Sunday, July 29, 2007
Saturday, July 28, 2007
Friday, July 27, 2007
For lunch I wanted Linguini Aglio Olio. Unfortunately this is not so straight-forward without the olio. How can there be no olive oil in my kitchen? After scrambling around for a bit I ended up using some olive oil spray, a teaspoon of butter, and a couple of drops of canola oil and to my great surprise, the dish came out edible and pretty tasty. But I guess it's not that easily messed-up as dishes go!
When I was a medical student I watched a senior anesthesia resident during a case, tweaking the rate of IV fluid administration here, adjusting the dial on the vaporizer there. It all seemed so mysterious - why did he pick that particular moment to turn the gas flow up a notch or down a notch? The patient looked just the same. I asked him, "How do you know when to do that?" He answered laconically, "Practice."
As I learned to do the job, and found myself making the very same moves, I asked myself the same question, and my answer was, "Cooking." How many times have I turned the heat up or down on garlic being sautéed in the pan, or added an ingredient to a simmering sauce, or taken a spoon to toss a vegetable around, simply because my instincts told me it was the right move for that moment? And how did these instincts arise? From making the dish a number of different ways about a hundred times.
I find there's a lot in common between delivering anesthesia and cooking without a recipe (though when I mentioned this comparison during residency once, my attending shot it down instantly with a, "No there isn't." Different strokes...). I emphasize without a recipe, because with the exception of resuscitation algorithms, recipes can make for faulty medical practice. It's true that there are drugs and techniques I can say I usually use for any given case, but I try to practice flexibly. The minute we start handing out drugs according to some preconceived "cookbook" - remifentanil and propofol for this, midazolam and fentanyl for that, every time, all day, every day - we've stopped using judgment, creativity, knowledge, and adaptability. We've stopped being physicians, designing anesthetics in an actively engaged way, taking into account the needs of each particular patient or case.
Moreover, very often plan A just doesn't work out. No one starts the day wanting to perform an awake fiberoptic intubation on someone, but if safety concerns arise, and it's the right decision, then plan B it is. It's not what the patient wants, and it's not what I want in terms of comfort for my patient - but it's the right thing to do, and it's not a judgment I would make lightly. Cases like that highlight the folly of a consumer model of health care delivery. "Customer satisfaction" - or its equivalent, patient satisfaction, because patients are not customers - comes second; patient safety comes first. Always.
That said, I try my best every day to be open with my patients, hear their concerns, and carry out a plan that results in maximal safety and comfort for everyone. This is why when a patient once adamantly said she did not want a particular drug, and I was trying to ask questions to clarify my understanding of her experience and her position (i.e. doing my job), so that I could come up with a safe and viable alternative, I was offended and irritated when her husband yelled at me, "Why do you people always start asking all these questions the minute she says that? She doesn't want it, period! We don't need all these questions!" Well, sir, you're wrong, we do need these questions if we're going to be prepared and provide the best care we can for your wife. It's a shame you're too short-sighted and hot-tempered to appreciate that, but that's the truth of it. I didn't reply in those words, of course, but I said to his wife something like, "Your experience with this drug is important for me to know about, because I care about making your comfortable and keeping you safe. Could you tell me a little more about the reaction you had...?"
Speaking of communication, a couple of things keep coming up (most recently, just last night) that I want to highlight because they really help us anesthesia folks provide the safest anesthetic we can (the following is just a sample; I'm sure I could think up more):
-Please follow any instructions you receive about eating and drinking prior to surgery, to the letter (usually some variation of DON'T eat or drink for 8 hours prior). And if you have consumed anything, please say so - this is a SAFETY issue.
-Please remove all contact lenses and piercings. Yes, even those piercings. :)
-If you drink 12 beers a day, please don't say you only drink on holidays. First of all, it's not safe to understimate the amount, because then we might incorrectly estimate the anesthetic dose for you. Secondly, once you are under, we can tell. Trust me. Your body will reveal to us that you in fact drink ten times more than you say you do.
-If you just had cocaine yesterday, or today, please don't tell us you've been off it for months. Again, it's NOT SAFE. And again, once you're unconscious, we'll be able to tell that your body is in fact totally revved on crack. But more importantly, something really BAD could happen to you on the table that we can do something to prevent if we know ahead of time, and we'll be able to choose the RIGHT drugs to help you, as opposed to the drugs that might indirectly contribute to your having a brain hemorrhage.
-Last but not least, please, please, please tell us what you're most concerned about. Your anesthesiologist should WANT to listen and do everything in his or her power to care for you attentively and safely. Please also hear us out if there's something we're concerned about explaining, from our end of things. We are NOT trying to be pains in the neck, but rather to provide thorough and good care. Our job is to protect and watch over you, and most of us do take that very seriously and wish to do our best.
