Senseless

It's a matter of perspective really.

Contact Hypothesis, a concept I've discussed several times on this blog, describes that idea that your mind only understands, only computes, what the brain already knows.

"A year ago," CNN's John King explains from his own shared hometown neighborhood of Dorchester in Boston, "eight-year-old Martin Richard held a sign with five words: No more hurting people. Peace." An all too ironic premonition of the "senseless acts of violence," as King called it, that would end his life.

Martin Richard

If you are losing faith in human nature, the Washington Post describes, go out and watch a marathon. I've run two, and have made it a life goal to run another in each city where I live. Interestingly, the concept of 26.2 miles--and a certain disdain for your knees--has been described a certain way by friends and family in the past. They use a word that describes something outside their understand, outside their comfort zone, outside their horizon. Senseless, they call it.

Indeed they are emotional events. The finish line, for those who make it, is where families and friends scream your name loudly--some even cry. You made it. They're proud. They either sympathize from their own experience, or marvel at something they don't imagine they could have done. Months of training, weeks' worth of Advil, heartache, schedule changes, setbacks, and mostly dedication culminate in the last 0.2 miles. Boston, New York, London, Chicago, major running events line the streets, the colloquially known "finishing chute," with signs, photographers, race officials, bands, and fans. Running is about separating. It's a debrief, a relaxation, a zone. It's what makes marathon training make sense to a runner; runners who also happen to be mothers, brothers, cancer survivors, war veterans, people with a cause--a reason to run, a meaningful part of their life.

Also senseless, is the direction some people chose to run when the bombs went off. Boston EMS paramedics and EMTs, Boston Police Officers, Boston Fire Fighters, and volunteer physicians, nurses, and others chose a road less traveled. We're engrained as emergency responders in the post-9/11 world about mass casualty incidents, weapons of mass destruction, and incidents perhaps as textbook as yesterday's tragedy. Secondary devices, the typical caution, are common: targeting responders, wreaking more havoc. They knew exactly what they were doing: but they went anyway. I've enjoyed my experiences as an EMT. It's taught me much about life, about humanity, but I've even said myself that I'm glad so many times to be in EMS, not police or fire. The idea of running into a gun fight, or a burning building, is to me--or at least was on a mental level--senseless.

Sense is something we try to make of things that have little explanation. It's human nature to answer "how" and "why" about an event. It's much more difficult to apply our own experience to ensure something makes sense.

What makes sense to me about the tragedy at Boston yesterday are the good people. The ones who dedicated their lives, decades of their life, to become a trauma surgeon or emergency room doctor. The ones with "BOSTON EMS" on their back who turned around, grabbed their equipment, and ran towards danger, but more importantly towards people they had never met begging for help. The same people who moments before were cheering for people they had never met who were accomplishing something they worked so hard to do; they took off their belt and made it a tourniquet.

And so we'll run again. The only senseless parts of this tragedy were not the deaths of innocent people. In fact, the most astonishing and remarkable senseless aspects were the inspiring actions of people who acted in ways they may have never previously understood. These are the senseless parts of our life, parts of our humanity, that only have the unfortunate privilege of being exposed when something equally senseless tests our resolve to be good people.

Go and See

FYI    This post was written as my first contribution to a blog called "We Were Partners" that I recently agreed to work on with my former paramedic partner Josh Barber. You can find the same version there, along with Josh's first two entries. We learn a lot from those we work with, but indeed also--as this post will share--those we work for.
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I recall a story from the New York Times, Health Section not terribly long ago that struck me as ironic and cheesy; but, it had a point, though not one made by the article's author. The writer's point seemingly highlights the beneficence of physicians roused from sleep on an airplane by the fabled "is there a doctor on board?" announcement. How noble. As an interesting aside, it's not unreasonable for the airlines to rely on such an announcement either. The flight crew is trained in basic first aid and CPR, then told to ask exactly that question. As some research has indicated, at least one doctor is on board somewhere between half and 90% of all flights.

The article lands itself column [and server] space because of how "heroic" it must be for a doctor to act outside of the sterile, white-walled, safe environment of an official exam room or hospital ward. Images of ballpoint pens stabbed into the neck come to mind. (I hear it works.) Ironically, the figurative ballpoint-pen-to-the-neck is exactly what EMS professionals are asked to do every day. The gift of it is not the part that they get paid to do (though some also volunteer)--i.e. respond when called, and help--but it's what they get to witness every day; and, where they get to witness it.

Back on Manhattan's Upper East Side, the mantra (at my high school) was consistent, if nothing else. "You have to meet them where they are..." the chat would always begin. The Jesuits are big on being a "man for others," but not on your own terms. A person-in-need's true problems don't exist in a vacuum, or in the gym of a high school, or policy-making war room. You can't honestly discuss someone's troubles or passions from opposite sides of the serving table in a soup kitchen line. You could undoubtedly pontificate about them. Certainly, though, you could never understand them without experiencing them. After a recent visit back to Regis started the wheels turning about memorable classes. "CSPI," Mr. DiMichele's senior elective on contemporary social and political issues, had one read called Nickel and Dimed, an investigative narrative by Barbara Ehrenreich chronicling her attempt to understand what it was truly like to be poor, working manually taxing jobs for little pay, struggling to make rent, and choosing between necessities. I don't plan to summarize the book. Suffice to to say: she gets it. If anyone is to effect change, they have to meet the problems where they are, "get it," and understand how they can be practically addressed.

Ehrenreich literally completes the storied "mile in someone else's shoes." In grad school, when introduced to the concepts of Lean process improvement, step one sounded shockingly familiar. "You won't get it, or know what you're supposed to get, until you go to where they are." Or as the Toyota process improvement model more simply puts it, "go and see." It strikes me, this is what is great about EMS; more specifically, what I have been struggling to put my finger on, struggling to craft into words, to explain why I value my ten years on ambulances so much. How it is that you--so quickly--get remarkably close to people that you spend 8, 12, 16, 24 hours within four feet of each other.

We get to go and see.

Doctors--or to speak for myself, med students--are trained in silos. Schools across the country have made small efforts, and increasingly so, to develop a better teamwork approach. This will somehow get us to, theoretically, better understand the tiers of people responsible for the care of any one patient. I'm skeptical. I see how my classmates react to "nurses' mistakes" in videos for some team-based exercise. I watched as residents degraded nurses and techs I worked with everyday in Pittsburgh. I, and my EMS partners, have been spoken to as though we were twelve years old. It's an interesting dynamic how we treat each other. It's a dynamic I have blogged about extensively, and a dynamic I hope to spend my career helping to correct.

