Monday, August 31, 2009

Did somebody mention healthcare reform?

One of the interventional cardiologists at our hospital (who is neither formally trained nor board certified in interventional cardiology) parked a brand new Lexus LS 450 (base MSRP $77,260) in the physician's lot this morning. Almost as disturbing as the Ferrari owned by one of the other cardiologists who holds no board certification whatsoever.

Swam at Nitro next to Eric, Steve, and Greg. Tom coached. I suggested the main set, which is a favorite of mine used by my old coach in New Bern, Frank McGrath.

1000 warm up
10 x 50 @ 1:00 build
10 x 200 @ 3:00 swum as follows:
4 x 200, held 2:26
100 easy/active recovery
3 x 200, held 2:23
100 easy
2 x 200, held 2:22
100 easy
1 x 200, went 2:17 (1:06+/1:10)
100 easy

Saturday, August 29, 2009

Two degrees of separation

In the film Six Degrees of Separation we are told that everyone on the planet is separated from each other by no more than six people. I was reflecting on this today while I watched coverasge of Senator Kennedy's funeral. During freshman week in college back in 1976, my roommate Daniel Smith and I decided that we should meet Caroline Kennedy. We would use the pretense that we were inviting classmates to a party that evening at our dorm. Anyway, it seemed like a good idea at the time. So we grabbed a shuttle bus to Radcliffe, located her dorm, and obtained her room number from a student working at the front desk. We knocked on her door, and it was opened by a casually dressed young woman wearing a pink shower cap. To her credit she was extremely polite, introducing herself and shaking our hands. She didn't attend the party, and our paths never crossed again. Nevertheless, I suppose that anyone who knows me (or Daniel) is separated from the late Senator by only two degrees.

Yesterday was pyramid Friday, a recovery day (100, 200, 300, 400, 400, 500, 600, 500, 400, 300, 200, 100). Swam at Nitro this morning with Steve, David, Greg, Kirk, and Tom. Clint coached.

Warmup was a "snake" (575 yards)
800 pull
5 x 100 kick @ 2:20
16 x 50s starting in the middle of the pool @ 1:00, 500 race pace, held :33 or better
10 x 50s stroke (back/fly) @ 1:00 starting in the middle of the pool
4 x 25 from a dive
200 easy

Thursday, August 27, 2009

Why IM...tired

Swam at Nitro next to Steve, Kirk, and Melanie. Tom wrote the workout and coached.

8 x 50 IM drill @ 1:00
200 IM easy @ 3:30
100 fly fast @ 2:30, went 1:11
200 IM easy @ 3:30
100 back fast @ 2:30, went 1:16
200 IM easy @ 3:30
100 breast fast @ 2:30, went 1:24
200 IM easy @ 3:30
100 free fast @ 2:30, went 1:02
100 easy
200 IM for time, went 2:32, which is I believe a Masters personal best
200 easy

Wednesday, August 26, 2009

The 300

Swam at Nitro next to Greg, Steve, and David. Tom coached.

500 swim, 200 kick, 300 pull, 500 swim (smooth/build by 50)
8 x 300:
#1 pull breathing 3/5/7
#2 build by 100, went 3:42
#3 kick
#4 negative split, went 3:35
#5 drill
#6 moderate/smooth/moderate by 100, went 3:34
#7 easy free/stroke by 50
#8 fast, went 3:27, a Masters personal best
100 easy

Tuesday, August 25, 2009

Tuesday August 25, 2009

Swam at Nitro with Steve, Greg, David, and Tom. Clint coached.

300 SKP
8 x 100 IM drill @ 1:45
8 x 50 pull IM order @ 1:00
8 x 50 kick IM order @ 1:00
5 x 200 IM, 1-3 @ 2:45 (tough interval, went too fast on the first one--2:38), 4-5 @ 3:00
200 easy

Monday, August 24, 2009

A bit sore today...