Thursday, July 26, 2007
Tuesday, July 24, 2007
My call started yesterday. My first case yesterday involved an elderly man with numerous medical problems including a serious heart condition that made me warn the nurse on my team - a smart, reliable guy with years of E.R. and O.R. experience - "FYI - if he codes, he dies." I wanted to be sure we were all on the same page. With the kind of heart lesion this guy had, conventional CPR, using external chest compressions, was not likely to help him. My seasoned O.R. nurse said something like, "Yeah, let's not go there today." No, let's not. The patient did fine.
After that there was a cute little 8-year-old who needed her broken wrist fixed. She did fine too.
Then I drove to one of our other hospitals, where I got paged to do an epidural for a woman whose baby had died inside her. It was her first pregnancy. I was sad, but glad I was able to contribute to some physical pain relief, even if I couldn't make a difference to her emotional pain.
As soon as I left her room, there was a flurry of activity because another woman needed a C-section for worrisome fetal heart rates. Placing the spinal in this woman, who was morbidly obese, was difficult. We got through it and got the baby out, which was a good thing because it had been swimming in meconium.
After I was done with that, the vascular surgeon paged me and said there was a young guy in the E.R. who had pulsatile bleeding from his arm after he smashed it through some glass. When the E.R. nurses brought the patient down to the O.R., the smell of alcohol emanating from his mouth as he answered my preop questions was so overpowering I thought I was going to pass out. I anesthetized him, watched over him, woke him up. He looked happy as a clam later when the recovery room nurses were wheeling him upstairs to his room.
By then it was past midnight. I was too wound up to sleep. I read a little more of The Last Duel, which is riveting, an outstanding piece of writing and research. I hear it's Martin Scorsese's next film project, and what a worthy project it is. I'm thrilled for Eric Jager. Eventually I got to sleep, but I awoke a couple of hours later when the phone in the call room rang - 3:45, epidural please. *sigh*
Which brings me to Epidurazilla. No, not the 3:45 woman, who actually turned out to be fairly pleasant when she finally got some pain relief after holding out for hours without. But the way she walked right past me - actually, around me - in her room without even looking my way triggered a memory. I hadn't dredged up this memory in a while, but I found myself thinking of a woman from a hospital in my past.
Believe me, I understand labor pain. I understand how it can not only blind you to the people around you but also make you perfectly disinterested in being in any way civilized to anyone. If you're like me, all you can think about is the PAIN - when it's coming, how you're going to survive it when it's here, and what you can do so it won't be so BAD. When I was having contractions at 9 centimeters of dilation, between humiliatingly loud sobs of agony and blubbering whimpers of dread, I wanted to ask my husband to cut off my head. I hope I was still somewhat nice to people, but you know, I may very well have turned into an Epidurazilla myself, especially when I assumed the position to receive my epidural, had to hunch over with my nurse standing in front of me, and found that her enormous breasts were an inch away from my face and suffocating me. Yet as I recall I was a paragon of obedience and cooperation.
But I digress. Back to Epidurazilla, a ghost from OB wards past. Epidurazilla was pale, skinny, educated, and rich. She came to the hospital with a plethora of accoutriments. A CD player and George Winston piano CD. Burt's Bees lip balm. Popsicles, which she ordered her labor nurse to fetch and over which she showed considerable exasperation when people had trouble locating them, even after she sent her husband out to help (read, supervise) the nurses.
When I arrived in her room after her nurse paged me there for an epidural, I began to introduce myself, "Hi, I'm Dr. - "
"SHH!!" she cut me off, with an irate swat of her hand. I had unfortunately begun to speak just as a contraction was beginning. My mistake; I'm usually pretty good at timing the conversation, but I was a little off that time.
I understand not being able to focus on someone's words when your insides feel like they are being yanked from Alaska to Dubai, ripped into pieces, and set on fire. I've been there. But usually the NICE women either pant until the contraction is done and ask you to repeat what you said, or manage to groan, "Sorry-doc-just-a-sec..." I had never been shushed and swatted at before.
That pretty much set the tone for this woman's interactions with the entire staff. The more I listened to her snapping at people and ordering the hospital staff around, the more I felt like saying, "Yes, Massuh" to her face. She was impatient with the questions I asked her as part of my preop evaluation and with the directions I gave her to facilitate placement of the epidural. She gave me the impression after it was placed that she felt quite entitled to have it there now and what took us all so long to serve her anyway? It was clear she was used to relating to people as their superior and had scads of servants at home waiting on her hand and foot.
I'm ashamed to admit it, but when I checked on this woman the following day during my rounds, I was civil, and even dutifully kind, but nothing more. Usually I'm warm and sweet, but I couldn't be my usual self with her. That's ultimately a reflection of me, not of her, I regret to say. And to her credit, at the end of our conversation, she did thank me.
Overall I was so appalled by what I saw of this woman's demeanor with the nurses, and other docs too, that I googled her. And there it was, confirmation of what I suspected. Engagement announced in the society pages of a prominent national newspaper. Wealthy family united in marriage to another wealthy family. Advanced studies in Paris. Ivy League degree.
