A MAN FOR ALL SEASONS

Today, we lost Senator Edward M. Kennedy, aka Ted Kennedy. He was a giant among men, and he earned the nickname "The Lion of the Senate" after 46 years of service. My first exposure to politics and Democratic politics (capital D) was through my father. He revered the Kennedys and often spoke of the time during college when he shook President Kennedy's hand. To him, the Kennedys represented everything that was great about America- a family of Irish Catholics who worked hard, made the highest sacrifice with their public service and their own blood, and who never ceased to look out for the little guy despite their station in life.

While Teddy was considered to have the dimmest prospects of all the Kennedy boys for success, his contributions to Americans and people the world over may have been the most profound of any of his family. The list of his legislative accomplishments is far too long to review here tonight, but they include: S-Chip, the Voting Rights Act, OSHA, Americans with Disabilities Act, and No Child Left Behind. He was also able to work across the aisle, and I was struck by the tone and words of comfort expressed by Republicans today after news of his passing. Despite that, he was a liberal through and through, and he was one of the few Democrats to vote against authorizing the Iraq War in 2002- how prescient.

He knew how to give a great speech, and he will go down as one of the greatest orators of our time. Who could forget the eulogy after RFK's shooting, the concession speech at the 1980 Democratic National Convention, and the addresses at the nominating conventions for both John Kerry in 2004 and Barack Obama in 2008? He was America's senator and the face of the liberal wing of the Democratic party. Teddy is, to a great extent, why I am proud to call myself a liberal, and why I always viewed it as a compliment whenever a conservative critic attempted to malign Barack Obama or another candidate by saying his legislative record was to the left of Kennedy.

While his dedication to public service is unmatched in the modern era, he also had his own personal failing including an episode of cheating while at Harvard, a role in the death of a young woman at Chappaquiddick, struggles with his weight and alcohol abuse, and rumors of womanizing. It was those failings that were brought to light in real time, which made Ted Kennedy the most scrutinized Kennedy of his generation. It was also what made him seem the most real of any of that dynasty and what endeared him to many of his constituents and Americans whose lives were affected by similar problems.

The political scientist Norman Ornstein put it best today when he said about Teddy, “He was a quintessential Kennedy, in the sense that he had all the warts as well as all the charisma and a lot of the strengths. If his father, Joe, had surveyed, from an early age up to the time of his death, all of his children, his sons in particular, and asked to rank them on talents, effectiveness, likelihood to have an impact on the world, Ted would have been a very poor fourth. Joe, John, Bobby ... Ted. He was the survivor. He was not a shining star that burned brightly and faded away. He had a long, steady glow. When you survey the impact of the Kennedys on American life and politics and policy, he will end up by far being the most significant.”

You will be missed Teddy...

THE MUSIC MAN

This is a video of Nicholas participating in a "Toy Symphony" with the Portland Symphony Orchestra from Laurelhurst Park in Portland on 8-15-09. It speaks for itself.

AIN'T NO MOUNTAIN HIGH ENOUGH

This past weekend I read, from start to finish, the book "Mountains Beyond Mountains" by Tracy Kidder about the physician Dr. Paul Farmer. The book chronicles the story of Dr. Farmer from his childhood, to his work as a volunteer and student of anthropology in Haiti, to his days as a medical student, resident, and fellow in Infectious Disease in Boston, and to his numerous pursuits to rid the world of suffering, particularly in the poor. I had first heard about Farmer from an article in the New Yorker many years ago. It was one of those classic articles in the magazine that goes on forever, but which is entirely compelling. I had the good fortune to meet Dr. Farmer and to go on rounds with him at the Brigham and Women's Hospital in Boston when I was a visiting Chief Resident there in 2002. Unfortunately, I joined the team near the end of rounds, but I found Dr. Farmer to be both incredibly personable and captivating. His belief in the primacy and divine right of health care is enunciated best in this piece from NPR's "This I Believe" series.

Farmer's work with the poor in Haiti is the focal point of this book, and much of the focus is on the hospital Dr. Farmer helped build in Haiti called Zanmi Lasante, Creole for Partners in Health, which is the name of Farmer's global health non-profit organization. In the book, Farmer quotes from Virchow to summarize what motivates him, "Physicians are the natural attorneys of the poor…and social problems should largely be solved by them." This book and this quote reminded me of the patients I served during the course of my early medical training, which took place in county hospitals in Houston and Dallas. In both cases, these hospitals were the only place the poor in these communities could get quality medical care. Particularly in Dallas, however, I still feel as though the level of emergent or inpatient care these patients received was among the best in the world due to the drive and passion of the physician residents and attendings who worked in Parkland Hospital. What we lacked, however, was easy access to outpatient care and services and a system of community outreach to help patients improve their lots in life (educational services, social services, job training). Without the latter, can a patient or a population truly thrive? The answer, in my experience, as I saw the same patients present with the same problems over and over (congestive heart failure exacerbation due to the fact that salty canned foods were more affordable than fresh vegetables, asthma exacerbation because steroid inhalers were too costly or because of the poor air quality of the inner city, etc, etc) was clearly no.

