...COLD

I wrote this essay that was published in the Annals of Emergency Medicine last December. Enjoy :)

"Icicle"

As the dawn sign-out trailed off, the loud bell of an EMS ring-down disrupted the relative calm. Moments later the charge nurse emerged from the radio room, waving a white
sheet of paper on which he had scrawled some notes: “Unresponsive. Homeless. Very cold. HR 30. ETA 5.” The senior resident finishing her night shift quietly said, “Don’t
move him around too much or he’ll code,” and then slipped out the double doors to the parking lot while we prepared.

The bear-hugger was inflated and warmed, heated fluids at the ready, blankets in several hands. We pounced on him as the stretcher rolled in. Nurses, techs, and physicians on all
sides. His skin was as cold as ice, barely moving. If not for the quiver of heart motion on the snowy ultrasound screen, I would swear he was dead. He was homeless, huddled outside
on the stairs of a church throughout a cold December San Francisco night, during which rain intermittently turned to hail. We never learned how he was discovered that morning,
or who brought him to the attention of the police. They only knew he was frigid and barely breathing. His hair was matted against his head, stiff with cold. Harsh weather had aged his
face beyond his years and a fine layer of dirt settled among the wrinkles in his face. Unable to say his name, he was dubbed Medical Patient “Deer.” The medic’s thermometer showed an “-E-” on the screen. Given the frost of his feet, we knew it was not broken, only too cold to read. A Foley was deftly inserted. The bladder temperature winked alongside
the other vitals on the green and black monitor: 23.4. The number gave us all a brief pause. How could a person still live at 74 degrees Fahrenheit?


For a patient this cold, there are several mantras. Move them as little as possible; the heart is so sensitive to the cold it may twitch into a deadly ventricular arrhythmia at any
moment. Passive rewarming is ineffective; warm water and air must be pushed into the body. A Foley catheter was inserted into his bladder and warm fluids flowed in and out.
We deferred placing a central line into his neck as the catheter would sit too closely to the irritable heart. Instead, a large cordis threaded into his femoral vein provided a route
for a great volume of warmed saline to squirt through the level 1 blood transfuser. Earlier that day the same machine kept alive an exsanguinating trauma patient. A blanket
wrapped as a turban kept in the precious body heat lost through the head, replacing his worn SF Giants ski cap that was riddled with holes.

The core temperature reading slowly began to creep upwards: 24, 24.5, 25. But his heart remained slow, breaths intermittent. A breathing tube slipped between the vocal
cords supported his efforts and pulling air into his lungs. Still cold. Too cold. The chest tube tray was opened, and following a cut with the scalpel, a large tube was slipped
between his ribs. A second infuser pumped a liter of warm fluid into his chest to bathe his heart and lungs, and then sucked it out. In and out: 26. In and out: 27.


Throughout this time his blood pressure remained low as his heart was still so slow. Supportive drugs helped bring it upwards. I waited with bated breath for him to slip into
cardiac arrest. A bleary-eyed ICU resident appeared with admission orders in hand. We “packed up” the patient and all the various tubes hanging off him and headed towards the
elevators. That is where we parted, he to the ICU and I to my teenager with a broken ankle, and then a woman with chest pain.

Four days later, on the next ICU call schedule, I encountered that same critical care resident while resuscitating a GI bleeder. I learned that our frozen man lived through the night, and the next and the next. His temperature rose and eventually he emerged from his coma,
with minimal neurologic deficits. We cool patients postarrest; he cooled himself before we got to him. Is it neuroprotective in the same manner? Eventually he made it
out of the ICU and then passed out of the main doors of San Francisco General Hospital, past the Heart Statue and onto Potrero Ave. From there, who knows?

I suppose his case is a triumph for the emergency department team of physicians and nurses who literally brought him back from the dead. Later that day, I had boasted to a fellow resident that I placed 6 lines in the patient in under 30 minutes (endotracheal, nasogastric, left internal jugular, right femoral, left arterial, left chest tube).
But honestly, I could do that to a cadaver. Triumph for me, perhaps.


But while I was driving home, that patient was in the ICU. Would it not be cheaper to buy him a sandwich, give him a roof over his head, than pay the daily room rate of an ICU bed? I
hear those rates beat the Hotel Continental’s presidential suite almost 20 times over.

My day off this week, I went shopping in Union Square. Walking from a coffee shop towards Steve Madden, I passed a tiny church sandwiched between 2 commercial storefronts.
Crouched in the corner, under a pile of blankets and old wool hat was a similar-looking man getting some rest. The day was warm, yet a shiver ran up my spine. Would I see this
homeless wanderer in the resuscitation bay in the future? I dropped a dollar in his Styrofoam cup and hoped we would never meet again.