She must be one of the stereotypes people think of when they think of Ivy League schools. So then I started to wonder, have I ever been like that? I went to a "prestigious" college. I speak a foreign language or two, on a good day. My family is relatively well-off and well-known in our country. Part of what bothered me about Epidurazilla was the familiarity of her behavior. I've seen it before. The stereotype of the master or mistress who's mean to the servants or who barely even notices their service comes up on Philippine TV shows a lot. Although some of the wealthiest people I know are also the kindest, most humble, most generous people, I know there is a basis for the stereotype. But there was more to it than that. I think I was also bothered by Epidurazilla because I recognized in her a capacity for narcissism and elitism that I fear within myself. I think when I met her, I thought, "I could totally have become that, under the wrong circumstances..." My husband doesn't think so, bless his heart; I'm touched by his faith in my character; but we all know the potential evil that lurks within us, and I don't imagine for a second that I'm any less vulnerable to its traps than the next person.
I said to a couple of my friends, "Please, if I EVER start speaking or behaving like an entitled prima donna, please whap me across the face, okay?" My husband's pretty good at being honest with me if I fail to be at my best, so I'm hopeful all these allies and teachers can help keep me in line.
(The photo shows one of my friends placing a lumbar drain, not an epidural, but the procedures are similar and for the most part, with a little local anesthetic, well tolerated by patients.)
Sunday, July 22, 2007
I was just enjoying Anali's blog and her post mentioning Dionne Warwick's song, "I Say a Little Prayer for You." Lately prayer's been coming up a lot; a personal ramble seems in order.
A few days ago I came across Dr. Sid Schwab's brilliant post about a family who had chosen prayer as the sole intervention for their child with neuroblastoma, after one arduous course of conventional medicine after another had failed.
I can understand why people would feel totally exhausted in the effort to fight a ruthless cancer. I took care of a 5-year-old with rhabdomyosarcoma my first year out of medical school, and that experience completely destroyed my faith--at least for a time. She was only five but looked like a hundred and five - emaciated, her skull and skeletal form detectable beneath her greyish skin, barely any wisps of hair on her head, miserable beyond description, unrecognizable when compared to the photograph of her at her hospital bedside, showing a healthy, smiling, fair-haired little girl, all sweetness and promise.
Her x-ray was unrecognizable too. We doctors get used to seeing certain things on an x-ray - large black spaces outlining the lungs, heart in the middle of the chest cocked just so, ghostly traces of familiar internal structures all in their proper places and configurations. Looking at her x-ray was like looking at a jumbled mess of alien, unfamiliar objects, which of course it was. Piles and piles of tumor had ravaged her on the inside, taking over every nook and cranny and claiming them as their own. There was barely anything identifiable to be seen.
The girl died after weeks, perhaps months, of indescribable suffering. If I'm ever asked to be on a jury for a "pain and suffering" case, I'm going to have to explain, "Well, guys, just so you know what my idea of 'pain and suffering' is, ever hear about rhabdomyosarcoma?" Five years old, lung spaces so obliterated by cancer that she could barely breathe. Five years old, body wracked with pain from head to foot, then untimely death. Hopeless.
My own daughter was five years old at the time - exuberant, full of laughter and life, pleasingly plump, sunny and bright. Naturally, I had a lot of questions. At the time my conclusion was that no one was listening; we were fundamentally alone, and after our lives ended, we turned into dust, our consciousness, "spiritual" growth, memories, and identity completely snuffed out into oblivion. But if you were to ask me today if I pray, the answer is, actually I do.
Dr. Schwab was able to articulate questions about intercessory prayer that so many people, believers and non-believers alike, ask, especially in the face of extreme hardship or tragedy. I've put a link to the full post on my sidebar, but here are the passages that I found so eloquent and so powerful:
I must also say this: there's something perverse to the point of revulsion in the idea of a god that will heal the girl if enough people pray for her. What sort of god is that? To believe that, you must believe he deliberately made her ill, is putting her through enormous pain and suffering, with the express plan to make it all better only if enough people tell him how great he is; and to keep it up unto her death if they don't. If that sort of god is out there, we're in big, big, BIG trouble. If people survive an illness because of prayer, does that mean that god has rejected those that didn't pray? If you pray for cure and don't get it, and if you believe that praying can lead to cure, then mustn't you accept that God heard your prayers and said no? If so, are you going to hell? But if you say either outcome is God's will, then what's the value of the prayer in the first place? In this case, it seems, it's only to make the girl feel guilty and unworthy. How sad. Since the whole idea is so internally inconsistent, give the poor kid a break.
Does this family's god need reminders; does he have DADD? Or is he waiting for them to hit a magic number of people praying? A certain quantum of prayer-units that must be achieved? Does he give credit for getting close, maybe knock off a little pain when they hit 80%, or is it all or nothing? In praying to him -- and if, as the article says, people around the child see God at work in all his glory -- shouldn't they be thanking him for their daughter's misery rather than asking for a change of plans? Shouldn't they be delighted with the whole thing? If He's perfect, how can you add to that by praying? Or expect a change? I simply don't get it.
