a doctor visiting a house." And that’s all! (We did not rank him very high on our list!)

This year, I used The Gross Clinic by Thomas Eakins (1875): I chose it because it was recently in the news when Thomas Jefferson University in Philadelphia decided to sell it for $68 million. Both the painting’s classic appearance and its surprising contrast appeals to me. Most medical students have seen it before (it’s on the cover of most surgery textbooks), but not all have really looked at it closely. If you do, you will see the strange contrast Eakins created by placing a horrified, cringing female figure (I am pretty sure she’s female- she has female hands and she is wearing a bonnet) just to the left and below the noble, shining, spotlighted central figure of Dr. Gross, who is directing the procedure. I was curious to see how many candidates noticed the cringing figure and what they would say about her. Most of the students saw her, and almost all of them interpreted her as a relative, possibly the mother of the person undergoing the operation. Why the patient’s mother would be in the operating room is a question no one could answer. A few applicants shared the same thought that troubles me about the painting: the depiction is inherently anti-feminist. Eakins painted an entire room full of expressionless, stoic men involved in academic study, yet the solitary figure showing any degree of emotion or compassion is also the only female.

I considered this painting to be a test of observation skills and sought to hear if students would go beyond the simple, "there’s a teacher in an operating theatre." My favorite answer was given by the student willing to label Dr. Gross as inadequate! She imagined that Dr. Gross is looking up, puzzled, not sure what to do next in the operation, and perhaps even looking to his right at a surgery textbook for a clue on the next step. One creative student (and fan of mystery novels) invented that scene as an autopsy of a victim of Jack the Ripper. Clever back stories aside, I marked students down for calling the patient a cadaver- one can clearly make out an anesthesiologist holding the ether sponge over the patient’s face. The position of the patient’s legs created confusion for some students- it is hard to tell what body part is being operated on. But I have trouble giving credit to the student who thought this was a veterinary scene and the patient is a horse!

I have no idea if art interpretation has any role in the selection of residents. I have no outcome data to tell me if reading the scene in a painting predicts success in residency training. But I do know that education in the medical humanities is associated with increased compassion and more successful communication with patients. I believe that my unique interview question serves as a surrogate for testing that understanding of medical humanities. Besides, showing a painting is a nice break from the tired old, "So, why do you want to go into emergency medicine?"

My question for the membership: any suggestions of paintings for next year?

0308iowa2

Winter in Kyrgyzstan, February 2007
Kathryn L. Hall-Boyer, MD, FACEP
Crawford Long Hospital, Atlanta, GA

 

 


 

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Two Lovers

Elizabeth Mitchell, MD, FACEP
Boston Medical Center, Boston, MA

Two lovers walk the beach.
They move like shifting sand,
First, arm in arm, then front to back, then face to face.
Their lips are here and there, first skin then hair, and back to skin
And lips on lips
Again.

Her eyes reflect the ocean’s green,
As wind whips tears upon her softly freckled cheeks
He gazes with the bluest blue
And whispers sweet,
And in the sandy bed they kneel,
As words he writes, an arrow,
"I love you."

She laughs, a startling joy
And all the seabirds rise at once and whirl away
To leave them there, two lovers on the beach
Embraced in wind and cold and lifted up
To kiss and kiss, that perfect
           Winter day


 

 

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Photo: Winter in Wyoming, Iowa 2008

0308iowa1

 

Winter in Wyoming, Iowa 2008
Travis Brownell, MD
Mercy Medical Center, Sioux City, IA

 

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Can I Get a Soda?

Paul Austin, MD, FACEP
Durham Regional Hospital, Durham, NC

The shift had been going well, until the paramedics brought in a 42-year-old woman in cardiac arrest. We’d been able to resuscitate her, but her blood pressure was still bumping along in the 90/60 range. She’d had a huge heart attack. I’d already talked with the cardiologist, and she was on her way in to take the patient to the cath lab.

I went to tell her husband the woman was not doing well. "Not doing well" in this case meant she might die. The husband and a chunky boy who looked to be about five years old were waiting in the family room.

The man stood when I walked in. He wore jeans, a white tee shirt, and a ball cap with a curved brim.

"I’m Paul Austin, one of the ER doctors." I reached out to shake the man’s hand. "I’ve been taking care of your wife."

His handshake was loose, his palm damp. "She okay?"