The next step, then, is to realize how that passes through to the people we care for. It is hard to understand someone's life, someone's illness, and someone's experiences when the only time you get to encounter them is among four white walls, fluorescent lighting, and a sterile environment. Optimistically, some medical schools, such as the newly formed Hofstra North Shore-LIJ Medical School have taken some steps to change that. First year medical students at Hofstra, those traditionally spending the majority of their time in classroom settings rather than clinical ones, are required to participate in a buffed-up EMT course as a part of their initial training. I am, as you may imagine, a huge advocate for this program, but not for the reasons you may imagine. It turns out, this happens to be the same reason I think the article from the NYT/Health I opened this post with has some dramatic and creative thinking value. This program doesn't just help new medical students tackle basic physical exam and history taking. It doesn't just help new healthcare providers (just like their colleagues in EMS) experience asking difficult questions and physically touching other people. It doesn't just help new caregivers work with a vulnerable person who has called for help, perhaps at the most difficult moment of their entire life.

It helps them go and see.

It turns out people's lives don't exist in a four-white-walled sterile room. Their problems began long before they typically see the doctor. Their lives became complicated and their pathology developed because of where they live, and how they live, not why they made a clinic appointment. Hofstra medical students get to go and see the lives I have had the chance to witness in my ten years of doing EMS in five states and systems from the slow rural to the busy city. I've watched asthma patients gasp for air, as they try to convince me--in one-to-two word phrases--why their air conditioning can't be on (they can't afford it) during a hot, humid July afternoon. I've explained the value of peanut butter and jelly sandwiches to diabetic patients who can't afford a diet that will prevent them from calling the ambulance again soon--a diet that will prevent them from going blind, losing their legs, or having a fatal heart attack. I've felt the shriek of a mother who just lost a child. I've transported the same seizure patient every week because he can't afford his medication (and when he can, splits it with his friend, who also has seizures). I've been in the back of the ambulance with victims of hate, illegal weapons, legal weapons, accidents, domestic violence, mental illness, suicide, addiction, and a system that may have determined their destiny long before they had a chance to do anything about it. You can read plenty of statistics and anecdotes about "when people say they're going to die, they probably will." Then you hear it: "make sure you tell my kids I love them." (The worst kind of patient death is the one where you spoke to a patient moments earlier.) Just a few weeks ago I watched a nun die alone (but for my ambulance crew and the doctors and nurses at the hospital), her closest family was several states away--and they wouldn't be coming. These experiences shape my attitude, my life, and my politics. They shape who I am, how I think, and how I approach every patient that comes next. Beyond that, they form my ability to think critically, broaden my life experiences, and help me make decisions in my personal affairs. They're invaluable, often inexplicable, and certainly irreplaceable. 

Plenty of medical schools provide experiences in "the real world" working "with the community" we serve. In fairness, I should mention that here at Tulane medical students operate a dozen or so free clinics around the City of New Orleans. Most other medical schools operate some form of a free clinic for people who would otherwise be dejected by the healthcare system our country's policymakers fight so passionately about. I have already had some unique experiences at these clinics (several of which are at homeless shelters, substance abuse rehab facilities, and certainly in less fortunate neighborhoods) and enjoy talking to the patients even though they tend to be surrounded by four white walls. My ability to "talk-the-talk" with many of them, though, is no accident.

Every day EMS providers make a difference. Every day EMS providers are subject to abuse, tough patients, tough scenes, and complicated scenarios. Many calls are routine, others emotionally and physically taxing. Indeed a good EMT knows that the most challenging part of any call isn't the medicine or the protocols, it's the logistics and the decision-making. We often intervene during a very narrow window of time that actually makes a difference in outcome, but every once in a while we get the chance to truly save a life... Story time to wrap things up...

(Typical disclaimer: Names, numbers, times, street addresses, details may be fictionalized to protect privacy and identification. The essence of the story and players in it are preserved.)

Clear from the base and time for the day to start. I was supposed to be working a "tac unit" (basic life support 911) this particular morning, but two late "bang-outs" (coworkers calling in sick) put Richie and I together on a "medic unit" (advanced life support, paramedic, 911) on a day where the flu meant staffing was bare bones. It would probably be busy.
M40: "Medic 40, Central. 10-8, post 7" 
Dispatch: "Medic 40, post 3."

Post 3. Great! Coffee and breakfast before we get bumped up to a busier post. As fate would have it, second in line at Dunkin Donuts...
Dispatch: "Central to Medic four zero."
M40: "40"
Dispatch: "Medic 40, 444 North Jones Street, back up the BLS, 80-year-old male unconscious, EMD in progress."
M40: "40's responding."
Dispatch: "0822"

The dispatchers were giving pre-arrival instructions over the phone. This usually tips the scale of "are they really unconscious?" in the affirmative direction. At this time of the morning it's more than likely a cardiac arrest.

Dispatch: "Central to Medic40, ETA? CPR in progress, K."
M40: "We're pulling up, Medic 40 is 25" (on the scene)

Indeed it was. An elderly male lay in bed, in cardiac arrest who was discharged from the hospital an hour earlier and brought home. Definitely a sick individual with semi-permanent tubes for urinating and feeding already in place. The fire department and our agency's BLS unit were doing CPR on the bed, an AED was applied and I heard the automated voice "no shock advised" as I entered the room. "Let's get him on the floor guys," I said directed to the FD as I walked in the room. (CPR isn't effective on a cushioned surface and we would have a lot more room on the floor.) To the family: "Does he have any advanced directives? Do not resuscitate, DNR? Do not intubate, DNI?" ("No, please help him.") "What happened this morning?" ("He just stopped talking a few minutes ago, we did CPR and called 911.") "What kind of medical history does he have?" (They produced a long list and a large tupperware full of medications.) "Diabetic, hypertension, CHF, pancreatic cancer, ..." I started listing to my partner as I scanned the medication bottles. By now he was on the floor, our student was doing his first ever chest compressions, and I was slapping new defibrillator/monitor pads on his chest as my partner placed an IV line in the patient's neck. I tossed a ResQPOD to the firemen at the airway. "Joe, put that between the mask and the bag."