And what of children who have no one to pray for them? If prayer works, what's going on with those kids? Does this prayer-tabulating yet perfect god not care about them? Or isn't he paying attention? Has he deliberately set them up...?
The most recent research study I know of, the STEP trial, showed that prayer makes no difference to the outcome of coronary bypass surgery. In fact, people who were prayed for and knew it experienced a significantly higher incidence of complications than those who either were not prayed for or were not sure they were being prayed for. The study had no control group (people who were not prayed for and knew they were not being prayed for). The "prayer" consisted of Christian prayer groups, who were told the date of surgery and the patient's first name and last initial, asking God for "a successful surgery with a quick, healthy recovery and no complications," twice a day for two weeks, starting on the eve of surgery.
Already I have a problem with this - not with the results, but with the underlying presumptions. One time my son wanted to ask God to prevent rain as the storm clouds were already gathering overhead. I told him this was not the right way to pray - asking for something so self-serving, and also asking for something not to happen when it was already beginning to happen. Even Jesus prefaced a desperate petition with "If it is possible..." Asking for over 1200 patients to recover quickly without complications from cardiac surgery is asking the impossible, especially when many of them were having the surgery BECAUSE they already had conditions which were the first step in developing those complications - previous heart attacks, high blood pressure, diabetes, lung disease, and the like. I think there's something inherently disrespectful and counter-productive in turning prayer, which is not merely an act but a way of relating, into what amounts to a GAME. Let's see if God will play - will he help out 50% of the time? 55%?
Like Dr. Schwab, I reject the notion of a Vending-Machine God. My husband said it well when we were talking about this: a prayer life is so much more about a relationship than about asking for things. Prayer is an intimate expression of longing, faith, hope, and love. If we do have spirit beyond our conglomeration of cells and molecular reactions, prayer, being a spiritual form of engagement, has real gifts for us. C.S. Lewis pointed out that prayer is not for transforming God but for transforming ourselves. I think we can pour out our longings and our pain in prayer, and we can even ask for help, but I also think if God is the parent that so many believe God is, this parent has to let us live our own lives freely, without interfering every time we have trouble. I believe help is possible, but using prayer solely or primarily as a means of acquiring fixes is missing the point and misusing the act.
I used to get mad at God for the suffering of children - sick children, abuse victims, the impoverished. Then someone pointed out to me, "What do you want God to do, make everything perfect? You're looking for the Christ who healed lepers and gave sight to the blind. He's not here." How startling it was to me to hear such simple, familiar, yet eye-opening words as if I'd never heard them before. Even the scriptures ask, "Why do you seek the living one among the dead? He is not here." I think Jesus lived out the example of what a loving God would want: when you see suffering, try to heal it. It's not what we're meant for, not "God's will."
We're the eyes and hands now. We have our work cut out for us.
The brothers were adorable trying to figure out what key to start singing the Hebrew blessing in before dinner Friday night - both are musicians, one with a deeper voice than the other. "Baruch-no, that's too high...Baruch-ato--no, still can't reach that..." But they found their note and set the tone for a nice evening.
I love the way family prayer, sung or spoken, can re-center our scattered lives and bring us together around the table from the various forces that tug us away from that center every day. When we four are alone as a family we often resurrect the old Catholic tradition of saying the Angelus at dusk, another call to pause and refocus busy lives on love and family. It's balm.
The rest of the weekend was truly relaxing - seemingly ordinary, but to me quite special. We enjoyed a blueberry pancake breakfast at a farm in Concord, went on a hay ride, played our favorite family card game, ouistiti, two nights in a row, maneuvered around a birthday party here and a tennis game there, discovered a tiny local lunch place that serves breakfast all day as well as some exotic items (falafel), and spent time enjoying the weather in Harvard Square hopping from book store to book store (my favorite!). My daughter has big plans to sing for her supper on a street corner. She gave her last dollar to a boy who was playing Sarasate's Zigeunerweisen, fairly well, too.
I envied all the students reading and writing in the Yard. I do get nostalgic for my college days; I remember only what was best about them, not the stress. We took position at an old favorite spot of mine, one of Widener Library's broad "sphinx pedestals" as I call them, and watched tourists and students crossing each other's paths below. It was wonderful to be able to just watch and have no fixed time-table.
Today I bought a book called The Last Duel, by Eric Jager, in a used book store called Raven. It's a gripping tale of medieval Normandy, the true story of a fight to the death between a squire and a knight whose wife had accused the squire of raping her. The result of the duel was supposed to demonstrate God's judgment of who was right and who was wrong in the matter. Or, as one of my "temporary sons" intelligently said when I told him about the book, "So, whoever was more physically fit would turn out to be innocent?" It was the last time a dispute was mediated in this manner, hence the title of the book.
