Ups & Downs

Up: assigned to the "eye room" today to give anesthesia for my

ophthalmologist colleague, one of the nicest surgeons to work with. Coincidentally, my new glasses ready for pick-up at his office. Smooth work day.

Down: long talk with my (great) boss about various issues around us at work. A good talk, but one that conjured up considerable stress.

Up: not on call today, so got to see my kids at dinner.

Down: husband away on business.

Up: had an oboe lesson this evening.

Down: it was bad. Well, no, IT was wonderful, but I was bad. Pachelbel's Canon is kicking my caboose. (My 7-year-old patted me on the arm while I was practicing the darn thing last night and said sympathetically, "Just do your best, Mommy.")

Up: Kyoko is patient and full of mirth.

Down: Orlando had to cancel the next 2 chamber orchestra rehearsals & move the concert date to one that I can't make, because he has a big gig.

Up: Kyoko has the same gig: all 6 Brandenburg Concerti at the Isabella Stuart Gardner Museum.

Down: the gig is sold out.

Up: I tried to transcribe the Wexford Carol in F# off a CD onto some staff paper a couple of weeks ago. Plunked it down in front of Kyoko and begged her to play it to see if my transcription makes any sense (my music theory being totally rusty). She sounded so beautiful; I felt like someone was applying healing balm directly to my frayed nerves. The transcription totally works.

Down: When I try to play it I sound like - well, you know. Plus, all those accidentals! But she had some helpful pointers for how to start working on phrasing.

Up: Watched Shrek the Halls and How the Grinch Stole Christmas with my kids tonight. Got to laugh with them - always one of the best moments of my day.

Time to get some rest and start all over again in the morning.

***

Addendum December 1, 2007:

I have to thank Bardiac for alerting me to the following HILARIOUS work of genius on the subject of Pachelbel's darned Canon, performed by comedian Rob Paravonian (RobPRocks.com). It is just brilliant!

Country Medicine, Medicine Woman, and Women's Work: thoughts at the start of Advent

As I was driving from one hospital to another during my Thanksgiving call duties (on-call for 4 days straight), this sweet, curious guy approached me while I was pulled over by the roadside.

I never thought that as an anesthesiologist that I'd qualify as a country doctor!

***


My daughter and I have recently gotten into the old Dr. Quinn, Medicine Woman series starring Jane Seymour. Talk about a country doctor. I never really got into the show while it was on the air but now I find it's great, escapist fun. We're suckers for period pieces!

While I find a lot of the surgical scenarios and outcomes totally implausible, I'm enjoying the portrayal of frontier village life and the peek into 19th century medicine - chloroform for asthma in the absence of albuterol, stramonium leaves instead of Atrovent, but also drugs we still use today, like digitalis, and aspirin in the form of willow bark tea.

Depictions of childbirth in these period pieces always make me shake my head with disbelief and a sense of unworthiness. I admire women who are able to endure labor pain without anesthesia. I kneel in spirit and place my brow to the earth in homage. I know that by the time I got to my fourth centimeter of cervical dilation I couldn't imagine wanting to (or being able to) live a moment longer with the contractions I had. So to the millions of women out there who give birth repeatedly without doctors like me easing the pain, I say: you are made of stronger and more heroic material than I.

***

I saw quite a few babies come into the world on my call these past four days, and though I've given birth myself more than once and seen it countless times after some years in practice, I can't get used to the whole process. I am still somewhat aghast every time I stand by, ready to help (but usually not needed), while a woman's body somehow stretches and pushes and tears and toils to squeeze a little person the size of a melon through a canal of tissue only a few centimeters wide. I'm aghast, and also awed.

Yet while many people exclaim at moments like these, "Isn't it a miracle?" it's precisely at these very moments that I find myself at my most agnostic. I gaze at the almost feral process, with its primal cries, bloody chaos, and torn tissue, its swirl of individual instinct and human social support, and I have the distinct feeling of being lost, a bundle of muscles, fluid, vulnerable tissue, and jumbled thoughts among many others, an anonymous organism caught up in multiple interconnected cycles of birth and death. I think to myself, "This is it. Humanity. A bunch of cells and physiologic systems generating more cells and physiologic systems. Natural processes repeating themselves generation after generation, keeping the species going." Physical reality is all of reality - so many feel this is the whole truth.

Perhaps there's more meaning behind it all, an intangible but real spirit flowing through, but it's at moments of birth that I find that idea hardest to grasp, ironically. Even at the birth of my own children, I had moments of feeling totally aspiritual. The moment was all there was, their petal-soft hands in mine, there breathing bodies resting on my beating heart.

Perhaps that is the the whole truth, but there's another possibility, of course - the possibility that meaning does exist and that we can put our hope and trust in it. Advent is coming up, when Christians traditionally reflect on the ancient belief of the divine incarnate. I like to think the divine might be present - perhaps we even generate it, give birth to it by defining it, a little Christmas in every life - in those very earth-bound moments during which we enter fully into human experience, feeling the amniotic fluid gush out of us, the flesh stretching and yielding, our breath and blood moving through us with unimaginable power. For all that is energy, and matter, neither of which is created or destroyed - ultimately a thought full of hope.

An Oboist's Christmas (or pre-Christmas)

Lots of folks have a traditional holiday show they try to see each year. For some people, it's The Nutcracker. Others just gotta go to Radio City Music Hall for the "Christmas Spectacular," or to Rockefeller Center to see the Christmas tree lighting. Then there are those who have to catch a version of Dickens' A Christmas Carol, or The Christmas Revels, or perhaps curl up in front of the TV to sigh over It's a Wonderful Life or smile over How the Grinch Stole Christmas. I know I've been to a few Grinch parties in my day, and mentally hurled at someone at least once the very un-Christmasy thought from that story: "Your soul is an appalling dungheap, overflowing with the most disgraceful assortment of deplorable rubbish imaginable." :)

There are favorite holiday readings, too, of course - The Best Christmas Pageant Ever, The Fourth Wise Man by Summers, and my all-time favorite, The Christmas Miracle of Jonathan Toomey.