...caveman garden part deux

I know you are all waiting in suspense about how La Jardin Du Grog is faring after it's massive planting this past Saturday. Wait no more! Most of the plants are happy and healthy! I think the best looking are the Costa Rica Red Peppers: (but then I am biased given my love for both that country and red peppers)

The blueberries are also faring well!!! Yum Dericious.

They all got quite a drenching when I got home from work this afternoon. Turns out farming is pretty fun already, and I haven't even gotten to the pickin' and eatin' stage yet. Growing up in very suburban NJ and then spending close to a decade in the urban jungle of NYC, this is all pretty foreign to me. I didn't even know about the urban sustainability movement until this year. The closest I got to growing anything before this was when I tried to grow my own pumpkin in first grade. The darn plant insisted on growing sideways instead of nice and straight. Lil' Jen didn't quite realize that Cinderella's pumpkin grew alongside the ground and got so frustrated that she gave up the farm dream altogether. Expect for the yearly Basil plants I purchase from Trader Joe's and always manage to forget to water. I'm much better with taking care of our cats. They trip me if their bowl registers "empty". Danimal on the other hand had a garden growing up in La Honda and is quite facile with the dirt and plants. I have no delusion that this Jardin is mostly his handywork. But I'm pitching in and really stoked to learn more! Even if there might be spider sightings involved
I must say, I always heard farming was hard work but it never registered just how difficult and labor intensive it could be. It's changing my appreciation of growing food and appreciation of where my food comes from.
Now the next question - what veggie will be harvestable first? 

Crossfit

Since returning stateside after Costa Rica and the completion of my Cleveland Yoga TT class, I've been back at Crossfit Distinction with a vengeance. It feel great to be back in the gym again. Not only do I love the challenge of the skills and WOD, it's a great community. Seriously, how can you not love walking in the door and having over a half a dozen people smile and wave hello to you. Awesome. Especially after a grueling day of greeting people who are not necessarily thrilled to see me in the ED.

So tonight, after jumping in my car at the hospital I sped only slightly illegally down 480 to Beechwood in time for the 6pm WOD.  Daminal was still cooling off from the 5pm group, while others were already in the midst of warming up. I quickly exchanged my Clark Kent scrubs for not-quite superwoman (but I can dream) workout clothes and joined the throngs.

WOD:
For time:
50 Double-unders
40 Abmat sit-ups
30 Medicine ball clean [20/14]
20 Box jumps [24/18]
10 Handstand Push-ups
20 Box jumps [24/18]
30 Medicine ball clean [20/14]
40 Abmat sit-ups
50 Double-unders

It actually went a lot faster than I was anticipating. I was really struggling with my double unders so ended up doing 3x singles cause it might have taken me an hour. The rest felt really solid. Although I need to use a pad for the HSPUs, it just felt great going upside down. The worst part was the second set of medicine ball cleans. Hello, gluts! Afterwards, JM and CW et al played around doing handstand walks. JM showed me how to do a one handed handstand against the wall, my new favorite "skill" to practice. 
All in all a great way to finish the day :)

CSA

And CSA is for "Community Supported Agriculture".

Yesterday, Danimal and I took a mini-field trip to Valley City, OH where the farm of our summer CSA is located. Plum Creek Farms is just a decade shy of their 200th anniversary, although they have only been running a CSA for about 5 years now. For those of you who don't know, a CSA is a group of individuals who "buy-in" to shares of a farm at the beginning of the growing season in exchange for a portion of the weekly farm produce. They share in all the risks and rewards of the farm. For the farmers, they get fo eliminate the advertising and middle men and focus more energy on what really counts - growing good food. Each week, they are going to deliver a food box to our local farmers market for pickup. That box consists of whatever is in season and grown on the farm. For example, this week we got fresh strawberries, rhubarb, mint, salad greens, asparagus. And delicious, delicious eggs. Have you ever had fresh eggs from pasture raised chickens? If you haven't you are totally missing out.

D and I were surprised how quickly the towns turned rural as we got off of I-71 in STrongsville. There were lots of big open fields, barns, horses. Finally, the GPS "declared" you have arrived at your destination. And boy, had we! A big silo towered over the dairy barn where the milkin' cows were kept. A tour was already in progress, but we jumped on the tail end of it. My coworker from work who recommended this CSA to me was there with her family. It was so great to see her "out of the office!"

They led us through the milking facilities, then into the pens where the cows were kept. They don't like to be outside in the heat. I was mesmerized by the calves. They were so cute!

We also saw the plots where the vegetables were growing strong, rows of lettuce and other good greens. There were bee hives off in the distance. I guess we might get some honey! Yum! Bees are one animal we have no desire to take care of ourselves. (D is haunted from the time one flew in his ear in kindergarden.)