It's amazing to me that people ever thought God would work like this, and flabbergasting to me that they sometimes still do.
Friday, July 20, 2007
I had to post some videos (they're not in English, but it doesn't really matter). In the rehearsal section of the first one she plays Odile, daughter of the evil Baron von Rothbart in Swan Lake, in the process of seducing Prince Siegfried in order to get him to break his vow to Odette, the Swan Queen. In the second video she rehearses Odette, the tragic heroine of the story, all pathos and brokenhearted love.
(Incidentally, for anyone who might have preferred an embedded video of Stierle's incredible solo "Lacrymosa" on my Celsius 233 post, it's there now, finally.)
Recently one of the nurses accused me of having low self-esteem for saying matter-of-factly that I wasn't a beautiful woman. Why is an honest, realistic assessment of one's physical attributes necessarily "low self-esteem?" I mean, sure, I'd LOVE to look like Polina, but I'm also accepting of the fact that I don't, nor do most women in the world. Do THEY have low self-esteem if they observe they don't have super-model looks? Come on. Just because we acknowledge facts doesn't mean we loathe ourselves. In fact, I think it takes genuine self-love to be comfortable with being ordinary, especially in a world that puts such a premium on being "exceptional," and I try to grow toward that kind of maturity every day. It's a work in progress, as always.
In addition to drawing the wrong conclusion about my opinion of myself, this nurse was also equating esteem-ability with extreme beauty - I mean, if it's OKAY not to be drop-dead gorgeous, then why is it "LOW" self-esteem to acknowledge that one is not exactly drop-dead gorgeous?
When I was all into ballet, I would notice things like perfectly pointed feet, musicality, pleasing line, etc. Now I can't help noticing how GREAT her landmarks are for a central line, and how easy it would be to insert a sixteen-gauge needle into her jugular, using that prominent sternocleidomastoid and her pulsating carotid as guides...It's funny how circumstances can change the way you look at the world...
Thursday, July 19, 2007
I remember being a young girl watching a concert on TV with my mom, and after hearing him sing - he was then "new" to the scene, as I recall - she and I looked at each other and exclaimed, "WOW, who is THAT?! He's amazing!"
He was only 55 when he died. I cannot imagine how anguished his loved ones must be.
I have scanned through many posts and web articles about suicide. So many of my search "hits" opened their discussions with reasons people try to kill themselves - despair, lost love, money problems, low self-worth, and any number of contributory factors. But these are not the ultimate reason people commit suicide. I was relieved when at last I found a site that states the truth from a medical standpoint: "Simply put, people commit suicide because they are ill."
This is not an insult, any more than saying people with diabetes have an illness, or people with cancer. In fact, depression, be it major depression or manic depression, is considered by many psychiatrists and psychologists to be not just an illness but a potentially life-threatening illness.
No, you can't tell someone to just snap out of it and pull themselves up by the bootstraps, unless you also think you can make someone's islet cells secrete more insulin somehow, without medical intervention.
Neurotransmitter deficiency can be just as lethal as insulin deficiency. We are, to a degree many people don't want to acknowledge, at the mercy of these chemical messengers, for cognition, perception, and emotional well-being.
The problem with accepting mental illness as a physiologic reality lies, I believe, in the nature of thought. Thought is a very real presence for most people, yet it cannot be seen or physically grasped. It seems otherworldly, mysterious; we don't know what it's made of, but we know it's there. In part it's made of cells and electric charges and neurotransmitters, but these are so physical, and thoughts are so...ethereal. Surely despairing thoughts can be healed with something other than medicines for a physical process such as the biochemical pathways between serotonin and its receptors? Surely thought is not so bodily?
Well, it IS, like it or not. Mind is body. We would like it to be more, but the evidence we have so far is it's all right there, in the workings of the physical brain. Take the case of Phineas Gage: all it took was an iron rod through his frontal lobe to change his character completely - all those elements we think are part of some more metaphysical realm, like virtue, and personality, all of that, very physically inhabits the frontal lobe. Frontal lobe syndrome has been observed with traumatic brain injury, strokes, tumors. People all of a sudden are no longer who they once were. So who are we, really? Personality, taste, character - these all depend on the little molecules bouncing around inside our frontal lobes. Beyond those - who am I?
Through medicine I have had to confront suicide up close. The trauma ICU was a charnel house for terrible stories. Even now I don't breathe comfortably any time a guy in my family goes up a ladder, and I can't even begin to count the patients who lost the use of their limbs because of motorcycle accidents. But the patients who had attempted suicide made me especially sad and feel particularly helpless. I had to take care of a young woman who had jumped off a building and whose mother kept hoping for signs that she was "still in there somewhere." On my last ICU call I also had to admit a man who tried to electrocute himself on the high voltage line of the subway system but managed only to burn half his face off. It was awful.