"Asystole," I said and reached in the bag for the drug kit. I passed the epinephrine bristo-jet up to my partner at the head and spiked a bag of saline to flow into the IV line. "Finger stick is 110" (his blood glucose level didn't cause the arrest). At this point you start running the "Hs and Ts" as they're known in ACLS, or advanced cardiac life support, the dozen or so possible and potentially reversible causes of asystolic (flatline) cardiac arrest. This patient hadn't been down very long, and given the way his lungs sounded, we assumed this may have been a respiratory problem first. Richie intubated ("lung sounds are good, tube's good"), attached the capnography, and we continued. Rhythm check. "Rich, I'd call that V-fib, you agree?" "Yeah, everybody off, let's shock that." "CLEAR!" (Yes, we really say that, especially in a crowded room.) This 80-year-old had some fight left in him, and an organized rhythm appeared on the monitor. ("Does he have a pulse with that?") "Yeah, a weak radial down here, let me try for a BP." Our supervisor was walking in now to back us up. He mixed up the next round of medications as I packaged the patient with the FD.

Supervisor: "302, Central. Medic 40 is going to be 10-2 to John's with one status-post-cardiac arrest, notification made, I'll be code 5."

Save #1 of the morning was in the books.

Dispatch (on the phone, not over the air): "Ryan, can you guys free up?"
M40: "We can be in another 60 seconds or so, just got finished cleaning up, what's up?"
Dispatch: "I have another unconscious around the corner from you at [...], you're the only ALS available, BLS and the supervisor are enroute."
M40: "Ok, put us enroute."
Dispatch (back on the radio): "Medic40 will be responding from 817 to [...] for the unconscious."

This one was a little easier. Big open nursing home room, nursing home staff were doing good CPR (not typical, by the way), and an IV had been placed before we even arrived. "Whose patient is this?" I asked generally of the people in the room. I suspected the scared looking Asian nurse in the doorway would be the one I was looking for. "Was he complaining of anything? Advanced directives? DNR? DNI? What happened this morning? How long has he been down?" ("He said his stomach hurt. He's full code. Only a few minutes.") "Ok, history, meds, allergies; do you have his chart?" (She provided it.) "Ry, let's just get him on the stretcher and work him on there." "Ok." Same routine. The AED chimed in it's opinion, "stand clear, analyzing, do not touch the patient." (Cool, 20-30 seconds to get other equipment out while it does it's thing.) "Shock advised, charging." (No sh*t, this guy has a shot, too.) "Ever shocked someone before, Mitch?" (Our student reported he hadn't.) "Button is all yours, as soon as it says so, press it." Zap. "Ok, compressions!" Richie started a bigger IV line, I put the pads on. ResQPOD went on the end of the ET tube. Rhythm check: V-fib again. "Ok defibrillate again." As the machine charged "302" (our supervisor) walked in: "where's your stretcher? I'll get it set up." "He's already on it, Mike. Ok everyone CLEAR!" Zap. Sinus tach. Eyes open, reaching for the tube. More post-arrest drugs, more careful monitoring.

Supervisor: "302, Central. Medic 40 is going to be 10-2 to John's with another status-post-cardiac arrest, notification made, I'm 10-8."

Save #2 of the morning was in the books. We got the typical banter from coworkers when we got to the ER. Richie and I were "taking all the glory" for the morning. "No place to go but down from here, guys." It was true, two in arrests in a row happens, (two in a shift could even be considered typical,) but not that often is it two saves.

M40: "Medic 40, Central. 10-8 from John's, got anyone breathing for us?"
Dispatch: "Medic40, post 1." (It's ok, I knew from her tone she got my joke.)

About a half hour later, documentation just completed from the first two...

Dispatch: "Central to Medic four zero."
M40: "four zero"
Dispatch: "100 [...] Avenue, cross of [...] Street, for the 26 year-old-male unconscious, possibly not breathing, caller is refusing EMD."
M40: "40 responding from post 1." (I imagine my chuckle could be heard/understood.)
Dispatcher (on the phone again, almost immediately): "Wish I were kidding, guys. Another one for you."

We could hear the YFD engine over their frequency (Richie and I liked to scan) asking their dispatcher to let the ambulance know the patient wasn't breathing. South Yonkers is known for its old construction homes. Narrow stairwells and homes on hills can mean complicated extrications. This patient was a solid 350 pounds and on the third floor. Lucky for him, though, he had a pulse, albeit a very slow one. He was not, however, breathing more than an unacceptable agonal breath every 10 seconds. Looks like Mitch would get some more skills practice. "What do you want to do, Mitch? He's not breathing so well, huh?" ("Bag him?") He was doing really well this morning. I tossed him a BVM and an oral airway. It wasn't a difficult picture to put together. The room was filled with drug paraphernalia and this patient was apparently well known to the ESU cops in the room with us. After plugging in the oxygen, I put the monitor on and set up a Reeve's stretcher to get him out of this scene. His vitals were predictable. Hypotensive, bradycardic, and hypoxic. He bought himself some Narcan. By the time we arrived at the hospital he was breathing on his own again and semi-conscious.

The last one doesn't necessarily count as a "save," in the true sense of the definition, but this was the third person in a row (it wasn't even noon yet) that wasn't breathing before my partner and I had anything to say about it.


The "three-in-a-row morning" as I have come to refer to it in my memory is certainly one shift that will be on my EMS career highlight reel for some time to come. Moments like these define lifetimes (our's and the patients') and remind us why we weed through the nonsense of a typical EMS shift's worth of drunks, insignificant complaints, and minor car accidents. One lesson I learned from one of my personal idols and favorite TV characters, Mark Greene from NBC's ER, is that no matter how hard it may be to deal with a difficult patient or personality, it's always more difficult to be that patient. It's why I think EMS--aside from everything else about the job--is unparalleled life experience. It's why I'm inspired by emergency medicine. It's why I'm inspired by people who don't hesitate to stand up every day to a more figurative "is there a doctor on-board?"

You get to experience so many people's lives in so many different settings. We get to learn what motivates people, what harms people, what steers people. We get a completely unadulterated view on human behavior. Every patient teaches us something that, whether we realize it or not, will help us talk to another one. Our partners experience it with us and become our close friends because we live through extremely emotional, mentally difficult, and notably vulnerable situations together. We get to be there, if you're lucky, for someone's first breath and also someone's last. And there is nothing like it. The job is great, and the experience invaluable, because when you're out there it's obvious: this job isn't about the tragic and dramatic ways that people die, it's actually about how people live.

We get to go and see.

Let's Roll

Never forget, we're told. Or so it's been said.

***

I never thought it would happen. "Oh, thank you again for last week," he says as I'm walking out of the lobby, heavy bag slung over my shoulder, stretcher-patient-partner trailing behind in that order. Last week? I'm thinking to myself. I've been primed for the situation though. I'm at a nursing home, wearing my uniform, picking up another patient in sad shape for an unplanned--we think--ER visit. "You're welcome," I reply somewhat casually. I have no idea who this guy is. I must have taken his family member to the hospital. Let's take a gamble here: female. "How is she doing?"