...after moving my daughter into her fourth floor dorm room yesterday. Good cross training, I suppose. It was a bit surreal to see a Bruce Springsteen poster (the cover photo from Born to Run) hanging on her wall. My son and I play a lot of table hockey (which I prefer to video games); we had a highlight reel play last night when the head came flying off of one of my players and rolled across the "ice", a career-ending injury one would assume. Amazingly he was able to continue playing, but his head just wasn't in the game.

Swam at Nitro this morning next to Greg, Steve, David, et al. We each had our own lane (short course), but that will change next week when the high schoolers begin practicing early in the morning. Clint coached.

400 SKP
10 x 100 @ 1:30, breathing 3/6/9/3 by 25, averaged 1:16
800 pull
16 x 25 sprint @ :30, first 10 stroke (did fly/back), last 6 free
200 easy

Saturday, August 22, 2009

"Tell me everything is all taken care of by those qualified to take care of it all."

Another line from the new Dave Matthews cd. I have been thinking about this a lot lately in relation to events at work and in the news. Yesterday I performed a complex coronary intervention on one of my patients with whom I have become very well acquainted over the past two years; the success of the procedure was a product of my training, seventeen years of experience, and continuing education in the form of conferences, self study, and the board certification (and recertification) process. Patients should be able to make the assumption that we are qualified to "take care of it all" (although there are practicing interventional cardiologists who are neither board certified nor formally trained) just as we should be able to place our confidence in our elected leaders.

Yesterday morning I swam at Nitro next to Greg and James. Clint coached. He called it "Pyramid Friday."

800 swim
700 pull
600 swim, alternate 100 free/100 breast
500 pull, went 6:12
400 free, alternate 100 free, 100 back
300 pull, went 3:40
200 swim, alternate 50 free, 50 fly
100 pull
50 fast
200 easy

Swam at Nitro this morning. Clint coached. The pool was set up short course.

Warm up was a "snake" with a push up on the deck after each 25. I went first and was not supposed to let anyone catch me. Steve started third or fourth in line but quickly moved into second. He is a national champion in the 50 free, so I knew I would need some help. As I got out after each 25, I shoved a gear bag in his way to slow him down. When I ran out of gear bags, I threw a water bottle which (unintentionally) hit his goggles. In truth, I believe he swam into the water bottle, although he may dispute this version. He caught me in the last few yards (575 total).
8 x 75 drill @ 1:15
600 pull
400 kick
5 x 200 @ 3:30 broken 10 sec at the 50, averaged 2:10
5 x 25 sprint from a dive, worked on my track start which is coming along
100 easy

Thursday, August 20, 2009

You cannot be serious

A Scottish judge today released the convicted Lockerbie bomber so that he may return to Libya to be with his family. Apparently he has terminal prostate cancer with only months to live. It is unfortunate that his victims on Pan Am flight 103 were not shown the same mercy before their deaths. Trading lives for oil--again.

Lifted weights last night. Swam at Nitro this morning with Steve, David, Greg, James, Tom, and Eric. Clint wrote the workout and coached. Long course season appears to be over.

300 SKP
10 x 100 IM drill @ 2:00, averaged 1:24
10 x 50 @ 1:00 starting in the middle of the pool and working on turns, did 1 SDK off the wall on each turn
5 x 75 kick with fins @ 1:10
20 x 25 @ :30, odds sprint IM order (I swam most of them fly), evens lung busters underwater
200 easy

Tuesday, August 18, 2009

Tuesday August 18, 2009

Swam at Nitro next to Steve, David, Lynne, and Tom. Clint coached. The pool was set up short course.

200 SKP
10 x 200s: 1 & 2 free @ 3:00, 3 & 4 back @ 3:00, 5 & 6 breast @ 3:30, 7 fly broken at the 50, 8 fly broken at the 25, 9 IM (went 2:40), 10 IM kick
200 easy (had to leave early for a meeting)

Monday, August 17, 2009


Swam at Nitro next to David, Steve, Greg, Eric, Eryn, Larry, and Melanie. Tom wrote the workout and coached. The pool was set up short course.