I cannot help being offended by Sean Kingston for trivializing suicide in his current hit song (on a completely borrowed base line) "Beautiful Girls (Suicidal)." Suicide is tragic and terrible, not something to toss around in a pop song about getting rejected by people you're regarding merely as objects anyway.
If you know people who might be depressed, please don't blow them off for being "down" or treat them with exasperation or contempt.
If you think you might want to end your life, PLEASE don't, please get help.
Wednesday, July 18, 2007
Tuesday, July 17, 2007
Sunday, July 15, 2007
Me: Chocolate Therapy
Saturday, July 14, 2007
The answer is, while I was able to avoid developing a caffeine habit all through college and medical school, during my second year of anesthesia residency, when I was working in the ICU, I started drinking coffee.
It may have helped me GET THROUGH the nights and actually be able to TALK during rounds the next morning, but although I felt a little more alert temporarily, at first sip, I think there was nothing that was going to make me feel anything other than nauseatingly ILL after 18, 24, or 30 hours of being on my feet.
So instead of spinning webs like this (web of a drug-free spider):
The webs I spun might have been (and probably were) like this (web of a spider on caffeine):
(These particular pictures are on multiple websites, so I'm not really sure how to give them the proper attribution, but the website I got them from was this one.)
You know what I love? They needed a STUDY to PROVE that sleep deprivation makes people perform below their capabilities. Dr. Charles Czeisler, chief investigator of the study conducted at Brigham and Women's Hospital, discussed the results on NPR. "The traditional 30-hour shift is based on the notion that it's better to have a tired doctor who started with you that day than to have a fresh doctor. But we found actually that the tired doctors made many more mistakes," Czeisler said. Well, DUH. Impaired judgement. Compassion fatigue and mood lability. Less safety and satisfaction for patients. I really don't think we needed a study to point out the OBVIOUS, but perhaps we need it to document these consequences, as a necessary step in the effort to begin instituting some change.
I remember once overhearing a patient say to a surgeon, "I don't want anyone operating on me who's been up all night," and thinking, now is really not the time to try to buck the system. Did you write any letters of protest to your congress person or whomever, prior to showing up, decrying the use of torture to train physicians and transmogrify them from compassionate idealists to cynical, IRRITABLE, bitter, resentful, disillusioned bags of sheer exhaustion? Probably not. But you want the system, based on the insomnia of cocaine-addicted "father of American surgery," William Halsted, to change spontaneously and suddenly into something liveable and REASONABLE? I don't think so. This ain't Europe.
I think I might be sounding a little peevish right now. I think it's because I'm on call tonight and away from my family. Not all residents hate the sleep deprivation system as much as I did. Some need less sleep than others, and some cope very well with the arduous schedule. But I despised it, because I thought it was unnecessary and unhealthy for both physicians and patients, and thus unjustifiable.
Incidentally, my hospital's solution to residents' increased risk of falling asleep at the wheel driving home from a 30-hour shift? Cab vouchers. So, we were so tired we needed cab vouchers, but we were still expected to be at the top of our game making decisions about patients, cutting them open, sticking needles and wires into their necks, etc., the same day we were supposed to be taking the cab home?
It's true what they say, even about the Brilliant Minds of Medicine: ignorance can be educated, but stupid is forever. Although maybe not forever, in this case. Maybe if enough major errors are made, or enough patients die at the hands of exhausted physicians, this country's medical establishment will get the "wake-up call" it has needed since a cocaine-addicted surgeon instituted the system over 100 years ago.
Addendum: the spider web images, thankfully, are in the public domain because they were produced by NASA, whose copyright policy states "NASA material is not protected by copyright unless noted" (see NASA copyright page and JPL image use policy.) They were created as part of this research paper: Noever, R., J. Cronise, and R. A. Relwani. 1995. Using spider-web patterns to determine toxicity. NASA Tech Briefs 19(4):82. Published in New Scientist magazine, 27 April 1995.
Thursday, July 12, 2007
Wednesday, July 11, 2007
But I've been thinking a lot about how I got to this point - trying to juggle the home duties, motherhood, chores, etc. with a full-time profession in a high-stress calling. Why did I take this path? Should I have?
When I showed up to med school with my kid, even my primary care physician exclaimed, "Are you CRAZY?!"
Then there was the first day of day care. My little daughter, 10 months old at the time, thew herself on the nest of stuffed animals and cried all day. ALL. DAY. Even when they put her in a high chair so she could at least feed herself some Cheerios, there were big tears rolling down her pudgy little cheeks. That night I cried - not all night, but after all, I had to get up early to get all her diapers and bottles packed to go to day care the next day before my anatomy class. Maybe all the finger-pointers were right. I was selfish to push on with med school now that I had a child.
Well, if they were, I pushed on anyway. Over the years the judgments have come and gone. Not just for me; when a woman who was a year behind me in residency was expecting her first child, she overheard a female attending physician declare that it was irresponsible for women to get pregnant in residency.