I gestured to the chairs, and the man and I sat. The boy stood next to his dad’s chair. The man leaned forward, as if he wanted me to get on with it.

"We got her heart beating again, but she’s still in critical condition."

He nodded.

I was unsure of how much he had seen, or understood. "Did you see the rescue squad shock her with those paddles?"

He nodded again.

"That was because her heart wasn’t beating right. But the shock didn’t work. That’s why they had to stick that tube down into her lungs and start CPR. Did you see them do that?"

He nodded and squinted his eyes in a subtle grimace.

The boy said, "I saw it too." He seemed eager to be included.

I looked at him, then back to his father. "We’re doing our best, and I hope she’ll be okay." I took a quiet breath. "But, right now it doesn’t look good. They were doing CPR when she got here because her heart still wasn’t beating on its own." I looked into his eyes.

He nodded a quick nod, telling me to get on with it.

"She’s had a heart attack. We gave her some more medication and her heart started beating again, but she’s still very ill." I don't like speaking in code – saying "very ill," instead of "close to dying." And this man looked like someone who would also rather hear plain hard words, but with his child standing next to us, looking from my face to his father's, I couldn't think of the right way to say it. "Dr. Turner’s on the way in," I said. "She’s a cardiologist. A heart doctor."

The husband took off his hat, as if he’d just realized he was inside. His forehead was a pale white and contrasted sharply with his sunburned cheeks. His hair was dark, and plastered to his head with sweat. "She’s been complaining about her left shoulder-blade hurting for a week now. Saw the doctor yesterday, and he changed the pain medicine and sent her home. Said it was just arthritis in her shoulder. Said she’d be OK." He stopped, and wiped his face with a blue bandana. "This morning, she said I better take her back to the doctor’s, cause it was hurting worse. We left right then. But before we got there, she groaned, and quit breathing. There wasn’t nowhere to stop." He shook his head, and with a baffled look, continued. "There wasn’t nowhere I could stop. It was terrible. I was doing seventy miles an hour. I couldn’t find no place to stop. So I went on to the doctor’s office, just as hard as I could go."

"You did the right thing," I said. If he'd come straight here, instead of going to her doctor's office, she may have had a better shot of survival, but there was no point in saying so.

The overhead speaker crackled loudly, "Dr. Austin, we need you in room 26. Now."

"I’ll be back to talk with you."

The man nodded.

I walked quickly. Lisa, one of the nurses, leaned over the woman’s bare chest, pumping up and down. Well, goddamn. I put on a pair of latex gloves, and placed two fingers in the crease between the leg and the pubic hair, feeling for the femoral pulse. I felt a faint rolling bump of blood under my fingers each time Lisa pumped on the woman’s chest. "Good pulses with compressions," I said to Lisa. "Let’s see what we’ve got. Stop CPR." The thin green line on the monitor slid down into a smooth, flat line. Damn. "Start CPR. Give her another amp of epi." I kept my fingers pressed into the femoral crease, checking for a pulse every few minutes. I didn't want to go back out to tell the husband and kid that the woman was dead. "Let's run it a little longer." Lisa nodded. So often, we work codes on patients with no prayer of survival – they're just too old, or too sick, or both. But this woman was young enough that she might survive. After a few minutes of work, her pulse returned. "We’ve got a pulse," I said. "Do we have a pressure?" Lisa quickly pumped up the blood pressure cuff, and let it hiss slowly down. "80 over 40." She made a quick note on a scrap of paper.

"Better than nothing," I said.  

Dr. Turner, the cardiologist, walked in. I handed her the EKG.  

She glanced at it. "You're right." Her English accent was crisp. "Let's get her to the cath lab. See if we can open her up."

"Want to talk to the husband?"

She nodded, and handed me the EKG.

I introduced Dr. Turner to the husband, and she sat beside him. I sat on the other side of Dr. Turner. She took a deep breath. "Things look very grim. She’s had a severe heart attack. One of the arteries that supplies the heart with blood has been clogged." Dr. Turner ducked down to catch his eyes. "We can take her to the cath lab and open the artery, but her heart and brain have been starved of oxygen. They’ve both been damaged." She paused to let it sink in, then continued, "She’s so young we want to do everything we can. But you need to know that even if we can wake up her heart, we may never be able to wake up her brain."

He stared at her.