I read a review of "Mountains Beyond Mountains" by Abraham Verghese after I finished the book, and in it he describes Kidder's book the following way:

''Mountains Beyond Mountains'' is inspiring, disturbing, daring and completely absorbing. It will rattle our complacency; it will prick our conscience. One senses that Farmer's life and work has affected Kidder, and it is a measure of Kidder's honesty that he is willing to reveal this to the reader. In 1987, a book called ''And the Band Played On'' changed the direction of my career and that of many physicians of my era who decided to devote themselves to the care of persons with AIDS; I had the same feeling after reading ''Mountains Beyond Mountains'': that after I'd read the book something had changed in me and it was impossible not to become involved."

I had the same sense after I turned the last page of Kidder's book, and I find it quite impossible to sit on the sidelines and to not work, in some small way, to ease the vast suffering which plagues our world. The mountains out there may be high and the troubles that the world faces may be vast, but is there a more worthy endeavor than helping those who are less fortunate? I leave you with a quote from my hero Albert Camus, which summarizes Paul Farmer's life and his life's work:

"I leave Sisyphus at the foot of the mountain! One always finds one's burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart. One must imagine Sisyphus happy."

WORDS BY WHICH TO LIVE

If you ever want a good dose of fear, become a doctor or a parent. I have certainly had some very scary moments during my medical career and most of them involved young patients (unlike my current practice of prostate cancer patients) who had very serious but potentially reversible illnesses (e.g. a 20 year-old asthmatic to whom I gave medicines to paralyze him, in order to facilitate placement of an endotracheal tube and mechanical ventilation, whose vocal cords I could not quite visualize for 60 seemingly interminable seconds in the middle of the night during residency, a 27 year-old whose fruity breath from across the room, due to the accumulation of ketones, and whose slow, deep Kussmaul's respirations betrayed a diagnosis of new onset diabetes and life-threatening ketoacidosis, and my own son whose audible wheezing and shortness of breath at the age of 5 months taught me to respect the virulence of Respiratory Syncytial Virus. I cite these examples not for dramatic effect but rather to highlight the incompatibility of life with inadequate oxygen content, abnormal pH, or inadequate perfusion of one's tissues.

Last night, I had a scare of a very personal nature. Little Cate had been having loose stools for about 4 days. She had been drinking okay, but her appetite for food was poor. Yesterday, however, she began to refuse even bottles while her diarrhea continued. A babysitter watched her during the day, and when I returned home, the sitter said she had not had any wet diapers, although she had had plenty of loose stools. To anyone in the medical field, there are a few simple nitrogenous credos, "no urine, no life," "urine is golden," etc, etc. I feared that she was severely dehydrated and that she would not be able to make up for her GI losses by taking food or drink by mouth. Thus, I threw her in the car and headed to the ER.

I was met by Kathleen and Nicholas there, and we were quickly taken back to a room. The nurses attempted to stick the little one for blood work and placement of an IV. First try, no success. At that point, I decided to take Nicholas out of the room in order to not make his rejection of the medical profession 100% certain (currently at around 99%). We came back in 30 minutes, and 3 additional tries later there was still no IV access. Cate took a few sips of water, and the senior nurse suggested we simply encourage her to drink more and re-assess in 1 hour. Mind you, I am a pretty diplomatic guy and physician, but I flat out told her that that was stupid. The patient was clearly volume-depleted and had not been taking enough in by mouth for several days. No amount of oral consumption was going to ameliorate the situation... fast enough. I told her that we needed to try again. A different nurse was called in (it is funny but the best nurses for procedures always seem to have some goofy article of clothing, and this nurse was no exception in his Sponge Bob tie over his scrub top). He was able to secure an IV and obtain labs after his second attempt, and the re-hydration commenced.

I took Nicholas home after that and Kathleen stayed with the baby, who was admitted to the Peds unit. Little Reese (Cate's middle name) was kept overnight, and about 7 hours after IV fluids were started, she finally made urine and wet her diaper. I was not aware of this until this morning... after a night of little sleep and much worry. I have never been so happy to hear that she needed a diaper change; again, urine is golden! Cate was discharged today and is taking food and fluids better. Although her illness, a case of Enterovirus gastroenteritis, has not completely resolved yet, we expect it to run its course in the next few days.

I suppose I never realized the parallels between medicine and parenthood, both of which should be about helping people by identifying problems and their gravity early and then instituting the appropriate courses of action to solve/prevent said serious problems. This may be encapsulated in a simple phrase from the Hippocratic Oath- "First, do no harm!" Harm can occur as easily through acts of omission (not placing the IV for a clearly dehydrated child or not teaching one's children about safe sexual practices) as it can by acts of commission (performing an unnecessary procedure, which leads to a poor outcome, or spoiling one's children). The answer in this situation was not to take an inferior course of action, a seemingly easier course of action, and to hope for the best; we all knew the baby needed an IV, but it's placement was not easy given her dehydrated state and poor veins. The answer was to do the right thing, the hard thing, which was the only tenable solution to the problem. That is how I have tried to practice medicine, and that is how I try to raise my kids. "First, do no harm!" Words by which to live.