A few years ago my daughter and I started a holiday tradition of our own: we try to find a production of Giancarlo Menotti's lovely 1-hour opera, Amahl and the Night Visitors, each year. We've been three times in the last four years - not bad, considering how hard it can be to find a good production of this Christmas fairy tale / miracle story / family favorite.

This year we found what was unfortunately the weakest production we've seen so far. Frankly, they butchered one of the nicest little operas ever written, and one whose beautiful oboe parts specifically inspired me to want to learn to play the oboe. But the production had one saving grace: live professional musicians, including an amazing principal oboist who produced what has to be the BEST OBOE SOUND I have ever heard.

The oboist was Andrew Price, principal oboist of the Civic Symphony Orchestra of Boston and former pupil of the late Ralph Gomberg, playing on a rosewood Laubin oboe. At least, I assume it was rosewood, unless grenadilla comes in soft brown as well as black. I mean, WOW. Listening to the warm, rich tone Price got out of that instrument was like enjoying a delicious hot drink on a cold winter night - soothing, pleasurable, and perhaps even a little intoxicating. The Loree next to it sounded lovely, but the Laubin in Price's hands sounded absolutely, breathtakingly GORGEOUS. It was worth it to sit through the otherwise cringe-inducing production just to hear him play the oboe passages, as well as other parts of the orchestral score for which there weren't enough other instruments present. So for me, this year's Amahl wasn't a TOTAL disappointment...

Laubin produces something like 20 instruments a year, by hand, out of their workshop in Peekskill. There's an 8 to 8 1/2 year wait for the rosewood instruments. My husband said good-naturedly that maybe if I order one now I'll actually be good enough to play it by the time it arrives... :)

LOL and *Sigh*

***

I'm working on a list of oboe-friendly Christmas music. So far I have

-"Ding Dong Merrily on High" from the Taverner Consort's Carol Album (sounds like more of a shawm than an oboe on this track, but I'm easy - a family resemblance will do!)

-the settings of "Fum, Fum, Fum" and "I Wonder as I Wander" on Kathleen Battle's CD A Christmas Celebration

-"Un flambeau, Jeanette, Isabelle," "Personent Hodie," "I Saw Three Ships," and the haunting "Wild Wood Carol" sung by The Cambridge Singers (the latter might actually be arranged with English horn...)

-"Jesus of Nazareth" and "Three Kings" from the Jesus of Nazareth film soundtrack

-and for playing as well as listening, I've actually found the Wexford Carol, the Huron Carol, O Come, O Come Emmanuel, Do You Hear What I Hear, and Wassail! Wassail! pretty user-friendly.

Stroope's "There is No Rose" should be on here too, of course - though I don't have a recording yet, nor am I even close to being able to play it. Other suggestions welcome!

Move Over, Plymouth Rock

How about a familiar story: White guy comes to the New World from Europe, shares a meal with native people, and settles in a place that becomes America's first permanent European settlement.

The place? St. Augustine, Florida.
The date? September 8, 1565, 54 years before the arrival of settlers to Berkley Hundred, Virginia ad 56 years before the Pilgrims supped with the Wampanoag.
The activity? Catholic Mass, followed by a meal of bean soup with the Timucua Indians.
The guy? Pedro Menéndez de Avilés, of Asturias, Spain.



Here's an interesting article on the subject from USA Today.

***

A friend just returned from a trip to Jordan with her daughter. They enjoyed the camel rides and the visit to Petra, but they had to sideline their side visit to Saudi Arabia because a) women are not allowed to travel alone there and b) they needed a man to represent them for their visa application at the consulate, and things didn't work out in time.

So, on the top of my list of reasons to say "Happy Thanksgiving" today is FREEDOM.



If I could make a true list of all the things for which I'm thankful, it would (or should) be practically endless. But here's a short ad hoc list, one I limited to any 10 items that came to mind within the first hour of getting out of bed:

-food, shelter, and clothing: our basic needs in abundance
-my husband's patience and affection
-my children's health and happiness
-the option to take a warm shower any time I feel the need to clean up
-reliable indoor plumbing
-a quiet beeper (for now)
-friends and family who accept me as is
-books (and the literacy and education to be able to enjoy them)
-music
-computer technology

HAPPY THANKSGIVING TO ALL - AND MAY THE SEASONS TO COME ALWAYS BE FILLED WITH THANKFULNESS AND THE FREEDOM TO ENJOY EVERY BLESSING.

Photo by Colin Gregory Palmer

Sweet Potato Pie

I'm trying to get into the Thanksgiving spirit but so far it hasn't been an easy holiday for me to adopt. I grew up without it. I don't like turkey all that much. The myth about the pilgrims and the natives bothers me. I am not a football fan. My in-laws are French. So how do I make Thanksgiving meaningful for our American children, especially when most holidays we celebrate, including our sabbath, already have spiritual meanings connected with the idea of thankfulness?

I'm still working on that, but in the meantime, inspired by one of my coworkers, I made my first sweet potato pie ever today, and people seemed pleased with the results. So here's my handiwork, adapted from various internet recipes. If anyone has suggestions/recipes for a favorite holiday side dish, please help me out!

Crust:
1 1/3 c flour
1 ½ t sugar
¼ t salt
4 ginger snaps, crushed
½ c butter
ice water to bind together

Filling:
2 sweet potatoes, baked, peeled, & mashed
5 T butter
1 c + 2 T sugar
1 ¼ c evaporated milk
2 eggs
½ t cinnamon
½ t nutmeg
1 t vanilla
1 T rum (optional, of course)
¼ t salt

Bake at 350 degrees for about an hour.

Midlife Already? A Look Back At My Education...

It's finally happened. After years of despising it when patients or colleagues look at me and say, "You look so young to be doing this," I finally crossed over to the dark side.