I never thought it would happen. Professional EMS poses a real challenge to remember every patient, but just a week later? I, on average, saw at least fifty patients (maybe many more, and a couple from this same facility) since I potentially met this kind man's relative, but he didn't even look remotely familiar. Could he have not been there? How else would he know that I was the one who transported his family member. That's it! Maybe I didn't! He is just saying thank you to the first guy he saw in an ambulance uniform. Thoughts raced methodically, logically, sequentially by as I no sooner thought it time to force my foot so far into my mouth that it would kick my logic-focused mind.

"She died. My wife and I were here when she choked at dinner. Don't you remember?" It turns out he's here to finish up some loose ends with the nursing home after his mother-in-law had a massive stroke--then choked--during dinner about two weeks ago. Then it hit me. I had to pry his wife off my arm to get the 80-some-odd-year-old patient out of her wheel chair and onto the floor. Quick recovery. This professional, less social, faux pas is salvageable.

"Of course I remember. I was asking about your wife. How is she doing?" He went on to explain that she was taking it quite hard. I would imagine she would. Every time I get to thinking about what some patients and their families could be going through it's difficult not to apply it to my own life. It's like a series of bad dreams--the kind that you can't immediately shake from your memory when you wake up in the morning. The kind that you live most of your day fighting to decide they did not, in fact, really happen. The only way you're able to handle several cardiac arrest calls per week is to avoid becoming attached to the story, the family, the bad dream. You're empathetic, not sympathetic, but not apathetic either. Your ability to forget is a crucial part of being able to handle emotionally charged situations and move on to the next one.

***

It's been eleven years since that absolutely beautiful Tuesday morning and the emotion is still raw. I've tried many times to put into words the piercing and thoroughly encompassing heaviness that certain images or audio clips trigger. Two years ago I blogged some of the more rote details of that morning and afternoon. Some time ago, I picked up a book (electronically of course, for my Nook) written by Lisa Beamer, Let's Roll. The book chronicles her version of events that day, and in the days, weeks, months, and years that followed and preceded her husband, Todd Beamer's, final moments aboard United flight 93. Todd was somewhat famous among the thousands of stories of normal days, heroism, and tragedy we heard. "Let's roll" was not only, apparently, his signature phrase, but his last heard words on the phone to a Verizon telephone operator from the Airfone as passengers attempted to regain control of the plane.

Lisa Beamer's story isn't terribly unique. She woke up that morning and heard the local news, went about her morning. Hours later her world unequivocally changed. Beamer tells the story of the unexpected death of her father when she was a young girl. Her responsibilities instantly changed. She was forced to grow up faster than she should have to. The sorrow she felt from that situation had long passed by the morning of September 11, 2001. What had not been forgotten, though, was the strength she had from what happened to her as a young girl. She is certain that, though she could not rationalize it then, were it not for the loss of her father, she would have never been able to handle the loss of her husband while caring for her own two young girls.

I worry when I hear the words "never forget."I worry they carry a connotation of the things we felt immediately: the shock, the hate--the things that hold us back, rather than the things that help us move forward. One of the greatest benefits of our human minds is the ability to forget. It helps us stay in the batter's box for curveballs (every once in a while they don't break and you get one in the side). If you don't have the ability to forget how bad something hurts, you can't focus on the things that make you stronger.

Within minutes, first responders knew how bad the situation was and how dire it would become. They could not predict the towers collapsing, perhaps not immediately, but within the first two minutes of the first plane strike, FDNY officers transmitted a "10-60" or a "major emergency," New York City's most troubling, most resource-demanding code. Manhattan's Squad Company 18 states over the air "this may be terrorism" three minutes after the first reports. No one can ever explain exactly why they feel what they feel and immediately know what they know--evidence lacking, instincts abound. I write this blog about fine tuning those sentiments, those inklings--touch points in our lives that shape our ability to make decisions.

It's strange the pieces we do consciously forget, but it's even more intriguing the things we subconsciously never will. Firemen, police officers, EMTs, engineers, dispatchers, and trade laborers worked their entire careers for the moments shortly before 9AM eleven years ago. Physicians, psychologists, construction workers, mothers, fathers, husbands, wives, and children would soon thereafter realize how well (or not so well) they were prepared for what just happened.

I choose to try to forget the pieces that get me the most upset. Many moments, I'm sure, have already escaped my narrative of that morning. Other things I know I will never forget: from the empty, longing feeling in my gut, to the blue and white fabric pattern on the chairs in the "Hearn Room" where I sat and listened to 1010 relate the live events.

If we know nothing else, eleven years later we are better people, stronger individuals, and more capable as a group. We're better prepared for what may come our way, perhaps hardened by what hatred can bring into our lives, but more so comforted by the heroism, fortitude, and commitment to move forward. I'm inspired by that, more than words of "never forget." I know I won't, and it may be a long time before I stop crying on this anniversary every year.

So what can we do? Keep saying "let's roll." The things we gained from experiencing 9/11--many we may understand, others may not be apparent for decades--will continue to shape our character and help guide our decisions. In our own small or grand tragedies we realize an opportunity to help other people manage theirs. Somehow, knowing that fate has a purpose, it helps it all make more sense--even if that means we have to cry every once in a while.

"Be patient and tough, one day this pain will be useful to you." --Ovid

Patience and Fortitude

Firstly, to those of you who have quietly and overtly asked when I would be writing my next blog, thank you for continuing to hound me. I apologize that it has been so long. I could make excuses, but I won't. Writing this blog is about habit--a good habit. It's one that I fell out of with a few distractions and a [very enjoyable and relaxing year] sans routine. I hope this will be a welcomed return and an essay-of-sorts that you will enjoy...

...

"Get your hands out another few inches, you can't get the full benefits from this pose until your hands are positioned correctly."

"She couldn't be talking to me... keep your focus in the mirror..." I thought. I've been doing this for months--maybe over a year--at this point. Bikram Yoga is the same 26 postures each and every class. I could not have possibly not been doing this one (number 15, by the way, Bhujangasana, or Cobra Pose) incorrectly for all that time.

Indeed, she was. Damn it. "Ryan, that's it, move your hands out further. Keep going. Keep going. Further..." her voice trailed off. Honest first emotion: pure anger. There's nothing like being called out in the middle of a class during your "personal journey" in front of 25 other people. Beginners, or "first-week-ers," have an identifiable, studio-provided mat and generic white towel. They have an excuse to be corrected! I am by no means an expert. The three balancing poses are truly an embarrassment each time, but I'm getting better; and, there is indeed no way I can ever follow the "lock your knee" scripted instructions for the duration of both sets for each posture.

