Balsamic Vinegar

Yum! I used it a lot this past weekend, with great results. Here's a recap:

Saturday, dinner with my friend and bridesmaid Karen, her husband Jake, and their 2-year-old daughter, Lily:

Brushchetta as an appetizer: Tomatoes, diced onion, fresh basil, a splash of good balsamic vinegar, a drizzle of EVOO, and salt and pepper. Serve with a good loaf of bread -- we got a baguette from the Asian grocery store down the street (Vietnamese cuisine has a lot of French influence, remember).

Balsamic-glazed grilled chicken:

Make a marinade using balsamic vinegar, olive oil, some lime or lemon juice, some dried oregano, salt and pepper, and minced garlic. Mix to combine, and pour over chicken parts. Marinate for a couple or few hours. Grill, basting with the marinade.

Cut up some peaches (it's peach season!) and put on the grill. Slice some onions into thick slices (I used yellow onions because I have a bunch of them right now, but red onions or Vidalias would be even better, I'm sure!), give them a swipe of olive oil, and add those to the grill, too. While everything's grilling, mix up a balsamic vinaigrette: good balsamic vinegar, salt and pepper, dried oregano, a sprinkle of sugar, and some fresh chopped herbs (I used basil). Whisk while drizzling in extra virgin olive oil, until it reaches the right consistency. I used a bagged mixed greens salad from the grocery store, topped it with tomato wedges from my garden, the grilled peaches and grilled onions, and poured the vinaigrette over the whole thing. Serve alongside the grilled chicken.

For a few reasons, I have started to buy different versions of certain oils and vinegars. For marinating and sauteeing, I use regular olive oil. I save the EVOO for salad dressings, bruschetta, and other preparations in which we'll be eating the oil in its raw and pure form. The regular olive oil is cheaper, and I save the good stuff for when it matters. The same goes for balsamic vinegar -- I use a run-of-the-mill balsamic for marinating and reducing into sauces, and save the sweeter, better, and more expensive balsamic for pure/raw preparations like vinaigrettes and bruschetta. If you're trying to make your dollar stretch farther, this is a great way to do it while still being able to use quality ingredients when it counts.

Sunday, dinner with some friends and an excuse to use up more chicken and peaches:

Same chicken marinated in the same balsamic marinade, but this time, served with a grilled peach and corn salsa, recipe courtesy of Mark Bittman's How to Cook Everything. Cut 2-3 peaches in thirds or halves and grill. Also grill a couple ears of corn. Let cool until able to handle, and then cut off the corn kernels and dice up the peaches and put everything into a bowl. Add about 2-3 tablespoons of chopped Thai basil (regular basil or mint would also work well), and half of a jalapeno, finely diced. Squeeze some lime juice into the bowl and season with salt and pepper. Serve warm over the chicken. We've been eating it cold ever since as a salsa with chips, but it was really best warm over the grilled chicken. The spiciness of the jalapeno in the salsa is cut by the lime and Thai basil, and it all goes wonderfully well with the sweetness of the balsamic glaze on the chicken.

To use up the jalapenos and banana peppers I've been growing, we also made jalapeno poppers. To make them, slice your peppers in half lengthwise and scoop out the seeds and white rinds. Mix shredded cheddar cheese with cream cheese, and spoon into the peppers. Wrap the whole thing with half a strip of bacon and secure with a toothpick. Grill for a few minutes over semi-direct heat until the bacon is cooked through, and eat warm. Very yummy. I thought about using a more interesting cheese instead of the cheddar, like Monterey Jack or Colby, but decided the heat of the jalapeno would negate any subtle taste differences, and I think I was right. That said, if all I had was Jack cheese, I wouldn't bother going to get cheddar for this recipe. We stuffed ourselves with jalapeno poppers and then ate the chicken with the corn and peach salsa, and it was plenty of food.

One of the things I particularly loved about cooking this weekend was being able to use so many items from my own garden and from the local market. One of my own tomatoes went into the bruschetta; I used my own basil for the bruschetta and Thai basil for the corn and peach salsa. My own jalapenos and banana peppers were the basis for the jalapeno poppers -- I definitely would not normally have made them if I didn't have an abundance of peppers I didn't know what to do with.

And the Italian market is definitely my favorite place to shop. I got 3 pounds of perfectly ripe peaches for $1, which went into the salad on Saturday and the salsa on Sunday; fresh Jersey corn for the salsa; amazing slab bacon -- for much less than the grocery store charges! -- for the poppers; and great whole chicken breasts to go with the dark meat I already had in the refrigerator. The butcher offered to split the breasts for me, but I chose to do it myself; it was a good lesson in chicken anatomy, and it gave me the opportunity to save all the little extra trimmings and bones to freeze and make stock with later. The only downside to the market is that everything closes down around 5 or 5:30 so it's hard for us to get there during the week.