This week my husband and I met with our children's teachers for parent-teacher conferences, and we sat across from two very bright, talented, attractive, wonderful individuals thinking, "Wow, they are so young."

It's official. We're middle-aged suburban parents, mom-of and dad-of. We have arrived.

Well, ok, maybe we're not quite middle-aged yet, but as my husband sat enthralled at "perky" Ms. W's assessment of our son's abilities, I thought to myself, "This is it. We're getting old together. How nice!"

I'll say this for the lovely Ms. W: she "gets" our son. She laughs at his quirky jokes. She appreciates his precocity and channels it to the aid of others. She encourages him to teach, and guides him to do so with respect and patience. In other words, she brings out the best in our son: a sign of a good teacher.

Then there's Mr. W, our daughter's teacher. I've often joked that we should get Ms. W and Mr. W together - she wouldn't even have to change her name. Mr. W "gets" our daughter too ("She seems to be the class expert on Wicked!"). In the end that's really what makes a teacher really effective: the ability to understand, appreciate, and adapt to each individual student's gifts and needs, and to guide those in the right direction. We've got two winners this year.

We've been reflecting on our own educational highlights, and I was shocked to learn my husband and father-in-law hardly remember their earlier school days. Parts of mine are still so vivid in my mind! I got inspired to make a "Signficant Educational Experience Timeline," a follow-up to my significant reading timeline from several weeks ago. It's been an interesting way to reflect on "how I got here from there."


Toddlerhood: my parents spoke only Spanish to me at home; my grandmother, English; and I was surrounded by Tagalog-speakers. I think growing up trilingual did something to my brain.

Age 4: my mother and grandmother taught me to read.

Age 5: I started piano and ballet.

Age 7: I learned my times tables by heart, a practice which seems to have disappeared from the landscape of American math education, which my husband and I find appalling and which we think will be a huge disadvantage to kids later in life when they just have to know things quickly without having to "think about the concepts." But hey, we're just parents, what do we know.

Age 9: moved to the U.S. Books everywhere, easily available. Mrs. R, the Lower School librarian, introduced us to Tuck Everlasting. Lower School Headmistress helped us create our own poetry anthologies, with art and binding. Sister H. did a unit on the life of St. Peter and encouraged us to do creative final projects - mine was authorship of St. Peter's "diary."

Throughout subsequent years: my mom's "reward" for good report cards would be a trip to The Cheshire Cat, a children's book store. My mom and dad took me traveling every summer - an education in itself.

Age 10: had to dissect a chicken leg in bio and almost barfed. Still picky about chicken dishes. The giant earthworm dissection was a bummer too...

Grades 6 & 7: Had a strict and superb social studies teacher, Mr. O, who insisted we keep up with current events. He spoke to us like adults and expected us to have some opinions and be able to articulate them intelligently, whether the topic was Savonarola's burning of the vanities or Reagan's latest Cold War projects. Had a great English teacher in 7th grade who likewise didn't "talk down" to us. In science I did an oral presentation on mitochondria. We learned about physiologic systems in organisms - respiratory, digestive, locomotive, etc. and had to design our own organism with its own physiology. Mine was boring - basically a cactus parasite.

8th grade: Algebra was terrible for me that year, but English was fantastic. My nostalgia has a Proustian side to it: I still remember the way the pages of my copy of Warriner's English Grammar and Composition smelled when I opened the book - a pleasant, "booky" aroma. Our English teacher had us write in a journal, introduced us to To Kill a Mockingbird and A Midsummernight's Dream, and actually went over the rules of English grammar - again, now lost to the American school age population. There IS a point to diagramming sentences, but no, now anything goes...and it's obvious from the egregious grammar errors and terrible use of language in American spoken and written media. (Perhaps I sound a bit curmudgeonly...)

High school: I really learned to write. Higher math and science not my strong points, though I loved bio and actually won a prize in a school science fair because the judges thought I wrote so well - talk about an unexpected turn of events. Took 3 years of French - which I use now, having married into a French family. Hit my peak as well as my decline in ballet. Scripture class in 9th grade was eye-opening, a course which influenced my formation both academically and personally for years to come. It really trained us to think critically about faith in the context of history, and to consider the various literary genres in the Bible (which really upset the students who took everything in the Bible as fact). I loved it. It made me sign up to take Ancient Greek the following summer at Stanford so I could read the New Testament in the original koine - talk about a super-geek! I am so grateful to my parents for letting me be me, and supporting all these interests, and now to my husband, children, and in-laws, who do the same.

College: I HAD SO MUCH FUN! Took a memorable course in Irish poetry from the great Seamus Heaney. It was inspiring to learn from an academic who could actually produce stellar work in the very subject he was picking apart!

Grad school: got a master's degree in child development while pregnant with our first. Really influenced my thinking - i.e., made me feel more relaxed about letting my own children grow and discover their own lessons and loves.

Med school: too many significant experiences to mention. Anatomy and pathophysiology courses and teachers highly formative. Clinical years make you grow up and face reality a little better, though still in a very sheltered way.

Residency: The picture of me with the fiberoptic scope up on the sidebar at right is only a partial one; the complete picture, above, shows that I had an attentive teacher at my side, in this case a very good one, ready to offer help if I needed it. So it wasn't all bad...but there was plenty of bad to go around. For the first time in my life I had a plethora of negative educational experiences, some quite signficant. There was not only plenty of bad teaching but also an abundance of bad attitudes to teaching/learning/education. I learned that being insulted really sets me back emotionally and worsens my learning ability/process. I learned that my friends and I can prepare for and pass any medical boards, written and oral, ENTIRELY on our own. Some positives included learning how to manage difficult airways, how to prepare for individual patients' challenges, how to manage crises, and how to define my own worth (an ongoing process).