200 swim/200 drill/200 pull/200 swim
5 x 4 x 25, odd rounds build @ :30, evens kick @ :35
12 x 25 no breathers, 1-3 @ :40, 4-6 @ :35, 7-9 @ :30, 10-12 @ :25
12 x 100, 1-3 @ 1:25, 4-6 @ 1:20, 7-9 @ 1:15, 10-12 @ 1:10, made ten of 'em
8 x 50 @ 1:00 breath control, 5 breaths on 1 & 5, 4 breaths on 2 & 6, 3 breaths on 3 & 7, 2 breaths on 4 & 8
200 easy

Sunday, August 16, 2009

Good one

Swam in the indoor 25 meter pool at Life Time. I really enjoy training short course meters, and the pool is maintained at a constant 79-80 degrees (which makes a big difference).

400 swim/200 kick/400 pull
5 x 100 @ 2:00, 1 & 2 twinkies, 3 easy, 4 & 5 zingers
4 x 4 x 100 @ 1:45, descend within each round (En 2, En 3, En 3-1, En 3-2), averaged 1:22/1:20/1:18/1:15, went 1:12 on the last 100 (400 race pace). Did 1 SDK off the wall on each turn
200 easy

Planning to combine two of my posts ("Second Opinion" and "Funny the way it is") and submit a letter to the New York Times. Very unsettling to watch our elected representatives (and the country as a whole) discuss an issue (health care) which I know intimately. It is becoming clearer to me how we as a nation have made some of the missteps, both foreign and domestic, of the past few decades.

Saturday August 15, 2009

Swam at Nitro next to Steve, Greg, Tom, and Jeanne. Clint wrote the workout and coached. The pool was set up short course.

15 minute warm up; I went 800 yards
4 x 200s "for time, 10 sec rest"; since I wasn't really warmed up at this point without a transition set, and 10 sec isn't enough rest for fast repeats, I decided to swim them on 3:30 and descended from 2:25 to 2:20.
10 x 150s "75 easy, 75 fast, 10 sec rest"; we swam these on 2:15, and with Steve's help I worked on taking one SDK off the wall on each turn
800 pull, no interval; I did breath control (3/5/3/7)
5 x 50s sprint from a dive
200 easy

Ordered Mastering Swimming by Jim Montgomery and Mo Chambers. Planning to swim at Life Time tomorrow.

Friday, August 14, 2009

"Funny the way it is, if you think about it..."

In the "debate" over end of life discussions, neither party has it right.  The Democrats have proposed payment to physicians when they perform this task (presumably because they believe it will reduce health care costs in the long run), while the Republicans have invoked the specter of a "death panel" and insisted that these decisions should be left to the patients and their families.  Under the current fee for service model of health care, I am paid for the actual work I do, whether that work involves a consultation, a diagnostic study, an invasive procedure, or a follow up visit.  I have always viewed end of life discussions as an ongoing narrative rather than a isolated piece of work.  They are an integral part of what we as physicians do in caring for elderly patients with a deteriorating quality of life and dwindling therapeutic options.  The octogenarian described in "Second Opinion" had been seeing me for quite some time, and we had had frank discussions about his prognosis and his wishes over the course of many hospital and office visits.  Unlike the hospitalist who works an eight to twelve hour shift, meets patients for the first time when they are admitted with an acute illness or progression of a chronic condition, and does not see them again in follow up upon discharge from the hospital, I am able to develop long term relationships with my patients that afford me a unique perspective on their care.  Carving out the end of life discussion (and reimbursing me for it) as an entity separate from the rest of my daily routine is unnecessary and awkward.

Patients have the right to decide how they will die.  But lacking medical training and experience, they need the advice of their physicians in order to make the best possible decision. No family member can supplant this, regardless of how well meaning they may be.  I believe my patient's daughter did him a disservice,  subjecting him to a battery of invasive and noninvasive procedures that in the end had no impact on his quality of life or life expectancy.  (As one of my attendings was fond of saying, "Beware the daughter from out of town.")  As for the cardiovascular specialists who recommended these procedures, only to decide in the end that he was not a surgical candidate, I can only say that the patient and I had reached the same conclusion months earlier.