And it's not just judgment; there's disrespect, too. Now, I am not that easily offended by non-"politically-correct" things. I hate the whole phrase anway - it's just a contrived, trendy way of expressing the concept of RESPECT, which needs no other glossy moniker. But here's an example of what I mean. When I was nursing my son and trying to pump and store milk during the day, during my surgery rotation, the surgery residents who were lounging around the call room door kept hooting, "Why don't you do that out here?" Let's not pretend the medical world has healed itself of sexist tyranny. The glass ceiling is not that much higher; I think our heads have just gotten a little more resilient hitting it.
But there were groups in the hospital that were nastier about it. The surgery guys - well, they were fooling around; they really didn't mean any harm. The ob/gyn residents, though - what a group of harpies. They gave me such a hard time about trying to nurse - ob/gyn! go figure - that I just couldn't make my quotas, and my milk dried up during that rotation. At the time I mourned because I felt I had failed my son and also missed the close bond we shared through nursing.
That was med school. Residency was harder. I was getting up at 5 in the morning and often not getting home till 6 or 7 at night. I was our household's cook. I was always exhausted and stressed-out, and thus frequently snappish and difficult to live with. My long-suffering husband admonished me patiently and did a HUGE chunk of the other household work - laundry, yard work, bills. And there were things that just weren't important enough on the endless to-do list, like ironing, de-cluttering, etc.
We shared our parenting responsibilities with day care in the early years, and recently with au pairs. We have been very lucky; our kids have done relatively well with our adjuncts. The separations were repeatedly painful, as were their disappointed groans every time I reminded them I'd be on call and wouldn't be able to see them for 24 hours. I could imagine the ghosts of people's mental judgments, hear them in my head: You let someone ELSE raise your kids, and spend more time with them than you do? Bad, bad mommy. You work 80 hours a week? Do your kids even know you any more? And look at your house, good Lord, how can you live like this? And you're feeding your husband cereal for dinner? What kind of woman ARE you?
The specter came to life every time my neighbor said hello. At EVERY school meeting or chance encounter in the neighborhood - I mean EVERY single one - she would greet me with, "Oh! You exist!" How on earth can one reply to that graciously seventy times seven times? Yeah, I exist, and see those happy, well-adjusted, creative, nice children over there? I helped them get to that place. Yeah, me - on-call every 4th-night, over-stressed, underpaid little me. Now I think I'll go make out with my adoring husband.
But there were signs that time apart, instead of having me breathe down their necks all day, offered its own blessings. We cherished our family time and never took it for granted. We laughed at each other's little failings and foibles more. Our precious little time together became extraordinary even if we were engaged in ordinary things. We were and are CLOSE.
Today I remain hopeful that my choices have done our family more good than harm. As my husband keeps reminding me, the proof is in the pudding. Our marriage is happy, our children are happy, our family is happy. Though there are frictions between us, when she's upset about something, something really important to her, my daughter comes to me. And my son reassured me, just today, "Even if you had to be on-call for a whole month, I wouldn't feel like you abandonded me."
This is the same little boy who sat on the edge of the bed listening to me have an awful practice session on the oboe last night and clapped at every pause, before finally asking,
"Mommy, are you a good oboe player?"
"No, sweetie, not at all."
Then, after pausing to consider this, he said, "Well, I think you are. Are you an okay player?"
"Not remotely, sweetie. It takes a long time and a lot of practicing to get to be even an okay oboe player."
"When I start my violin lessons, it'll take me a long time to get good too."
It's all a work in progress.
If I've learned anything about my decision to work, it's gratitude that I was free to make the decision in the first place, and that there's enough unconditional love in this family to enable that decision to bear fruit. So I guess I won't quit my day job just yet. Let the work continue.
Both guys were great - Colbert a comic genius quick on his feet, as usual, and Dawkins a good sport, well-spoken and good-humored.
If I ever figure out how to embed videos directly, I''ll do it, but for now, click here.
Monday, July 9, 2007
80% of U.S. families did not buy or read a book last year.
42% of college graduates never read another book after college.
1/3 of high school graduates never read another book for the rest of their lives.
Wow. Although I can't be too shocked, I guess - I absolutely love books, but slowing down enough to really sit and savor one seems impossible these days. Life's too stressful. I just know Noli Me Tangere is going to take me all summer. And now I find myself succumbing to sins I almost never used to commit, like failing to finish books I've started, or skipping parts of books just so I can get through MOST of the work, or reading too many different things at one time.
I feel like making another "List of the Week" - though I guess I haven't been doing them weekly! Tonight it's Books that Made a Difference in My Life. Not all are favorites, necessarily, but all affected me significantly, either because I read them at a time when I was very impressionable, or because they offered just what I needed to learn at the time that I read them:
10. The Agony and the Ecstasy by Irving Stone.
9. A Dove the East and Other Stories by Mark Helprin.
8. Emperor of the Air by Ethan Canin.
7. Two from Galilee by Marjorie Holmes.
6. Lying Awake by Mark Salzman.
5. The Little Flower by Mary Fabian Windeatt. I was in 8th grade, and it made me realize I needed to clean up my act and be a nicer person.