I'd like to quote something Paul Levy wrote so eloquently on his blog: “Soccer is a thinking person's game, and it is hard for a player to think if an authority figure is yelling at you as the ball comes your way. Kids who are trained to think learn how to make the right decisions in the split-second action of a game. Kids who are trained to listen to their coaches learn to wait to be told what to do.” That about sums up how I feel about my residency education.

Now: CHAMBER MUSIC! OBOE LESSONS! Talk about a signficant learning experience! And one that's a real pleasure...thanks, Orlando and Kyoko! :) (That's the two of them below, flutist and oboist, in a photo off the Anemoi Quintet website.)

Oboists and Orthopods

One other surgeon I enjoy working with (besides Caroline) is an orthopedic surgeon, or as we sometimes affectionately (and sometimes not-so-affectionately) call them, an "orthopod" with all the qualities one would want (but might have trouble finding all at once) in a surgical colleague. He is intelligent, educated, intellectually curious, down-to-earth, highly competent but not smug, and yesterday he lightened the emotional burden of my call night considerably by letting me listen to one of the CDs he ordered from The Teaching Company, from their series/website The Great Courses. I hope the company will consider this favorable publicity rather than copyright infringement: I just have to share a quote from a lecture entitled "Understanding the Fundamentals of Music" by Professor Robert Greenberg, a lively, humorous speaker with an engaging style. The following made me laugh out loud at the Main O.R. desk:

The double reed instruments - the oboe, English horn, basson, and contrabassoon -
are really, really hard to play. The mouthpiece consists of two tiny pieces of cane that are bound together in such as way as to leave an extremely small space between them. In order to get the two reeds to vibrate together, you must grasp this tiny mouthpiece tightly between your lips and blow for all you're worth. You blow until your eyes begin to bulge, until your nasal passages inflate like balloons and your brain gets pushed back against your skull case...

...Pain: it's a word often associated with the personalities of oboe players in particular, no disrespect intended. It is, however, one of those chicken or egg questions. Are overly-fastidious, anal-retentive people attracted to the oboe because of its technical difficulty and its nasal, arguably whiny sound, or do the technical demands and the sound of the oboe turn oboists into overly-fastidious anal-retentives?

I found this sooooooooo funny - especially the way he delivers it. It's a riot!
________________________________________________________

My orthopod colleague also clued me in to an oboe piece I hadn't heard before but just downloaded from iTunes: Stravinsky's Pastorale. I've been noticing a lot of great oboe parts on the radio lately - in Respighi's Ancient Airs and Dances, Dvorak's Slavonic dances, Schubert's Rosamunde overture, The Farmyard by Elgar, Saint-Saens' Rhapsodie d'Auvergne, Albinoni's Concerto a Cinque, Butterworth's English Idylls, even the overture to Die Fledermaus. Last weekend Kyoko and Orlando, the flutist who conducts the chamber orchestra I joined, played in a wind quintet concert and introduced me to some other wonderful wind pieces - the Caprice on Danish and Russian Airs by Saint-Saens and the Trio for Oboe, Horn, and Piano by Reinecke. But my latest "dream piece" is There is No Rose by Z. Randall Stroope (Youtube clip below) - an added bonus being that it's Christmas music, my favorite! Maybe someday...

Job

A Story for Veterans' Day

A Confederate Veteran and a Union Veteran at the 50th anniversary of the Battle of Gettysburg.

Not long ago when one of the morning surgical cases was cancelled, several members of the O.R. staff gathered in the break room for a little breakfast, coffee, story-telling, and laughter. It was a nice change from the usual pressures of a day in the O.R., but soon enough the time came to get back to work.

My friend Caroline, one of my favorite surgeons to work with, lingered after the nurses cleared their coffee cups and left the room. "I wanted to talk to you about an add-on case for this afternoon. It's not up on the board yet."

"Who is it?" I asked.

"59-year-old guy, Vietnam veteran, PTSD, schizophrenia, intermittently agitated. Gave Hilda in the O.R. a pretty bad scratch last week."

"Whew."

"Last week he had a perforated appendix, which was discovered pretty late because it took a while for him to seek medical attention. We operated and took it out. Now he has an angry-looking, infected fistula in his lower right quadrant that's draining some bad stuff out of it. A fecal fistula."

"What's the catch?"

"He's combattive. Stressed out and a potential danger to himself and others. And he refused to consent to the surgery."

"And if he doesn't have it, he'll be septic by tomorrow and possibly drop dead."

"Frankly I thought he'd go septic last week. Now we have a court-appointed lawyer as his legal guardian giving consent."

"So, we basically have to commit assault and battery to protect this guy from going into septic shock."

"Basically. But with legal permission. He doesn't want to be here, but he's also rescinded his consent to be transferred to the VA hospital - not that they'd have a bed for him right now. He wants to go to the psychiatric VA hospital, but they don't do medical things over there. So he's stuck. "

"Can't the lawyer guy give consent for the transfer?"

"No, because the judge says the patient has SOME capacity to make decisions, and the transfer is not a medical decision. Go figure. And after the surgery, they all wash their hands of him - the guardianship's only valid for the surgical part."

"How nice."

"My question for you is, from an anesthesia standpoint, is there any reason you might feel this guy would be better off transferred?"

"Not from what you've told me. Especially considering the urgency of the situation - it doesn't sound like we should be sitting on this for too long. Although if he's that belligerent with the staff, I wish I could convince myself that I felt uncomfortable treating him here. But the truth is I don't. We can take care of him. It's just not going to be easy."

Caroline nodded. I told her I would go and see the patient. She gave me his room number and warned, "Don't be surprised if he closes his eyes and shuts you out when you start talking to him. That, or takes a swing at you. Or tries to rip out his IV - he's ripped out four already."

***

I'll call him Job, after the Biblical figure smitten with all kinds of pain and suffering. I peered into Job's room from the corridor and saw a bearded, disheveled man sitting on a chair in the corner of the room, at the foot of his bed, hands in his lap, gaze to the floor. His nurse was in the room informing him that she would return soon to change the dressing on his abdominal fistula. When she came out into the corridor I asked if I could introduce myself to him and examine the area while she was doing the dressing change. I followed her to the supply area and tried to get a better idea of any problems he had been having. His chart was not a helpful source of information.

