Random Thoughts from a Restless Mind

Sunday musings…

1) Summer rain. Out my back window I look our upon two guys riding jet skis in the rain.

They might get wet.

2) PC. My alma mater, in what seems to be a trend, is calling the students beginning their college journey “First Years” instead of “Freshmen”. WTF.

I am now officially part of a small but hopefully growing rebellion against ludicrous speech.

3) Easy. Easy? No, it isn’t easy. It’s never easy. Simple, perhaps, but never easy.

Trust me.

4) Victory. “You know, in the old, old days there was no World Series, no real championship. For most teams, the idea of winning was finished by July. So what was there to care about? Each series, each game. Day by day. The rest of it, the big dream [of victory] was not their business. It’s a better way to live.” -Cubs fan.

A number of folks in the CrossFit community have recently weighed in with thoughts on the essential tension between training and competing. Some have a standing of sorts, and others just have a keyboard. It’s a topic I’ve pondered and one I’ve certainly discussed, here and elsewhere.

As is so often the case I’ve struggled to find a fitting vocabulary, one with terms that more adequately express both the issue and my viewpoint. Freddy Comacho, Master’s athlete and OG with chops, recently offered his take and in so doing shared with all of us a very nice diad: training v. testing. My anonymous Cubs fan above (a vet, incidentally), adds a little poetry to Freddy’s prose.

One of Coach’s many strokes of brilliance is the concept of measurement. You know, observable, measurable, repeatable. We measure our results pretty much every day. For most of us, indeed for most of the rest of the exercise and athletic world, measurement is the stuff of competition. We keep score so that we can declare a winner. Winning begets a champion.

Herein lies a fundamental misunderstanding of Coach’s creation: measurement in itself does not necessarily denote competition. At least not one in which we make a conscious decision to push on to some sort of concrete thing we might call “ultimate victory”. The training/testing conceptualization is very helpful.

If I give you notice that you will participate in a task, one in which all of the variables are known to you beforehand, a reasonable person will go about preparing for that task by mastering the specific skills necessary (practice), and acquiring capacity in the specific areas of fitness required to express those skills (training). A very nice example of a program set up to accomplish this is CrossFit Football. All of the domains in the competition are known beforehand, and the fitness program is targeted at those to the effective exclusion of others. A classic marathon program is another very good example.

A training program without metrics is one that is unlikely to succeed. Measuring in training allows one to assess micro-trends of the program. One accepts discomfort in training, but at the same time one is mindful of the need to avoid true injury while doing so. Testing, on the other hand, is different. By definition testing requires the exploration of limits. The limit of strength or endurance. The point at which technique fails for whatever reason. Testing identifies the macro-trend: am I/is my program succeeding? One must necessarily push beyond discomfort, push on to some version of victory.

It’s here where the wisdom of my Cubs fan is evident. One must be ever mindful of our place in the standings. There are meaningful games to be played for all of us, even those “playing” on a team that has been mathematically eliminated by July 4th. “Each series, each game. Day by day.” This is us. For the most part we are the people Coach was thinking about when he went all mad scientist on fitness. Freddy (and Chyna) can indeed dream “the big dream”, but for the rest of us it’s really “[d]ay by day”.

We measure, as Coach has taught us, because it improves our training. We should be looking for a trend toward IWCABTMD in the measurement of our training, but in doing so we should be testing our limits, pushing to those points closer to failure, a bit more infrequently and more cautiously perhaps. We have much to gain by focusing on the daily training, caring about each at bat or each game rather than the overall standings or a championship. To be in the game, to choose to be measured, to care about each individual game no matter where you stand is a concrete victory itself.

My Cubs fan, the Iraq war vet: “It’s a better way to live.”

I’ll see you next week…

Posted by bingo at August 30, 2015 7:05 AM

As I mentioned, I’m on call for our large semi-suburban hospital for the month of July. I was consulted for a patient who has monocular vision loss that is unexplainable, at least given the capabilities we have as ophthalmologists when we see patients at the bedside in the hospital. The consult brought back memories of Julys past as a resident on call.

Bellevue Hospital, and the Bellevue Hospital residents provide medical care for the New York City prisoners who are housed at Riker’s Island. This is actually quite an opportunity, especially for a child of suburbia like yours truly. It’s not as if I had never come across people in the criminal justice system prior to my Bellevue days, it’s just that I didn’t have such routine and regular contact.I don’t remember exactly, but there are at least three or four entire floors at Bellevue dedicated to the care of Riker’s Island inmates who have medical problems. One or two are for the criminally insane, and others who have some degree of mental illness. The remaining two floors house prisoners with problems as varied at coronary artery disease and pink eye. As disconcerting as it was for someone like me to enter a locked ward, the accommodations at Bellevue were at least a full order of magnitude nicer than those at Riker’s Island. This provided an interesting opportunity for Riker’s Island inmates to create a medical reason to leave The Rock, and created a very interesting learning opportunity for all of the residents  to discern real from not so real.