Perhaps it was the heat. 105 degrees isn't the best environment for fostering anger-free emotional responses from a volatile New Yorker in exile without a Dunkin Donuts within arm's reach. Perhaps it was the fact that I thought I had the pose right for all this time. More likely, it was that Sarah, my instructor, was right. The posture truly felt much better and that "tremendous stretching sensation" touted in the script was actually in the right place this time--for the first time. I was shocked.

Bikram Yoga New Orleans  |  Julia Street, NOLA

The first few weeks of medical school are a humbling experience. There's no single reason for it, but within a short period of time the weight of responsibility and vulnerability kicks doesn't just sit on your shoulders, it pounces there. The "shoulders" I speak of, by the way, are actually each four separate joints, with dozens of ligaments, arteries, nerves, and physical exam modalities that aren't a week's worth of material, they're one day. Sure the Masters Degrees help, as well as the nine years as an EMT, but it's roughly like drinking from a fire hose. Find that analogy too over-used? Well then try drinking water from a fire hose when you're in a city that's located three feet below sea level and still doesn't believe in proper drainage. Every drop the hits the ground is one step closer to a moldy car and sandbags at the front door of your apartment. In many ways, med school resembles a chocolate assembly line (from the famous I Love Lucy episode):

The patient safety brain is hard to turn off. I'm already involved in an OR pre-op checklist auditing program at Tulane Hospital, but little did I know my Bikram Yoga class would be the first patient safety lesson of medical school.

Atul Gawande wrote about coaching in the medical profession in his 2011--and one of my favorite--NewYorker article, "Personal Best." Among the various subtle and not-so-subtle observations, Dr. Gawande explains how averse--overtly or unintentionally--physicians are to coaching. Professional athletes, he notes, are at the prime of their career. They have trained their entire lives, practiced every day, studied countless playbooks and strategy guides, and achieved a level of mental and physical fortitude supported by muscle memory unlike an average athlete; yet still, they are coached by teams of people who critique their every move. Lots of money and responsibility rests on their performance, their consistency, their predictability, and their adaptability. Each football play, for example, is complex. 21 of 22 players on the field are not in possession of the ball at any given time, but they have a combined goal. One slip up, one inconsistent player, one teammate who didn't read the right page in the playbook, and failure could be imminent.

"No matter how well trained people are, few can sustain their best performance on their own.
That's where coaching comes in."
"Personal Best"  |  The NewYorker Magazine  |  October 3, 2011

The operating room, the ICU bed, or the trauma bay aren't terribly different. We could benefit from coaching just the same. (Go ahead and read the article for a more thorough exploration.) Upon personal reflection... As I sat through our first patient safety session as a med school class two weeks ago, I recited (mentally) some of the principles, biases, and concepts as Dean Sachs discussed them. I, like some of my classmates, have been exposed to some of this before, but as it turns out exposure doesn't necessarily breed understanding. That is what responsibility I think carries the most weight and puts the light at the end of this four year tunnel so distantly. I wish my first reaction to my yoga critique were entirely positive. Sure, I corrected my mistake. And yes, my anger turned to appreciation shortly following how much better the pose felt seconds after three inches worth of adjustment. Yet, my gut reaction was telling. I now have a challenge for myself, though: get better at critique. Appreciate it. Learn from it. Best case scenario: don't get angry at it...

No one wants to admit criticism could be right, systematic, or repeated. Doctors refuse to admit (despite personal experience and empirical evidence) they are less effective when worked without sleep or for hundreds of hour per week. One of my first emails to other officers as a leader of one EMS organization included a statement about how "extremely inefficient" a particular supply chain process was. The responses were scathing. I was a "new guy," the "low man on the totem pole," and criticizing something that had "been this way for years without a problem." In many ways, organizationally and individually, we're so incredibly opposed to fresh eyes--outside eyes--critiquing how well, or not so well, we do what we think we're good at. "Inefficient," I tried to explain, was a good word. It didn't simply mean irreparably broken. It meant fixable, maybe even simply. It meant hope. There is an art to delivering constructive criticism, but there is certainly more of a talent in developing it; more of a challenge in cultivating it, rather than reacting poorly to it.

New York Public Library
(c) New York Times | "City Room" Blog

It has long been one of my favorite parts of "the city." Dangling apposition aside, I wrote about my passion for this street corner in June of last year on a totally unrelated topic. The few surrounding blocks in the area of 41st Street and 5th Avenue in Manhattan, and I share a fair number of memories.

The lions in front of the New York Public Library Research Branch--to many New Yorkers simply serving as the backdrop to Bryant Park--have names: Patience and Fortitude. Guardians of the city's academic capitol of sorts, they serve as a constant reminder of what it takes to succeed in any discipline. Yoga, medicine, football, they all require two things to accompany efforts to improve: patience and fortitude.

Barring any unforeseen tragedies I will have the letters "MD" after my name in less than four years. It almost seems as impossible as I once thought becoming a medical student would be. The amount of information and skills that need to be added to my brain before then is a seemingly daunting task. One of my true mentors, David, gave me a pep talk one day in Pittsburgh with the words "put your head down, work hard, but the time you look up you will have accomplished more than you would have ever imagined." Another confidant, and truly a coach, Catrin, once told me (while she whipped me into marathon-running shape), "you can tell a lot about someone by how they run, Ryan. Your weakness is only that your head is holding you back." In the end it will take coaching and performance improvement. Lots of small adjustments, hopeful changes, and inefficiencies... among other things.

Each year, the baseball season is 163 of games long. It involves 30 of teams. Eventually 10 teams (up from eight last season) get to the playoffs in September and eventually two will play for the world series about five weeks later. while your record is important, it's about endurance. Playing 163 total games is about two things: making money on a long season, and survivability. Teams make mistakes, sometimes they lose a game (perhaps a key one), but it doesn't destroy their season (or their career) because it's a long haul. In the end, they hope they have made mistakes, because they learn from them and prepare for the same thing to happen again. Players hope their swing can be improved. Inefficiencies can be corrected and they can get better. Indeed, they also hope their opponents (even those who they will never play in a single game all season) make mistakes. They expose weaknesses they didn't realize existed, suggest new strategies, and open the door to discovering ways they could practice to improve small pieces of the game. They score every game in successes (runs), opportunities (hits), and also mistakes (errors) because in the end the outcome matters most, but how they got there isn't irrelevant. Before every play, positional players know what they're going to do with the ball if it's hit to them. They're "situationally aware" of where base-runners are, the complicating factors of strategy, sacrifices, and game timing, and ultimately how they will respond when the ball is put into play. They're confident that by October, they've made all the mistakes (or most of them), and over the course of their 20-30 years playing baseball (from the time it was being hit off the tee) they can rely on their fundamentals, but also what they have learned since. The intricacies become natural with practice--and they only became natural because they or someone else has erred in completing that task before. In the end, they hope that now, in the World Series, they won't be making any of those same mistakes.