When I accompanied the nurse back into Job's room he was lying on the bed with his hands folded across his belly, ready for the dressing change. Approaching from the right side of the bed, she began removing tape from the old dressing. I stood on the left side and tried to talk to him.

"Hi. I'm Dr. T. I work with Dr. Caroline Walsh. I wanted to introduce myself so you would know who I was. We'll be taking care of you together today."

He gave a sidelong glance in my direction, then resolutely closed his eyes.

"Dr. Walsh and I are very concerned about the infection in your belly. We'd like to help you get rid of it. Do you have any medical conditions I should know about in order to be able to take care of you?...Asthma?"

He shook his head.

"Pain in your chest or trouble breathing?"

He opened his eyes a crack and again shifted them toward the sound of my voice. "Why do you want to know?"

"Knowing your medical problems helps us take care of you as best we can. Have you had trouble with your heart and lungs at all, or with diabetes?"

Job shut his eyes. "You're not going to operate on me, are you?"

"I'm not, no. But Dr. Walsh feels that you do need an operation for this, and my job is to help keep you comfortable and safe for it."

"I don't need an operation. It's better already."

The nurse then interjected, "No, Job, this looks worse now than it did yesterday. It's a lot redder and it's draining a lot more. You need to have this surgery, or you'll get very, very sick."

"No I don't. I don't want to be here. It'll get better on its own."

We went around in circles for a bit discussing the issue. At one point I found an opportunity to ask if I could listen to his heart and lungs. At that, Job started, and his eyes opened quickly and he said, "I won't have none' a that. I know what you're trying to do. I don't want to talk to any of you any more." Then he shut his eyes firmly once again, and the conversation was over.

Out in the corridor the nurse said, "Well, at least he didn't yank his IV out that time."

***

At 13:30 we had a team meeting to discuss Job's care and safety - social workers, nursing care coordinators, the pulmonologist in charge of the ICU, Caroline, and I. I learned that Job lived in a group home for veterans, similar to foster care but for adults. We came up with a plan to give him enough sedation pre-op to ensure the staff's safety, but not so much that he was too "snowed" to breathe on his own. We would treat him like a trauma patient with unknown medical history and try to keep his vital signs as stable as possible during the induction of anesthesia. We discussed ventilation issues back and forth and decided my goal would be to remove the breathing tube at the end of the surgery, unless the long-acting narcotics I had to give him to diminish the pain of the surgery disabled his breathing too much. We agonized over what would happen if he decided to sign himself out "AMA" - against medical advice - after the operation.


***

After receiving a dose of a valium-like drug that would have rendered the average person totally unconscious, Job was still talking to us as we wheeled his bed toward the O.R., but he was also calm. I placed monitors on him and gave him oxygen, talking to him as gently as I could about what I was doing at every step. I injected the anesthetic into his IV and watched as his eyelids fluttered closed and remained motionless when I brushed my fingertips against his eyelashes. I placed the breathing tube, put a warming blanket on him, relaxed his abdominal muscles, measured his temperature, and gave him anti-nausea medication as well as a large dose of long-acting narcotic to blunt his response to painful stimuli. Throughout the surgery I watched over his ventilation, heart rate, heart rhythm, and blood pressure, made sure he was receiving what I thought was the right amount of fluid, checked his urine output, made sure his abdomen stayed relaxed enough to allow Caroline to do what she needed to do, and gave more pain and anti-nausea medicine.

A couple of hours later the surgery was over. I removed the breathing tube and most of the monitors, and as his eyelids slowly opened I spoke to him, again as gently as I could, reassuring him that all was well, that he was safe and not alone and that we were about to bring him to the recovery area. His eyes were large, like those of a child waking up in unfamiliar surroundings, but he wasn't queasy or experiencing significant pain. He didn't wake up violently, wildly flailing about as so many anxious or very young or very old people do. In fact, his eyes drifted shut again and he was completely peaceful as we wheeled him to recovery.

***

Veterans are invisible. Unless people know one, my impression is most people don't think about them. They suffer unimaginable trauma to serve their country, then come home and find everyone going about their business, blithely going to the grocery and playing soccer and hanging holiday decorations, oblivious to and, for the most part, untouched by the pain their soldiers, fellow-citizens, have seen and experienced. Then veterans disappear into an underfunded system that is backlogged beyond belief, into squalid hospitals that are stretched to their limit, ofen receiving what has been described in the press on more than one occasion as "substandard care" for their amputated limbs and nightmare-laden minds, all the while trapped in a vast societal blind-spot. No one wants to see their pain or hear their cries, or even look their way, after they volunteer to fight in the name of our own peace and freedom - sometimes against their will, in causes that they feel are unjust, in the midst of atrocities that warp and disfigure and dismember them forever. No one wants to hear or to see or to think of these very bad things. And so invisible they stay, among us but lost to us, because of our own need to protect our minds from horrible truths.

Joseph Ambrose, an 86-year-old World War I veteran, attends the dedication day parade for the Vietnam Veterans Memorial. He is holding the flag that covered the casket of his son, who was killed in the Korean War. Photo credit: U.S. Census Bureau. (I'm sorry, I don't know who took the picture above this one, and I don't know if it's copyrighted, but I thought it was such an important photo - found on http://www.freerepublic.com/focus/f-news/1146118/posts. It's of marine Cpl. James Wright, who received the Bronze Star for valor, and it may have been taken by Cpl. Richard Stevens of the USMC. I'm hoping it comes under the U.S.-federal-government-public-domain rule.)