Thursday, August 13, 2009

Thursday August 13, 2009

Swam at Nitro next to James, Steve, David, and Greg. The pool was set up long course. Clint coached.

400 SKP
10 x 75 @ 1:15 50 free/25 stroke drill
10 x 100 IM @ 1:45, last five were all 1:18 or better
5 x 25 sprint @ :30, did the first two no breather
200 easy

Would like to start adding 500-1000 yards at the end of practice, and I may start using my drag chute occasionally.

Wednesday, August 12, 2009

Wednesday August 12, 2009

Swam at Nitro next to Steve, Greg, and Chuck. Tom coached. The pool was set up short course today.

4 x 150 swim/50 kick
3 x 100 @ 1:30, easy/build by 50, fast/easy by 25, easy/fast by 25
4 x 100 kick without fins @ 2:00 (could not make this interval back in the day, so some things do improve with age)
2 x 150 swim @ 2:30 easy/six beat kick/easy, six beat kick/easy/six beat kick by 50
3 x 100 kick @ 2:00
2 x 150 swim @ 2:30 easy/build/easy, build/easy/build by 50
2 x 100 kick @ 2:00
2 x 150 swim @ 2:30 easy/build/easy, build/easy/build by 50
1 x 100 kick
2 x 150 swim @ 2:30 easy/build/easy, then fast for time, went 1:39 (31+/34/34)
150 easy

Tuesday, August 11, 2009

Second opinion

Last summer an elderly patient of mine managed to survive an out of hospital arrest and received an implantable defibrillator. He was in his eighties, had undergone a prior bypass, and was not in the best of health. He had developed significant valvular disease with congestive heart failure but was doing reasonably well with medical therapy. I knew him well and did not believe that he would survive a second operation; consequently, I recommended conservative management. We discussed his situation at length, and he agreed with my recommendation. When he missed a subsequent follow up appointment, I was not particularly concerned as I knew that his wife had a number of medical issues, and he did return to the pacemaker clinic for routine interrogation of his defibrillator.

Yesterday I learned that his daughter had arranged for him to have a second and a third opinion, a process which over the past several months included a cardiac catheterization, a transesophageal echocardiogram, a trip to the OR (without actually undergoing surgery), an evaluation at the Mayo Clinic, and consultations with two different groups of surgeons. After being seen by a dozen or so cardiovascular specialists, none of whom ever tried to contact me, the verdict was that he was a poor surgical candidate and should be treated medically.

Lifted weights and did crunches last night. Swam at Nitro this morning with Tom, next to Greg and Tripp (one of the age group coaches), James and Larry. Clint wrote the workout and coached. The pool was set up long course.

200 swim, 200 kick, 200 pull
8 x 50 @ 1:00 drill with fins, IM order
Main set:
8 x 200 IM @ 3:10 with fins, each followed by a 50 lung buster (underwater) ; fastest was 2:52
400 easy

Monday, August 10, 2009

Monday August 10, 2009

Swam at Nitro with Tom, next to Greg and Jordan, Steve and Lynne. Water temp was 83 degrees. The pool was set up long course.

400 swim, 400 kick
16 x 50 @ :55 drill/swim by 25
6 x 250 free @ 4:00 descend 1-3 and 4-6, went 3:39/3:37/3:34, 3:42/3:38/3:31
4 x 100 @ 2:00 easy

Thursday, August 6, 2009

Thursday August 6, 2009

Swam at Nitro with Tom and Jordan, next to Larry and Melanie. The pool is still set up long course.

600 swim/200 kick/200 IM drill
8 x 50 kick with fins @ :50
100 easy
10 x 100 IM @ 1:45, averaged 1:31-32
5 x 100 stroke @ 2:00, went fly/back, averaged 1:31
100 easy

Wednesday, August 5, 2009

Wednesday August 5, 2009

Lifted weights and did crunches last night. Swam at Nitro this morning with Jordan and Chuck. Tom wrote the workout and coached.