It's about patience and fortitude. 

A Neighborhood Reborn

Yesterday, I closed another chapter. Just about a year ago, I began a new one in Washington, DC, working on my second Masters degree at Georgetown. The year has been great and I often wonder how it went by so quickly. Aside from countless nights spent studying and, more importantly, too-numerous-to-count coffees, dinners, drinks, brunches, and happy hours with friends I did a lot here in eleven short months. I added two letters to my name, ran a marathon and a few shorter races, visited numerous monuments and museums, got to see some of my most-admired leaders and authors speak in-person, learned quite a bit about the human body, ate and drank at dozens of restaurants and bars, completed a major entrance exam (and prep course), volunteered with a local EMS agency, played intramurals, hosted friends and visitors, the list goes on. I've watched a few shows from beginning to end on Netflix, read about twenty books, blogged here at least five times per month, and managed to keep up a running training schedule. It's really no surprise the time moved quickly.

In my year in DC, the world has changed right in front of my eyes from decisions made only a few blocks from my Logan Circle apartment (Talk Slowly, Think Quickly | "Washington, DC - Week 1"). Health care laws have been developed and implemented over the course of the year. Don't Ask, Don't Tell has been ordered abolished (Talk Slowly, Think Quickly | "Don't Ask, Don't Tell, and beyond the military?") and yet we still witnessed the nation-wide tragedies of bullying-related suicides (Talk Slowly, Think Quickly | "Hate, Hope"). I watched hopelessly and prayed nightly as my undergraduate University, Cornell, struggled with a host of tragedies in too short of a time period (Talk Slowly, Think Quickly | "Gorge Jumping"). The "It Gets Better Project" held strong from, among many places, here in DC at the Human Rights Coalition national headquarters (Talk Slowly, Think Quickly | "It Gets Better") Fiscal debate nearly led to a government shut down. Osama bin Laden was killed. Revolutions have spread through the Middle East, while back at home we quarreled over whether or not a mosque could be built anywhere near Ground Zero in lower Manhattan (Talk Slowly, Think Quickly | "Wouldn't the Ground Zero Mosque Be a 'Win'?"). Glen Beck hosted a far-right rally on the mall, only to be countered weeks later by another, "Rally to Restore Sanity" hosted by comedians Jon Stewart and Stephen Colbert (Talk Slowly, Think Quickly | "Insane Sanity"). Indeed the World changed in eleven months.

At the Rhode Island Avenue NW entrance to Logan Circle Park, a sign reads,
A Neighborhood Reborn

The rest of the sign tells the story of Logan Circle throughout its history. In the 1870s, the sign explains, the neighborhood was home to several important dignitaries. Over the next few decades it would become, by the turn of the 20th Century, the hub for artistic expression in the city. Like many neighborhoods, it also shared in hardship. For many years, Logan Circle has struggled with poverty and crime. Today, however, Logan Circle stands as an example of one of the most historic parts of the Nation's Capitol. Victorian architecture and a prime example of the open and green city spaces that L'Enfant imagined when he designed this city, Logan Circle is surely a neighborhood reborn.

Logan Circle is in many ways emblematic of Washington's charm and personality. For many, this is home, but for a great proportion of the population, this is a temporary place to be. Administrations and their thousands of appointed and associated jobs come-and-go with elections. The city's several universities and graduate schools host students for only a few years before they move on to other jobs. By and large, the city has a transient nature. Logan, therefore, is not surprisingly a neighborhood filled with change and hope.

Two phrases from two separate professors have stuck with me throughout this year (and certainly will into the future). During our renal module, the course's director, Dr. Aviad Haramati (a native Brooklyn Jew now living here in Maryland/DC) often ended ever story of disease--or jokingly of his family's stressful situations--with the phrase "there is hope" in a thick Brooklyn accent somehow gracefully sounding pious and, well, hopeful. The other from our pulmonology professor, Dr. Chip Read. Dr. Read is Georgetown's Director of Adult Critical Care Medicine and often shared tidbits of his strategies for speaking with patients and their families. "If you want to instantly understand someone and become a part of their life," Dr. Read said, "ask them, 'what are your passions?' and you will be amazed how quickly the room lights up." Those two phrases are perhaps emblematic of this city and all that I have learned from it. There is no other place in the world where people are as committed to hope, passions, and ideals they hope they share with those they serve. Amidst the politics and the games, these two drives still make Washington, and this county, alive and well.

Just last week I finished watching the seven-year hit TV series The West Wing and I can only hope that I am one day as good at writing anything as Aaron Sorkin, but perhaps that is a wild dream. I'm working on it. I guess it is somehow ironic that I finished this series the week I am moving out of Washington (imagine what quote I would be pulling out if I had just finished The Sopranos, for example), but I am leaving this city hopeful, thinking about one thing. Indeed this is how The West Wing ended it's final episode. With the outgoing president leaving the city on his formerly-known-as-Air Force One, his wife asks, "what are you thinking about?" and fictional President Barlett (Martin Sheen) replies, "tomorrow."

In the end, I think I've had a good year. I've only had to call the police once (one of those "see something, say something" moments), only visited the ER a few times (never for myself), and managed to pay only a dozen or so parking tickets. I had one particularly funny experience at the DMV (i.e. the Department of Motor Vehicles, not the mnemonic for the District/Maryland/Virginia as a whole, Talk Slowly, Think Quickly | "DMV Tyrant") and had more time than I would have imagined to explore. Some of my favorite spots in the city (the Lincoln Steps, Tidal Basin, or just a street corner in Dupont Circle) are ones I will miss greatly.

Of all my favorite spots though, I have to highlight one in particular. An experience that is unlike any other. If you stand at the base of the Washington Monument and face north at dusk, the view is undoubtedly incredible.

Above you rises the tallest structure in Washington, the monument that bears our first president's namesake. Perhaps to some it gives perspective. The country we call home yields a great amount of respect to symbolism. Even then, you can help but feel two things: dwarfed and yet eager to see what that view is from the top.

To your left, the sun sets over the columns of the Lincoln Memorial (as though every four score and seven years yield hope and new life for people who at no time expected it to ever come). A plane banks so low you would think Lincoln could probably reach up and touch it. While tracking the Potomac, it makes its last turn on final approach to runway 19 at National Airport.  The sun sets and the sun rises over this building thousands of times. Expressions of "I have a dream" and those of Glen Beck share the same stage. It's a marvel of our democracy that we can coexist and move forward. In the weeks that followed two comedic political pundits would take the stage to satirize the same words, and in their belief in front of a crowd of equal or greater size, "restore sanity."