__________________________________________________________________________________

Addendum, Tuesday, November 13, 2007: A report in the CBS evening news tonight described the alarming rate of suicides among Iraq war veterans - numbering about 120 per week in 2005 alone, and by some calculations more than double the civilian rate - yet reporters had to dig for and do the math themselves to find the statistics. The responses from the VA and government agencies ranged from "This research is ongoing" to "We just don't have those numbers at the moment." They should be publicly held accountable - tarred with families' stories and feathered with questions demanding accountability. Again, there's a recurring evil here: no one wants to look at what's happening to these vets who survive the violence but return home and cannot survive the aftermath. Why? Because looking means finding - finding enormous trouble, corruption, and indifference in the system, and with that trouble, the need to be accountable for the evils perpetuated. The United States should be ashamed of the way these soldiers are used, abused, then abandoned and forgotten.

Paragons

Who are your paragons?

The MerriamWebster online dictionary defines a "paragon" as "a model of excellence or perfection" [Etymology: Middle French, from Old Italian paragone, literally, touchstone, from paragonare to test on a touchstone, from Greek parakonein to sharpen, from para- + akonē whetstone, from akē point; akin to Greek akmē point...Date: circa 1548].

A couple of days ago on his blog Running a Hospital, Paul Levy, president and CEO of Beth Israel Deaconess Medical Center, invited each reader to reflect on an individual who might come to mind as a "private moral guide" during moments of tension, difficult decision-making, or trying situations - the kind of person who, alive or dead, "serves as a standard against whom we judge our own behavior during a moral test."

Despite my struggles with faith I do often think of stories in the New Testament that give us a hint about Jesus' responses to the world around him. What I understand from most of these stories is that when he saw suffering he tried to heal it, and on more than one occasion when he saw human failure he would say, "Nor do I condemn you; go and sin no more." To me these responses on his part signify that we are not meant for pain but rather for peace, that we are not meant for shame and judgment but rather for acceptance and encouragement, and for the good work of striving to do our best, as people who have the capacity for reason, love, respect, and awe.

But a moral figure such as this, alive or dead, real or fictitious, can seem a little out-of-reach at times. Not so the person who inspired Paul Levy's reflection, the late Rose Finkelstein, a 101-year-old retired nurse who as a dedicated volunteer would often be found singing to the babies in the obstetrics department at BIDMC. A physician in conversation with Levy "said something about Rose along the lines of her being the kind of person who, when you do something in a patient setting that you feel really good about, you think that she would have been pleased."

When the going gets tough I do sometimes still think of my mother's mother (photo above), who died in 1985. I wonder how she might have handled things, or if she would be pleased at my handling of things. As I reflected on this question of moral guides I realized I do imagine a number of "spirit guides" looking over my shoulder for a variety of situations. Most of these "guides" are acquaintances from past chapters of my life who wouldn't even realize I still look to their example for guidance, and one of them is a fictional character! I thought I'd make it my list of the month: some of the exemplars against whose imaginary words of guidance I measure different aspects of myself.


For how to be a good spouse: my husband.

For writing: novelist and North Dakota poet laureate Larry Woiwode. His 1994 writing workshop at Cambridge University during a summer conference on C.S. Lewis was one of the highlights of my life; I only wish I could have lived up to the high ideals he set before us at the time.

For anesthesia: this is going to sound almost sacrilegious, but the other night when my husband and I were relaxing by watching a re-run of The Hunt for Red October, I realized that the character of Commander Bart Mancuso of the USS Dallas as played by Scott Glenn is the kind of leader I'd want to emulate - intelligent, knowledgeable, cool in a crisis, able to take charge even in unfamiliar territory, respectful of his crew's talents and concerned for their safety.

For medicine in general: Indira Dasgupta, M.D., a mentor from my days in pediatrics. Her knowledge, dignity, humor, and attentive care for her patients accompany me to each bedside as I try to do the best work I can, as she always expected of me.

For teaching: Matthew Pravetz (a great med school professor), James Stewart (not the actor!), and Wilhelm Burmann (one of the best ballet coaches in the world).

These are just a few; I could sit here and think of a few more, but what I find interesting as I enjoy this exercise is the realization that the people who come to mind as my mental "guides" were people I consider to have been my best teachers...

Pain and Suffering II: a confession

I’m haunted to this day by what I consider one of my worst moments as a physician. It’s hard for me to talk about or write about, because it’s about failure, a moral failure to live up to my own ideals.

In my first year out of med school I was an intern at a tertiary care center where the pediatric ward had a large population of children with different kinds of cancer. 3 North was for the younger kids, 3 South for pre-teens and adolescents. These wards no longer exist; the hospital has since expanded and undergone an enormous renovation, and it’s now one of the most physically attractive and impressive pediatric centers I’ve visited. The renovations were just finishing up the last time I dropped in on the hospital with a good friend who stayed in the program after I left to do my anesthesia training, and my friend was able to open the door to those old wards just a crack so I could see them before they disappeared entirely. It was eerie to see them empty, like a ghost town, and a torrent of images appeared in my mind, faces I remembered from my days as an intern there. [Photo: Poa_Pan-milk, private collection, released into public domain by Matthias Sebulke]



One of those faces belonged to a baby girl – I’ll call her Ana – whose parents brought her to us one night after they found that one of her arms had gone completely limp. Just the day before, Ana had been a happy baby, crawling around her home, active, playful, but that day she was completely different, listless and strange, with that alarming arm weakness.

Ana’s parents spoke mostly Spanish, though her father could speak some English as well. By the time they got through the E.R., with interpreters, consulted with a couple of specialists, and came up to the floor for admission, it was 1 or 2 in the morning. I was on call and I had been up since about 5:30 the previous morning. I had been on my feet almost all day with no end to stressful tasks, phone calls, procedures, paper work etc. that I had been working on for hours, between patient visits and admissions. Ana’s parents deserved to have a reliable, kind, sympathetic physician to help them through this unimaginably difficult night, but they got me, and I was at the end of my rapidly fraying rope. I had a mountain of charts in front of me that all needed updating and a floor full of cancer patients who needed their blood drawn before the pre-morning work piled up. All I could think about was sleep.