This  might have been the most fun part of my entire residency experience.

People who have something to gain from having an eye problem all seem to have the exact same complaint: “I can’t see.” Sometimes it’s “I can’t see out of my right (or left) eye,” and sometimes it’s simply “I can’t see.” The savvier the patient, the more subtle the symptom. The trick as the doctor on call is to simply demonstrate that their vision is substantially better than what they are describing. Oh yeah, it’s important to do so in such a way that you don’t make them too very angry; you don’t want to become a Bellevue Hospital “target” yourself!

Every resident develops a repertoire of tricks that he or she will use, a go–to list that tends to work for the majority of the malingering patients. To be truthful, especially when caring for children, sometimes the patient is actually convinced that he or she really CAN’T see. The kids are really pretty easy, though. I found, and frankly continue to find, that even with my limited attention span (often described as being slightly shorter than that of your average gnat) that I have more patience than almost any child under the age of 18. Most eye charts will start with a 20/10 line, and then move through 20/12, 20/15, and then several to many 20/20 lines. If you start at 20/10, by the time you get the 20/25 or 20/30 that line looks absolutely enormous! I think I’m batting about .997 in kids with 20/400 vision in the ER who “miraculously” and up with 20/25 vision in the exam room.

Folks who have something to gain from being diagnosed with visual loss weren’t always wards of the state or city. Occasionally there would be people who stood to gain from being diagnosed with profound visual loss for other, less existential reasons than wanting a ticket out of Riker’s Island. My favorite was a Hispanic woman who came with an entourage of family members, her complaint being complete and total loss of vision in both eyes from some vague and poorly defined trauma suffered at the hands of a landlord who was trying to evict the her from a rent–subsidized apartment. Her examination was totally unremarkable. Everything about her eyes was so  normal it was eerie. My suspicions were high because she just didn’t seem all that distraught over her new blindness, you know? There’s an instrument called an indirect ophthalmoscope which is used to examine the peripheral retina. The light we use can be cranked up to a level which is quite frankly rather painful. I explained to my patient through her translator that I was terribly sympathetic, and very concerned about how she would ever be able to survive if she was  evicted, what with her being totally blind and all. I just had this one last test to do, to look at her retina. With phasers set on stun I started to examine her eyes with the light cranked up. She started screaming in Spanish. What’s she saying? What’s she saying? Remember, now, this is a woman who has no light perception, everything in her world is black. Her son grabbed my arm and started yelling at me. “Turn that light off. It’s too bright. It’s hurting her eyes!” Yup, just another satisfied patient.

The prisoners really were the most fun, though. You had to be on your toes because some of them were actually quite dangerous. If the corrections officers were chatting amongst themselves in the waiting room you could be pretty sure that the patient in your exam chair was nonviolent. If, however, there was a corrections officer standing roughly 1/2 inch from each arm of the patient, well, that was one you had to worry about. But the prisoners got it, they got that this was a game. If they could beat me they got a stay at the Bellevue Hilton. On the other hand, if I got the best of them, it was back to Riker’s Island. The guys who complained of decreased vision in just one eye were actually not too difficult to fool. Again, all I had to do was prove that the vision and the supposedly “blind” I was normal. We quote discovered” all kinds of sight threatening needs for a new pair of glasses at two o’clock in the morning in the Bellevue consultation room.

The guys who complained of decreased or lost vision in both eyes were more challenging and therefore more fun. Can’t see anything at all? Piece of cake. All I have to do was prove that they had locked on to some image. There must be three dozen prisoners who complained of total loss of vision in both eyes who headed back to Riker’s Island one minute after entering my consultation room after they leaned over to pick up the $10 bill that I put on a footstool of the exam chair. Did you know that your pupils constrict when you focus on an image inside arm’s-length? You can imagine how handy that three-year-old Sports Illustrated bathing suit issue came in, and how many prisoners learned about accommodative pupillary construction after looking at THAT picture of Christie Brinkley.