4. A Ring of Endless Light by Madeleine L'Engle.
3. The Gospel of Mark - the earliest and plainest one, but by no means the easiest or "prettiest."
1. Tuck Everlasting by Natalie Babbitt. It was the first novel I ever read. It made me realize the true power of language and story and got me started on a life-long love of great reading and writing.
There are books I love more than many of those mentioned - Jane Eyre, Susan Summers' version of The Fourth Wise Man, and my all-time favorite, The Christmas Miracle of Jonathan Toomey - but the ones above repositioned my intellect or my moral compass such that it was angled a little more toward light and less toward shadow.
The musical play Missionaries by Elizabeth Swados, a heart-stopping, beautiful work about faith and courage, based on history (the story of the four church women raped and murdered in El Salvador in 1980).
The ballet Lacrymosa by Edward Stierle. I was inexpressibly moved watching a solo male dancer make his entire body sorrow - with every powerful muscle and sinew - to the music of Mozart's Requiem. There is a video of Stierle himself performing this solo here, under the link labeled "Lacrymosa Stierle," and now also on Youtube from that source. Worth seeing.
The short story The Expert on God by John L'Heureux. A perfect little gem - it said it all for me.
Sunday, July 8, 2007
Friday, July 6, 2007
A capacity for language? Reason? Creativity? An ability to experience love, appreciate beauty, discern, relate? Our genes? A soul?
Last month Catholic bishops in the UK stated, in response to the creation of chimeras, "at the very least, embryos with a preponderance of human genes should be assumed to be embryonic human beings and should be treated accordingly."
What's a "preponderance?"
90%? 75%? 55%?
Do I get to be considered human if only 51% of my genes are human? And if not, does that mean I get to kiss my rights goodbye?
One of the most memorable surgical cases for which I helped provide anesthesia as a resident was a case involving robotic surgery. I anesthetized, placed an epidural in, and watched over a little boy whose uterus was being removed. Yes, boy, and yes, uterus.
There are many conditions in which people who are genetically male appear female and vice versa. There have been stories and papers about attempts to raise these individuals according to their outward appearance, with painful consequences for those who felt strongly that they were the gender opposite of that in which they were being raised.
Is our identity how we feel about ourselves? Is it based on our genes? Clearly how we LOOK is an unreliable indicator. Reminds me of my recent wonderings about racial identity...and artistic validity, for that matter...
And if we are not just our genes, or just our feelings, or our physical manifestations, or predictably shaped by environmental influences, then again, how do we decide who we are, and who decides?
Thursday, July 5, 2007
I understand the protest, but I also think Filipinos need to examine their attitudes toward "white-ness." Skin-whitening cosmetic products are disturbingly popular in the Philippines, and many people openly speak of a fair complexion and European/Western features as beauty ideals. I don't know the answer to this, but do the exaggerated Caucasian features in Japanese animation stem from similar attitudes?
And then there's that other touchy / forbidden topic: why has the Asian female/Caucasian male couple become almost cliché? (There are numerous internet reflections on this phenomenon.) I am part of the trend. I remember how violated I felt when an Asian-American man in my residency program saw a picture of my kids and then questioned my reasons for marrying my husband, implying that his white skin trumped any other reasons I might have fallen in love with him, like his values, his compassion, his intelligence, and his good character.
So, are we proud of our "ethnic identity," or do we envy another? Did we express outrage at Filipinos cookies out of self-respect, or does the name bother us (or not bother us) because for some Filipinos, it actually contains a grain of truth? Sometimes there can be a fine line betwee self-love and self-loathing. I think the major problems with the cookie name are its use of skin color as a way to categorize people and its failure to represent Filipinos in general in a meaningful way. But I also think there's still a lot of ambivalence in our country around these identity issues. One commentator notes:
"I remember it being reported in the press, one person saying she (as a Filipina herself) thought there was nothing wrong with [the cookie name] since, (she was of the opinion), most Filipinos wish they had been born white anyway (!) Of course, many others did and do not hold such a view.
"But one wonders why anyone would say in the first place that any Asian would wish to have been ‘born white’. Is it a reference to culture or simply to the standard of living associated with the 1st (read: white) world? I think it is true to say that Filipinos are viewed by some other Asians as being more westernised than them, particularly with regard to American influences. And often this is viewed as something negative."
This commentator hypothesizes that a desire for "white" culture or living standards lies at the root of white-envy, but I thinks it's simpler: looking white, for whatever reason, seems to have been an advantage in the world. So in several countries, not just the Philippines, people buy creams or lotions to rub onto their skin to lighten it. What I don't understand is why racism of this kind - not just the perceived inferiority of non-whites by white people, but also the perceived superiority of whites by non-whites - exists and persists.