Ana needed an MRI, and I needed to accompany her to radiology with her parents so she could get one under sedation. For some reason it worked out that between the morning line-up of cases and the things that were going on that night, we could only squeeze her into the schedule at 3 or 4 in the morning. By this time I was crazed with fatigue – the kind that makes little kids cry irritably, but you can’t do that, or scream, either, when you’re a full-grown adult, so my coping mechanism was to speak as little as possible and just get the tasks done.

While Ana was in the MRI suite I set about trying to catch up with the endless amount of work that I just couldn’t seem to make a dent in. My eyes were sore. My whole body was tired. I felt like crying because I just wanted to be allowed to crawl into a bed and sleep. Every once in a while I put my face into the crook of my arm over a desk top but stress over getting through my to-do list would yank my head back up.

As Ana came out of the MRI Ana’s father approached me and politely asked, in English, “Excuse me, do you know what the test shows?” I looked at him incredulously, not processing at first the fact that he had no way of knowing that I would not have the MRI report for hours and wasn’t qualified to read the actual MRI myself. And I was barely processing, though I too was a parent of small children, the fact that this is the first question any loving parent would ask about his baby girl after a procedure like that. I must have stared at him blankly for a moment as these hazy thoughts tried to make it across my sludge-like mind. I could hardly think and felt like dropping to the ground to sleep, right then and there. Or setting my silly pile of charts on fire, one or the other.

“I have no idea,” I said finally. Perhaps curtly. I don’t know; I can’t remember. He didn’t ask me any more questions, and I don’t recall being terribly conversational. But I know I wasn’t the calm, helpful, warm, kind, gentle self I try to be for patients who are deeply anxious over something that could change their whole lives. This was, in fact, one of the most terribly important times in Ana’s parents’ lives, and I failed to be totally present to them for it. I wasn’t rude, I hope, or unkind, and I couldn’t help but be affectionate with Ana herself, but I wasn’t particularly supportive or actively kind to her parents. And from one day to the next her parents’ lives had changed forever: Ana had a tumor at the base of her skull that was encroaching on structures in her neck as well as her brain, robbing her of the use of her arm on one side.

Ana received the best care we could provide medically, and during subsequent admissions to the hospital I tried to be more attentive to her parents, but I felt I could never redeem the way I failed to make them feel less alone the night Ana was admitted for the first time. I had been physically present, but spiritually absent. I'm still sorry about it, as I was back then, but it's too late - and it was back then too. Eventually Ana died.

I saw lots of children come and go that first year. Most recovered from their illnesses and did well. Some lingered in their suffering - a little boy whose babysitter had bashed his head into a wall, an adolescent with little or no mental capacity, a number of children with stubborn cancers or metabolic disorders. Some died – a 5-year-old with rhabdomyosarcoma, a nine-year-old girl with an unpleasant attitude, a 13-year-old boy who was looking forward to seeing his grandfather in heaven and whom we sent home to die, a 16-year-old with leukemia and developmental delay whose memorial service I attended, a 2-year-old boy whose death from smoke inhalation was the first I ever had to pronounce officially. And Ana.

Of all those whose death I was somehow connected to, Ana is the one patient whose suffering I felt somewhat responsible for, not because I caused her condition or worsened it medically in any way, but because I wasn’t “there” for her parents when there was literally no one else around to help them. Because I was so tired that all I could think of was going to sleep. It seems weak and silly and selfish now, because now with some distance I can only remember that I felt overwhelmed by the fatigue but not how taxing it actually felt. But there it is – one of my weakest moments as a doctor. There have been others, certainly, but I always go back to this one, maybe because it happened early on, and because it showed me the disappointing truth that all it takes for me to fail to be generous is a minute amount of my own so-called “suffering.”

Pain and Suffering

I once knew an anesthesiologist who wasn't chosen for jury duty during a "pain and suffering" case after he stated, "I work in an ICU. I think I have a pretty good idea of what 'pain' and 'suffering' are."

Pain is our great nemesis. We deal with it every day - in fact, every case of every day. Anesthetists and anesthesiologists expend tremendous energy, mentally and physically, working to prevent post-surgical pain as much as they can. We plan certain drug regimens to be given before and during surgery, adjust them according to the way patients respond under anesthesia, and follow patients after surgery in an effort to ensure their comfort. This dimension of our practice, protecting people from their own suffering, occurs in tandem with protecting patients from physiologic danger, such as disturbances of heart rhythm or blood pressure that can on occasion be life-threatening. Pain is the enemy.

But that's not "what nature intended." One need only imagine life without pain to realize why it's important, even necessary. Pain is a message, an invitation to care and a warning that we need to start healing ourselves or seek help. I once knew a quadriplegic man who was unable to feel the pain of a very hot surface under his heel and developed a very nasty burn there. If we felt no pain from broken bones we might delay getting help and wind up unable to set the fracture properly. If we experienced no emotional pain from loss, our relationships would be empty of compassion and love and perhaps respect. When I imagine a world in which parents blithely wave to their children on college drop-off day, or brush off the deep gash in their toddler's leg (while the toddler, in this tearless, painless utopia, tries to pick it apart in fascination), I have to wonder if a world without suffering might not just be a hell of indifference and ill-health. Our responses to suffering define our humanity - do we ignore pain, revile it, laugh in its face, deny it, perpetuate it, or try to alleviate it? I believe we're called to take care of ourselves and each other because of pain and suffering.

Like death, pain might deserve to be personified as a kind of "angel," too, protecting us with tough love. But sometimes the demons get the upper hand. Pain can induce exasperation, numbed responses, or indifference after repeated exposures: the dreaded "compassion fatigue" among health care and humanitarian workers that's not often talked-about but should be. There's also what's often termed "pathologic" pain, pain that serves no physiologic purpose and winds up just torturing patients with a life of suffering that they just can't heal.