As exhausted as I am from working, I am really enjoying cooking this summer. I hope the weather doesn't cool down anytime soon -- we need to keep grilling!

Less depressing stuff

Last week we had a patient who came into the ER with chest pain. 33 years old, otherwise previously healthy, though with a significant family history of cardiac disease. Chest pain, and in the ER, he went into V-fib, and was shocked back. It doesn't happen all that often, but what made it even more exciting was that because he had no other comorbidities, he was a candidate for our hypothermia protocol. I had never heard of it before, but lo and behold, a day after we dropped his body temperature to 33 degrees Celsius, I saw this article on CNN.com: Cooling is catching on for cardiac arrest patients. (No, I do not generally get my medical news from CNN; however, I was post-call and just doing some fluff reading on the Internet.)

Our patient did great! He was cooled for 24 hours, then rewarmed slowly. He slowly came to and did well neurologically, and we transferred him from the ICU out to a regular floor bed later that day. The other night I was walking through the floor units and saw him -- sitting in a chair outside his room reading a book. Totally normal. He's definitely shaken by what happened -- imagine waking up in a hospital having no idea why you were there, and being told that not only did you die for a minute, but that your body was then frozen (OK, not really frozen Austin Powers style, but you know...) and rewarmed. Crazy! He'll do fine physically, but I hope he follows through with his emotional/psychological counselling, because boy, will he need it. In any case, I thought you'd enjoy a slightly more happy story from the ICU.

And here's a Can You Believe It story: I have an 87-year-old woman who is on a ventilator because she developed respiratory distress the other night. She's a sick woman, and when it came time to think about intubating her, we needed consent from someone, and since she was unable to give consent due to her respiratory distress, we called her son, who consented over the phone, saying she would want to be intubated. So she was intubated. The next morning, another son contacted us and said he was her healthcare power of attorney and she did NOT want to be intubated. Uh oh! The first son, when approached with that information, maintained that there was a newer document in which HE was named power of attorney, and she DID want to be intubated. And when we told him to go home and get the papers, he came back and said he couldn't find them. Hmmmm. And of course, it turns out the two brothers don't talk to each other. So we scheduled a family meeting and waited. And in the meantime, one of the nurses found out the scoop: The first brother, the one who initially consented to the intubation, is apparently $1.5 MILLION in the hole from gambling debts. And he continues to gamble. He has multiple sclerosis and lives with his mother, and he uses her social security money to continue to gamble! So of COURSE he wants to keep her alive and on the ventilator -- he wants her money! Juicy, juicy.

In the end, papers were found at the lawyer's office, in which the patient had checked off that she did want to be resuscitated and did want to be intubated, so we will continue to treat her. But I can't look at the son the same way anymore. The gall!

And finally, I walked home today via the Italian Market and stopped to pick up a couple lemons and some bread. Dinner plans tonight are for chicken scallopini and bruschetta (home grown tomatoes ripened yesterday!). Sarcone's was sold out as usual (they sell out first thing every morning!), so I walked down to Talluto's, where I've also gotten bread before, about 10 minutes before they closed. Alas, the bread bin was empty, but the woman behind the counter said there was some at the register. I peered into the large brown bag full of rolls and as I asked for a couple short rolls, the woman shoved the whole paper bag into a plastic grocery bag and pushed it toward me. "Oh," I said, a little confused. "How much for the whole bag?" "Have a good day," she replied. And when I looked even more confused, she explained, "We don't sell day-old bread so we won't sell them tomorrow, so you can have them." Wow! What luck! Yay for the Italian Market.

More life and death. Or just death.

I was going to update you yesterday on the status of my patient with relapsing lymphoma, and then yesterday HAPPENED, and it almost seems silly, and I almost didn't blog at all. You'll understand why in a minute. But I can already tell that if I don't write this down, I'll never remember it.

So last week was my last week on general medicine floors, and I took care of Ms. Jones, the 42-year-old with relapsing non-Hodgkin's lymphoma, who came in for abdominal distention and some difficulty breathing. As I recounted already, her heme/onc physician was sure there was nothing more that could be done along the lines of curative treatment, but she had not yet formally made the decision to become DNR, or enter hospice the program. She came in on Monday evening, and on Tuesday got a therapeutic thoracentesis (drain fluid out of the chest using a needle -- the fluid can be from a variety of causes, but in her cases, it was cancerous) and paracentesis (draining fluid out of the abdomen using a needle -- again, cancerous in her case). On Wednesday we let her recover a little bit and made arrangements to have a family meeting. On Thursday at noon, we met with her family -- her fiance, a tall, big, strong guy who had quit his job to take care of her and was incredibly caring; her mother, a larger woman who had been rather pushy with some of the other people on the medical team and whose motives may have been slightly suspect; her aunt, a thin, sharp woman who had her Bluetooth in her ear for the entire family meeting, which looked so ridiculous to me -- at one point, when she stepped out of the room for a minute, I really couldn't decide if she was overcome with emotion or was answering a call; her father; her brother; her sister; and the second of her three children, her oldest daughter, age 18. The heme/onc attending was there, along with his nurse practitioner, and the social worker from his practice, and then there was me, the primary doctor for her hospital stay, and my third year medical student. It was a packed room. Even though Ms. Jones was doing so poorly, she wanted to look presentable for the meeting, and so the start was delayed while she tried to get out of bed to use the bathroom, wash her face, comb her hair, and put on a fresh hospital gown, with her fiance's help.