And then... the poultry house. Today I have been stalking the web for news if the ordinance to have a chicken coop in Cleveland Heights passed. So I was pretty stoked to see how the CSA raised and kept their chickens. There was a myriad of varieties including the Rhode Island Reds and Plymouth Rocks we are eyeing.

But that wasn't the best part. Chickens are fun and all, but not much can beat the cuteness of ducklings. There were two metal tubs full of 'em. It took all my willpower to resist picking one up (they might not have minded but I didn't want to start out my relationship with the CSA on a bad foot!) I consciously made a point NOT to think about them as Christmas dinner, which is the destination for almost all of them. (Stay tuned for the sequal to "chicken run", "the great duck escape")

Anyway, after fresh homemade rhubarb lemonade, we gathered our basket and jumped back in the car to head home. Now to grill up some of that asparagus!

...Caveman Garden (Jardin du Grog)

First, there has been an appalling lack of posting by myself over the past few months. Apologies. Blogging time was in short supply between working full time, yoga teacher training, and life in general. But I'm back and aim to post much more regularly.

Today Danimal and I planted a garden outback. Now D has been working on the 10 x 20 plot of land adjacent to our garage for months now, digging up rocks and dirt and creating beds. A veritable jungle of plants had taken residence on the radiator in our dining room a few months back.

 (Displacing one very upset black kitty).

During his first full weekend off in about 6 weeks, he rented a roto-till from the Handy Rents up the street and churned the clay/dirt/compost up. He had the biggest grin on his face throughout! Meanwhile, I planted some shrubs around the deck. Tilling complete, he rolled the machine back up the street. Farmer Dan at large in Cleveland.

When he returned, and after a brief siesta by both of us from the hot Cleveland sun, we plotted out our Jardin. Peppers, Cucumbers, zucchini, huevos plantes. We put some crushed eggshells under the tomatoes before putting them in the soil so that they would have extra calcium to grow nice and strong. Serious fun. I hadn't played in the dirt like this in years!

Stay tuned to see if all our hard work pays off!

...crockpot shredded beef!

Today is GROUND ZERO... for a Whole30 challenge! As part of my Yoga Teacher Training program at Cleveland Yoga, we are supposed to do a "cleanse" for 3 weeks. As in no Alcohol, Animal Products, Dairy, Caffeine, Gluten, or Sugar. But all the "karma yogi" food such as rice, beans, corn, tofu, quinoa is allowed. What's a Paleo girrrl to do? Well, I can't bring myself to eat such a diet for 3 weeks. I've read too many primal nutrition books to do that to my body (especially the corn) so I enlisted danimal and decided to conquer a Whole 30 instead. Still no Alcohol, Dairy, Gluten or Sugar, but delicious and good for you grassfed meats, free range poultry and eggs, no grains of any kind. I'm also making a very conscious effort to decrease my caffeine consumption. I don't think I'll be able to get off the morning cup of Philz (oh sweet nectar of the gods!) but I'm substituting my afternoon cup for tea. Turns out Yerba Mate is pretty delicious!

Which comes to the point of this post... cooking. There's some prep work that comes with a Whole30 in addition to buying tons of Steve's grassfed paleo stix and the Just Mangoes from Trader Joes. One of the girls from Crossfit Distinction, Janine, pointed me over to paleOMG.com. This hystical crossfitter out of Colorado has one funny food blog. I poked through some of the crockpot recipes and found one that I had all the ingredients for in the house, but made some adjustments. I'm on a huge cumin kick - the spice of life! - and needed to add that in there along with a bit more heat. The final version came out pretty tasty. Equally important, it was super easy and produced a ton of grassfed meat to get our chow down on.

Easy Shredded Beef

Ingredients

• 2-3lb round steak (I used one from our CSA - buy whatever beef is cheap)
• 2 large yellow onions, sliced
• 1 4oz can of diced green chili peppers
• 1/2 cup chicken or beef broth
• 1 teaspoon salt
• 1 teaspoon garlic powder
• 1/2 teaspoon cayenne
• 2 teaspoons of Penzey's BBQ3000 (more to taste at the end)
• 1 teaspoon cumin
• 1 teaspoon black pepper
• 1/2 teaspoon ancho chili powder

Instructions

1. Pull out crock pot.
2. Put meat in pot.
3. Put broth in pot.
4. Put onions on top of meat.
5. Put spices on top of meat and onions.
6. Cover.
7. Put crock pot on low for 8-10 hours
8. Take 2 forks and shred
9. Pour off excess juice
10. Season to taste
11. Eat it like you mean it.

...california

heading back to CALIFORNIA tomorrow.

Granted it's San Diego and not SF, but it still is going to be great!

...more later...