To the right, the radiant beams cast an almost indescribable light over the dome of the Nation's Capitol. Inside, the two houses of our legislative branch, one representing the voice of the minority opinion, the other displaying an equal share of opinion for each of the nation's fifty states, steer the trajectory of history. Like any human, their influences and decisions are not always for the right reasons. I'd like to believe that at the end of the day, they're still trying their best. Multiply any skewed incentive system by hundreds of people and you are destined to have some degree of impropriety, no matter the stakes. Our lives change every day because of decisions made here.

Peering ahead, the ellipse of the White House paves a trail to a building that has burned down and been rebuilt; has been host to scandal, but also pardon; has housed dozens of presidents who don't agree with each other, and staff would may wage war before sitting in the same room as their predecessors; and been the figurative and literal home of the leader of the free world charged with more stress and decision making ability beyond any human should be expected to bear. The grey hair they each develop is no surprise. The gold statue atop its post in front of the OEOB glows in the reflection of what's left of sunset. Scaffolding on the building reminds you that tradition and facade are still also important for the minds of those who work diligently inside its walls.

In a few minutes, the sun will set, and darkness envelopes these treasures. Undoubtedly the people inside will be working for many hours. Lives are changing. You can't help by stand there and know you're some place special.

Ryan's "Read It" List - June, 2011

Don't forget to check out my new blog, "Don't Judge a Book" at http://rto3books.blogspot.com. I finish up with this round of grad school tomorrow, so I will have some more time to put into both blogs soon! Enjoy this month's "[You Should] Read It" (in the present/imperative tense) list...

• 
  The Emperor of All Maladies (Siddhartha Mukherjee) + [new]
  Amazon, Nook

• 
  Blue Blood (Ed Conlon) [new]
  Amazon

• 
  When the Air Hits Your Brain (Frank Vertosick) + [new]
  Amazon

• 
  Health Care Turning Point (Roger Battistella) + [new]
  Amazon, Nook

• All I Ever Needed to Know I Learned in Kindergarten (Robert Fulghum)
  Amazon, Nook
  Talk Slowly, Think Quickly | "All I Really Need To Know I Learned In Kindergarten"
  Talk Slowly, Think Quickly | "Bystander"

• Safe Patients, Smart Hospitals (Peter Pronovost) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Do Better, Think Bigger"
  Talk Slowly, Think Quickly | "Patient Safety - Part 1 - 'The Booklist'"
  Talk Slowly, Think Quickly | "Patient Safety II - 'The Scene'"
  Talk Slowly, Think Quickly | "Patient Safety III - 'Why Aviation?'"
  Talk Slowly, Think Quickly | "Patient Safety IV - 'The Culture Change'"
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• Diffusion of Innovations (Everett Rogers)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• White Tiger (Aravind Adiga)
  Amazon, Nook

• And the Band Played On (Randy Shilts) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Pump Handle"

• Highest Duty (Chelsey Sullenberger)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• The Experience Economy (B. Joseph Pine, James Gilmore)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"
  Talk Slowly, Think Quickly | "Blizzard Beach Behavior"

• Buy-In (John Kotter)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• Prescription for a Healthy Nation (Tom Farley, Deb Cohen) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Pump Handle"

• Getting to Yes (Roger Fisher, William Ury)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"
  Talk Slowly, Think Quickly | "Give the officials a break"

• Haroun and the Sea of Stories (Salman Rushdie)
  Amazon

• The Owner's Manual (Mehmet Oz) +
  Amazon, Nook

• Life of Pi (Yann Martel)
  Amazon, Nook

• Into Thin Air (Jon Krakauer)
  Amazon, Nook

• The Go Point (Michael Useem)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• Decision Points (George W. Bush)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Decision Points"

• Audacity of Hope (Barack Obama)
  Amazon, Nook

• Grapes of Wrath (John Steinbeck)
  Amazon, Nook

• Breakfast of Champions (Kurt Vonnegut)
  Amazon, Nook

• How to Be a Gentleman (John Bridges)
  Amazon, Nook

• Emergency Doctor (Lewis Goldfrank) +
  Amazon

• If Disney Ran Your Hospital (Fred Lee) +
  Amazon
  Talk Slowly, Think Quickly | "Blizzard Beach Behavior"
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy" 

• Wines for Dummies (Ed McCarthy)
  Amazon
  Talk Slowly, Think Quickly | "California, Napa, and Wines"

• Napolean's Buttons (Penny Le Couteur)
  Amazon, Nook

• The Meaning of It All (Richard Feynman)
  Amazon

• Your Money, Your Life (David Cutler) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Comparative Policy Analysis"
  Talk Slowly, Think Quickly | "Incentivized Solutions"
  Talk Slowly, Think Quickly | "Castigate and Litigate" 

• Why Hospitals Should Fly (John Nance) +
  Amazon
  Talk Slowly, Think Quickly | "Patient Safety - Part 1 - 'The Booklist'"
  Talk Slowly, Think Quickly | "Patient Safety II - 'The Scene'"
  Talk Slowly, Think Quickly | "Patient Safety III - 'Why Aviation?'"
  Talk Slowly, Think Quickly | "Patient Safety IV - 'The Culture Change'"
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy" 

• The Grand Design (Stephen Hawking)
  Amazon, Nook

• Weekends at Bellevue (Julie Holland) +
  Amazon, Nook

• White Coat, Black Hat (Carl Elliot) +
  Amazon, Nook

• White Coat (Ellen Rothman) +
  Amazon

• How We Lead Matters (Marilyn Carlson Nelson)
  Amazon
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• The Meaning of Matthew (Judy Shepard)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Hate, Hope"
  Talk Slowly, Think Quickly | "It Gets Better"

• Guns, Germs, and Steel (Jared Diamond)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Pump Handle"

• The Immortal Life of Henrietta Lacks (Rebecca Skloot)
  Amazon, Nook

• Nickel and Dimed (Barbara Ehrenreich)
  Amazon, Nook 

• Bowling Alone (Robert Putnam)
  Amazon, Nook 

• Unfriendly Fire (Nathaniel Frank)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Don't Ask, Don't Tell, and beyond the military?"