The nurse practitioner, Nancy, did most of the talking. She re-capped the situation for everyone: the patient had had multiple rounds of chemo, and the cancer kept coming back. There were no more options for treatment in which the potential rate of cure would outweigh the definite risks of side effects. And so, the physicians felt that she should focus on going home and spending time with her family. She explained hospice, and explained that it could be done at home. In the end, everyone agreed. The social workers started getting things organized. Ms. Jones would go home the next day, Friday. Overall, the meeting was sad, but I was more of an observer than a participant, and I kept myself mostly detached.

On Friday, the medical transport team was going to pick my patient up at 3 pm. By late morning, her fiance called to say everything had been set up at home (hospital-type bed, oxygen machine, etc), and could she come home sooner, because she wasn't feeling that well? So we moved up the discharge to 1 pm. I had to hurry to get all the discharge paperwork in order. And then a kink popped up and discharge was again reset for 3 pm. I saw her off, loaded in the stretcher, and she wasn't looking good. Discharge was delayed even further because when the ambulance team realized she was DNR, they had to call me to get me to fill out more paperwork certifying her code status. I noticed that the ambulance form specifically asked for an attending's signature, and I'm not one, but for things like that, it doesn't really matter. That was Friday afternoon. I found out on Monday that she died at home on Saturday. I'm OK with everything that happened, but I wish she had gone home sooner -- wish that she had become DNR and chosen to enter hospice sooner. But it's hard for doctors to give up, even when you're in the cancer business and it happens often. And it's hard to talk about those things -- if I had even been more willing to discuss everything with the patient, the meeting could have gotten scheduled sooner and she could have gone home on Thursday, instead of Friday.

I wanted to write down what happened with her, because I know I'll forget. I had the day off on Saturday, and was on call Sunday, with a fairly rough night that ended with me switching services post-call and starting in the ICU on Monday morning. And that's where Nancy the nurse practitioner ran into me, with my post-call addled brain, and told me Ms. Jones had died. I actually didn't even remember the conversation had taken place until Tuesday evening; that's how much damage being on call does to your mental function. You remember only what's completely necessary, and everything else gets pushed aside.

So that's that. I was on call again last night, and it was truly one of the roughest nights I can imagine -- definitely the worst I've had so far. The largest event of the night was a bad one, so bad that I don't even really want to talk about it, out of respect for the patient and in acknowledgement that I don't think I'm going to forget about this one any time soon. But here are some small thoughts from my first call night in the ICU:

-The 23-year-old died. Asthma, obesity, and pregnancy are not a good mix when it comes to swine flu. Her lungs were just shot, and in the end, there was no way to oxygenate her. Unfortunately, her family refused to "give up" and insisted in a family meeting a couple days earlier that we "do everything." When the time came, though, and they saw what "do everything" means -- chest compressions, with people, including me, taking turns bouncing her whole body around on the bed with the force of our compressions; sticking needles into every vein and artery we could find to try to draw blood or give fluids; bodily fluids coming out of every orifice she had -- a result of natural events, the medicines we were giving, or her impending death, I don't know; and the general chaos in the room, with us shooing them out of the room continuously while we tried to work on her and save them from seeing all these horrible things -- they reconsidered and asked us to stop. They spent a last few peaceful minutes with her instead, which was the right thing to do. Her family was a mess. I can't blame them. Her husband almost threw a chair at my resident -- he later apologized, and no one blames him for being so angry, but that's how much emotion there was. Now, a couple days later, the memory of it is at once completely fresh yet also blunted enough that I don't know how to put it into words. In a weird circle of care, it turns out that the whole rest of the OB/Gyn department worked with her in the beginning of her stay, when she delivered her baby and then got sick, and I, the only OB resident who hadn't met her during her obstetrical care, was the person who took care of her in the end.

-I got to put in a central line on a woman that night, too. First stick, and success!

-I found out the next day that a paper I worked on a few years ago will be published. It took this long because I didn't have ownership of the data, and so the work wasn't mine to publish. But the people who do own it decided to resurrect it, so it will be published later this summer in a big journal. Quite exciting!

I can't come up with a good way to end this post. I don't have any wise words or thoughts to bring things to a close. It is what it is -- the events and my feelings. I have to get them out of my head, though, both to document them and to start the forgetting/remodeling/healing process.