"So I need to know if I have your permission to take her to the cath lab to try to open up the artery that’s clogged."  

He paused a second. "Oh, yeah. Yeah. Do everything you can." He covered his eyes with his bandana. "Please."

His son tugged at his shirtsleeve. "Daddy, can I get a soda?"

"What?" He looked down at his son.

"Can I have some money? For the soda machine?"

I expected the father to reprimand the boy for interrupting.

Instead, he wiped his eyes with his bandana and then stuffed it in his back pocket. He stared at his son for a few moments. He then nodded, and dug a handful of coins out of his pocket. He cupped the coins in his palm and with a blunt fingertip began to separate quarters, dimes, and nickels. He looked down at his son, then back at us. "Please. Do everything you can."

The woman made it to the cath lab, and from there to the intensive care unit. I never found out if she made it out of the hospital. I don’t remember what she looked like. Wouldn’t recognize her husband or son. But sometimes, when I get a soda from the machine in the lobby of the ED, I remember that day.

I don’t know how the husband did it. I’ve tried to imagine myself driving as fast as I could towards the doctor’s office, with Sally, my wife, slumped in the front seat of the van, not talking or breathing. Or I imagine sitting in a vinyl chair, as a doctor tells me she’s near death. I’m sure I could do that part – the sitting and nodding. I would somehow endure the doctor’s words. But how could I manage a palm full of coins, or my son’s request for a soda?

 

 


 

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Code Blue,
     code yellow

Peter J. Paganussi, MD, FACEP
Fairfax Hospital, Falls Church, VA 
   

Black man, dead man,
          white man, deficient man.

One expires in front of me,
           the other lives, only to lie to me in contrived confusion.

Early morning toil to live a better life,
            late night foray to forget a flawed existence.

Sober, stable, a very solid sort, forehead kissing he leaves,
            last call and a barfly is shooed to take his brain, awash with alcohol, away.

A collision of colossal magnitude mortally injures the innocent,
            surprised and aghast the causal agent wonders what has come about.

Barely breathing and badly broken,
            drunk and rambling with wrecked ribs.

Asystole, hypotension and little hope,
            a split lip, bloody eyebrow and "wow, what happened"?

Life slips away on a bloody floor,
            as the other seems to come into his own.

A poor policeman must notify next-of-kin with the cruel news,
            then confronts the culprit who can’t recall the occurrence.

He isn’t talking, but his wife whispers newly widowed words in his ear,
             he ain’t talking, but is pleasant and polite to the police about it.

A mourning mother clutches close her children,
            alone, he has no family this friendless felon.

Who will bear witness for this gentle man,
            and will a seemingly calloused sort never forget his frailty?

Was a dream alive that now won’t come true,
            or is it something cynically worse?

Code Blue,
            code yellow.

 

 


 

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Kid Midas

(To the tune of Kid Charlemagne.Apologies to Becker and Fagen.)
By Dave Baehren, MD, FACEP
University of Toledo Medical Center, Toledo, OH

While the pit boys slaved you lounged beside your pool
Feeling smug and very cool
You had them by the hairs
The seven figures filled your pockets pretty fair
Of course the suits would share
That’s when the light turned on
Did you feel like Midas?
Did you realize
The whole damn thing could be your prize?

Deadlines loomed while presidents stood in wait
You knew you’d set them straight
They would see the door before the paint dried on your summer home
Carpetbaggers had your number in their phone
They wouldn’t sleep alone
Those girls would work it for a song
And toss the dogs a bone
Could you fool the long coats?
Could you close their eyes
‘Till the new ones came and pulled their own surprise?

Get along, get along Kid Midas now
Get along Kid Midas now

Now the masses line the lobby in despair
You couldn’t give a care
Dead presidents should ease the pain
All of your minions crunch the numbers good
They always understood
Some things will never change
All the yes-men cometh
Why can’t you see?
This damn mess is not the fault of me

Get along, get along Kid Midas now
Get along Kid Midas now

Clean this mess up or you’re next to see the door
This thing is such a bore
Just make your numbers man
Is there cash in my jar?
Yes, there’s cash in my jar
I’m off to play another round
I’m going far

Careful what you say now
‘Cause the man is wise
You are just a peasant in his eyes

Get along, get along Kid Midas now
Get along Kid Midas now

 

 


 

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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