There is one story out of all of my adventures with the Riker’s Island prisoners that stands apart. It was July, and I was doing my duty helping out the new first-year resident on one of his first nights on call. We got a call from the ER about this terrified patient who had lost vision in both of his eyes; he was defenseless. Dave, now a world famous pediatric ophthalmologist, was really unsure of how to proceed so I told him that we would do it together. We sat back and watched very carefully as the prisoner entered the room. He was totally on his own, not assisted in the least by the corrections officers. He managed to navigate around all of the little articles I had placed between the door and examination chair, not hitting a single one. He found the chair, turned just like you or I would, and sat down. His examination was perfect, naturally. After putting drops in his eyes to dilate his pupils this is what I said: “I can see that you are terribly frightened sir, and frankly I can’t blame you. I’m very concerned about your vision, and I’m going to do everything I possibly can to make sure that you are alright. I just put some drops into your eyes so that your pupils will dilate. Dr. Granet and I will then examine your retinas once the drops have worked. We are going to talk about what we’ve seen so far. Please go back into the hallway and take a seat in the blue chair, and we’ll come and get you in just a few minutes.” The prisoner left the room, once again navigating the “mine field” without incident.

Dave bowed his head, a little tiny twitch at the corner of his mouth as he shook his head. “There’s only one blue chair out there, isn’t there?” He smiled as he strolled over to the door. Sure enough, there was our patient, very calmly sitting in the single blue chair, surrounded by a dozen empty red ones!

We had to invite the corrections officers into the exam room when we explained our findings.

I am on call this month for the largest community hospital on the West Side of Cleveland. Covering a semi-suburban ER is quite different from covering a true big city ER, especially when the semi-suburban hospital has gutted both its trauma and eye services. My on-call role now is little more than that of foot servant, covering the loose ends of other people’s arses in the pursuit of a perfect chart. Bellevue, at least the Bellevue I knew in the 80’s, was quite a different story. Although it was July it was July in New York, pre-Guliani New York, and it was Bellevue Hospital.

There are only two kinds of people in New York City: Targets, and people who hit Targets. At Bellevue we took care of the Targets.

It’s the first weekend in July. For most people in America that means the 4th of July and everything that goes along with that. Barbecues. Fireworks. Festivals and ballgames of all sorts. And beer. Lots and lots of beer. But in that curious sub-culture of medical education the first weekend in July means the first time on call for newly minted interns, newly promoted residents and fellows of all sorts. Everyone and everything is new, just in time for July 4th and its aftermath.

Funny, but I ended up on call for every 4th of July in my four years of post-med school training. I’m not sure which, or how many, of the residency gods I offended, but whatever I did I apparently did in spades ’cause I hit the first weekend jackpot every year. I have no memory of my first on call as an intern, but the “Target Range” was open for business those first couple of years at Bellevue, for sure! In fact, if memory serves, the phrase “Target” was coined by yours truly that very first weekend of that very first year as an ophthalmology resident.

“Hey Eye Guy! We got a John Q. Nobody who got shot in the temple just standing on the subway platform. Says he can’t see. Whaddaya want us to do with him? By the way…welcome to Bellevue.”

Crowds and beer and heat and stuff that explodes. Welcome to Bellevue, indeed. Some poor schlub survives the bar scene after the parade, makes it through pickpocket alley intact, gingerly stepping over detritus living and otherwise, only to get shot in the head as the A Train approached the station in a random act of anonymous violence. The bullet entered through the right temple, destroyed the right eye, and wreaked havoc in the left eye socket before coming to rest against the left temple. Right eye gone and malignant glaucoma in the only remaining left eye. And there I was, all of 3 days into my opthalmology residency, backed up by a chief resident of similar vintage. Whoa…

There’s no way to avoid it. After all, med students have to graduate and residencies have to start some time. There’s just this unholy confluence of weak links in the system all coming together in time for the second (after New Year’s Eve) most difficult ER day in our big, academic hospitals. Get sick or injured on June 4th? Everyone’s on top of their game and everyone’s in town. July 4th? The fix is in, and the game is as rigged against you as any carnival game attended by a dentally challenged carnie.

As I sit here, an Attending on call for yet another 4th of July weekend, covering the ER and cowering each time the phone rings, the Tweets and Facebook posts heralding the arrival of a new crop of interns and residents send me back to Bellevue. Year 2, cursed again, covering the spanking new 1st year ophthalmology resident (was it Dave?) as he got his welcome “gift” from the ER. “Hey Eye Guy. We got a Target down here for ya. 10 year old girl. Some dumbass tossed a lit M80 to her and she caught it. Went off before she could get rid of it;  blew off her right hand and looks like her right eye is gone. You from NY? No? Welcome to Bellevue, pal.” Yup…there’s something about the 4th of July in every teaching hospital in the U.S., and just like everything else, whatever it is, there was more of it at Bellevue.

Only two kinds of people in New York, Targets and people who hit Targets. At Bellevue we took care of the Targets.