200 swim/100 drill/200 kick/100 drill/200 pull/100 drill
8 x 50 @ 1:00, odds DPS (36 strokes), evens build to 85%
3 x 50 @ :50 smooth
2 x 50 @ :45 build
1 x 50 fast
1:00 rest
3 x 100 @ 1:40 smooth, averaged 1:24-25
2 x 100 @ 1:30, held 1:21
1 x 100 fast, went 1:19
1:00 rest
3 x 200 @ 3:20 smooth, averaged 2:54
2 x 200 @ 3:00, went 2:48 and 2:51
2:00 rest
1 x 200 fast, went 2:40, split it 1:19/1:21
100 easy

Tuesday, August 4, 2009

Sword boat captain

In The Perfect Storm, George Clooney's character, Billy Tyne, tells Linda Greenlaw, a woman sword boat captain, what he finds special about his job:

The fog's just lifting. Throw off your bow line; throw off your stern. You head out to South Channel...the guys are busy; you're in charge. You know what? You're a goddam sword boat captain! Is there anything better in the world?

At the core of medical jurisprudence is the concept that the physician is the "captain of the ship," meaning that the ultimate responsibility for the fate of a patient rests with him or her. We may delegate tasks to other health care professionals, but when there is a bad outcome, we are the ones held liable. And this is how it should be. Yet today, in the politically correct environment of a modern hospital, we are told that we are to function as a team, unrestricted by the traditional hierarchy. Any and all members of that team can and should question the decisions of the physician, according to this new paradigm.

Last night I received a call from a hospital pharmacist regarding an order written by one of my partners earlier in the day. The patient was a gentleman with refractory heart failure which was not responding to conventional treatment. My colleague appropriately chose to initiate an infusion of a drug indicated for just such a condition. The pharmacist had called to tell me that the drug would need to be brought in from another facility, but then proceeded to share with me her opinion regarding the patient's care and our choice of treatment (which did not meet with her approval). She informed me that as a pharmacist she was qualified to do more than simply comment on drug interactions and incompatibilities.

After our conversation, I found it ironic that although I stayed at the helm as it were for the remainder of my call night, she finished her shift and left. As Linda Greenlaw wrote in her book The Hungry Ocean, never ask the crew of a sword boat if the hold is full, because "the crew always want to go home."

Swam at Nitro with Tom and Jordan, next to Lynne and Steve.

400 swim, 400 kick, 400 pull
16 x 50 @ 1:00 IM order, drill/swim by 25
3 x 200 IM @ 4:00, went 3:08, 3:04, 2:59, averaged :38-:39 for the fly
2 x 50 "lung busters" kicking underwater with fins, made it about halfway

Monday, August 3, 2009

Heat wave

Swam at Nitro with Jordan and Tom, next to Steve, Lynne, and Greg. Melanie wrote today's workout since Mike is on vacation. The pool was set up long course. The water temp was a balmy 84 degrees.

600 swim, 200 kick
Main set:
300/2 x 200/2 x 100/4 x 50 @ :50 base/50
100 easy
4 x 50/2 x 100/2 x 200/300 @ :45 base
100 easy

Sunday, August 2, 2009

Swimming with the fishes

Swam at Barton Springs (about a ten minute drive from my house) this morning with Channel swimmers Lynne Smith and David Blanke.  Here's an interesting fact:  fewer than 1000 people have successfully swum across the English Channel, compared to over 1500 who have climbed Mt. Everest.  We began at 5:30 while it was still dark and swam 12 round trips of 400 meters each for a total of 4800 meters, finishing shortly after 7:00.  Since I have trouble swimming in a straight line in open water, especially in the dark, I probably swam at least 10% more than that.  After each round trip, Lynne likes to announce the total ("That's one!"), sort of like the Phelps Visa commercial where he is swimming "laps" across the Atlantic.  I actually did lose count at one point, somewhere around number 7 or 8.  I had this song stuck in my head from the new Dave Matthews CD, Big Whiskey and the GrooGrux King:

I grew from monkey into man 
Then I crushed 15 million with a wave of my hand
I grew drunk on water turned into wine 
'Til I was slave and master at the same damn time

It's why I am 
It's why I am 
Why I am still here dancing with the Groogrux King