• Final Exam (Pauline Chen) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Patient Communication"
  Talk Slowly, Think Quickly | "Last 6 months, not 6 minutes"

• Mountains Beyond Mountains (Tracy Kidder) +
  Amazon, Nook

• Think (Simon Blackburn)
  Amazon

• The Best Practice (Charles Kenney) +
  Amazon
  Talk Slowly, Think Quickly | "Patient Safety - Part 1 - 'The Booklist'"
  Talk Slowly, Think Quickly | "Patient Safety II - 'The Scene'"
  Talk Slowly, Think Quickly | "Patient Safety III - 'Why Aviation?'"
  Talk Slowly, Think Quickly | "Patient Safety IV - 'The Culture Change'" 

• To Err is Human (IOM) +
  Amazon
  Talk Slowly, Think Quickly | "Castigate and Litigate" 
  Talk Slowly, Think Quickly | "Do Better, Think Bigger"
  Talk Slowly, Think Quickly | "Patient Safety - Part 1 - 'The Booklist'"
  Talk Slowly, Think Quickly | "Patient Safety II - 'The Scene'"
  Talk Slowly, Think Quickly | "Patient Safety III - 'Why Aviation?'"
  Talk Slowly, Think Quickly | "Patient Safety IV - 'The Culture Change'" 

• The Last Lecture (Randy Pausch)
  Amazon, Nook
  Talk Slowly, Think Quickly | "[Cost] Analyze This"
  Talk Slowly, Think Quickly | "5-Goofy Goodbye"
  Talk Slowly, Think Quickly | "Whenever you feel like criticizing someone..."
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• The Kite Runner (Khaled Hosseini)
  Amazon, Nook

• What the Dog Saw (Malcolm Gladwell)
  Amazon, Nook

• The Healing of America (TR Reid) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Comparative Policy Analysis and Highways"
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"
  Talk Slowly, Think Quickly | "Otitis Media"

• Golden Compass (Philip Pullman)
  Amazon, Nook

• Subtle Knife (Philip Pullman)
  Amazon, Nook

• She's Not There (Jennifer Boylan)
  Amazon, Nook
  Talk Slowly, Think Quickly | "An Uncomfortable Cocktail Party"
  Talk Slowly, Think Quickly | "It Gets Better"

• The Checklist Manifesto (Atul Gawande) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Do Better, Think Bigger"
  Talk Slowly, Think Quickly | "Patient Safety - Part 1 - 'The Booklist'"
  Talk Slowly, Think Quickly | "Patient Safety II - 'The Scene'"
  Talk Slowly, Think Quickly | "Patient Safety III - 'Why Aviation?'"
  Talk Slowly, Think Quickly | "Patient Safety IV - 'The Culture Change'"
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"
  Talk Slowly, Think Quickly | "Pit Crews, Dancers, Burger Flippers, and Red Light Cameras"

• Outliers (Malcolm Gladwell)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy"

• Another Day in the Frontal Lobe (Katrina Firlik) +
  Amazon, Nook

• Mother Night (Kurt Vonnegut)
  Amazon, Nook

• Super Freakonomics (Steven Levitt & Stephen Dubner)
  Amazon, Nook
  Talk Slowly, Think Quickly | "A Small Nudge"
  Talk Slowly, Think Quickly | "Reuse, Recycle, Donate"
  Talk Slowly, Think Quickly | "It's Not Really About Viability"
  

• The Alienist (Caleb Carr)
  Amazon, Nook

• The Curious Incident of the Dog in the Nighttime (Mark Haddon)
  Amazon, Nook

• The Spirit Catches You and You Fall Down (Anne Fadiman) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "Patient Communication"

• Nudge (Richard Thaler & Cass Sunstein) 
  Amazon, Nook
  Talk Slowly, Think Quickly | "Reuse, Recycle, Donate"
  Talk Slowly, Think Quickly | "A Small Nudge" 

• Tuesdays with Morrie (Mitch Albom) 
  Amazon, Nook

• The Great Gatsby (F. Scott Fitzgerald)
  Amazon, Nook
  Talk Slowly, Think Quickly | "An Uncomfortable Cocktail Party"
  Talk Slowly, Think Quickly | "Whenever you feel like criticizing someone..."

• The Alchemist (Paul Coelho)
  Amazon, Nook

• How Doctors Think (Jerome Groopman) +
  Amazon, Nook
  Talk Slowly, Think Quickly | "How Doctors Think" 

• Blink (Malcolm Gladwell)
  Amazon, Nook
  Talk Slowly, Think Quickly | "A Small Nudge"
  Talk Slowly, Think Quickly | "When Your Gut Says 'Wait'"
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy" 

• Tipping Point (Malcolm Gladwell) 
  Amazon, Nook
  Talk Slowly, Think Quickly | "Collegiate EMS Leadership Strategy" 

• Complications (Atul Gawande)
  Amazon, Nook

• Slaughterhouse Five (Kurt Vonnegut)
  Amazon, Nook
  Talk Slowly, Think Quickly | "Inception" 

• Better (Atul Gawande) +
  Amazon
  Talk Slowly, Think Quickly | "Patient Safety - Part 1 - 'The Booklist'"
  Talk Slowly, Think Quickly | "Patient Safety II - 'The Scene'"
  Talk Slowly, Think Quickly | "Patient Safety III - 'Why Aviation?'"
  Talk Slowly, Think Quickly | "Patient Safety IV - 'The Culture Change'" 

• Freakonomics (Steven Levitt & Stephen Dubner)
  Amazon, Nook
  Talk Slowly, Think Quickly | "A Small Nudge"
  Talk Slowly, Think Quickly | "It's Not Really About Viability"

• Don't Sweat the Small Stuff [and It's All Small Stuff] (Richard Carlson)
  Amazon, Nook
  Talk Slowly, Think Quickly | " 'All I Really Need to Know I Learned in Kindergarten' "
  Talk Slowly, Think Quickly | "Whenever you feel like criticizing someone..."

Previous Lists

Talk Slowly, Think Quickly | Ryan's "Read It" List - May 2011
Talk Slowly, Think Quickly | Ryan's "Read It" List - April 2011

Talk Slowly, Think Quickly | Ryan's "Read It" List - March 2011

Talk Slowly, Think Quickly | Ryan's "Read It" List - February 2011

Talk Slowly, Think Quickly | Ryan's "Read It" List - January 2011

Talk Slowly, Think Quickly | Ryan's "Read It" List - December 2010

Talk Slowly, Think Quickly | Ryan's "Read It" List - November 2010

Talk Slowly, Think Quickly | Ryan's "Read It" List - October 2010

Talk Slowly, Think Quickly | Ryan's "Read It" List - September 2010

Talk Slowly, Think Quickly | Ryan's "Read It" List - August 2010

Talk Slowly, Think Quickly | Ryan's "Read It" List - July 2010