One example of pathologic pain is chronic pain after nerve injury, a problem often treated by pain doctors. Pain medicine is a subspecialty of anesthesiology, neurology, and PM&R (physical medicine and rehabilitation), and pain doctors struggle long and hard to try to help patients whose problems are often so difficult to treat that the patients can become suicidal from their pain. In 1872 Silas Weir Mitchell*, who observed several cases of neuropathic pain during the Civil War, wrote a description of the effects of chronic pain in Injuries of Nerves and Their Consequences that rings true to this day: "Perhaps few persons who are not physicians can realize the influence which long-continued and unendurable pain may have on both body and mind. . . Under such torments the temper changes, the most amiable grow irritable, the bravest soldier becomes a coward, and the strongest man is scarcely less nervous than the most hysterical girl. Nothing can better illustrate the extent to which these statements may be true than the cases of burning pain, or, as I prefer to term it, Causalgia, the most terrible of all tortures which a nerve wound may inflict." Back then, when limb amputations were commonly used to treat war wounds, amputation was the common treatment for peripheral nerve injury as well.

This often brought about another pathologic pain state: phantom limb pain. 50-80% of people who have a limb amputated continue to experience sensations, including painful ones, from the amputated limb. Anesthesiologists have tried offering epidurals or nerve blocks to relieve the awful sensations from the area of the amputated limb, but such measures have been unreliable. Neuroscientist V. S. Ramachandran explained during his 2003 Reith Lecture for the BBC why this phenomenon occurs:

I touched [the patient's] belly and he said oh you're touching my belly. I touched his chest and he said you're touching my chest - not surprising. But the amazing thing is when I touched his face, the left side of his face - remember his left arm is amputated so he has a phantom on the left side - when I touched his cheek he said oh my god doctor, you're touching my left thumb, my missing phantom thumb and he seemed as surprised as I was. Then I touched him on the upper lip and he said oh my god you're touching my phantom index finger, and then on his lower jaw and he said you're touching my phantom pinkie, my little finger. So why does this happen?

There was a complete map, a systematic map of the missing phantom hand on his face, draped on his face. So you have a medical mystery of sorts...the sort of mystery that would have intrigued Sherlock Holmes, Conan Doyle or Berton Rouché. So what's going on? To answer this question, you have to look at the anatomy of the brain again. The entire skin surface, touch signals, all the skin surface on the left side of the brain is mapped on to the right cerebral hemisphere on a vertical strip of cortical tissue called the post-central gyrus...Now this is a faithful representation of the entire body surface. It's almost as though you have a little person draped on the surface of the brain. It's called the Penfield homunculus, and for the most part it's continuous, which is what you mean by a map, but there is one peculiarity and that is the representation of the face on this map, on the surface of the brain, is right next to the representation of the hand on this map...

So I realised that what's going on here is when you amputate the arm, the part of the cortex of the brain corresponding to the hand is not receiving any signals because you've removed the hand. So it's hungry for sensory input. So what happens is the sensory input from the face skin now invades the vacated territory corresponding to the missing hand, and that then is misinterpreted by higher centres in the brain and arising from the missing phantom hand. And that's why the patient says, every time you touch his face he says oh that's my phantom thumb you're touching, that's my phantom index finger, that's my phantom pinkie. In fact you can even put an ice cube on the face and the patient will say oh my thumb is ice cold. You can put a drop of hot water, in fact you put a drop of hot water and the water started trickling down the face, the patient will trace the trickle on his phantom with his normal hand following its path. On one occasion we had the patient raise his phantom and he was amazed to feel the trickle going uphill which is against the law of physics.

Anesthetizing the phantom limb doesn't always work, but Ramachandran found that tricking the brain might provide a promising alternative. He and his colleagues created a device called the mirror box, in which a patient with a hand amputation, for example, places the existing hand into a slot on one side of the box and a mirror image of it is created on the other side of the box. Both "hands" are visible to the patient, and he or she can then "retrain" the phantom hand to uncurl out of a cramped position or make "normal" movement painlessly, by using the existing hand.

The lesson once again is this: our experiences train our minds and transform our brains, physically. Learning "rewires" us, and new learning has the potential to heal us. Both physical and psychological pain cause changes in the cingulate gyrus, but we can send our brains to boot camp, and retrain them, to try to work against changes that cause chronic suffering. I find this ultimately uplifting. We can't always avoid pain in our lives, and it may be the worst thing about life, but our work to heal it isn't always going to be futile, and we have reason to have hope.

________________________________________________________

*Mitchell was physician to Charlotte Perkins Gilman, who wrote "The Yellow Wallpaper," a short story in which the narrator goes mad after her husband prescribes a "rest cure" for her postpartum depression. Interestingly, Mitchell had prescribed a rest cure for Gilman...

Should I or Shouldn't I?

Chamber music rehearsal was great!

I can't believe just two weeks ago when I first joined, I just sat and stared at the score when the conductor plunked a Corelli concerto down in front of me, but tonight I was actually playing along, with far fewer sit-outs than in that first week or the week after. I was a little annoyed that my favorite reed was beginning to deteriorate. I'm still not at the point of being able to play consistently no matter which reed I use, and it sounds like such a lame excuse when you start to complain about your reed...

Last week, after I played an A and one of the violinists used it to tune, I joked that I could get up and go home, having achieved a life-long dream. This week I got to do it for the whole group because the principal oboist is away on vacation. Little ol' me! Can you believe it? I'm sure we were a little flat, but hey, at least we would all be a little flat together!

Now the question is, given my horror of performing, should I join the group when they do the Corelli, the Pavane, the Pachelbel Canon, and a Mozart piece for a concert in mid-December? Kyoko thinks I should hunker down, practice like mad for a month, and go for it. Despite my self-doubt, I kinda want to! The only problem is I'm on call almost every other day this month...This feels so different from the dread of a piano recital. I'm actually a little excited at the thought of a concert. I guess I just really enjoy a) playing the oboe and b) playing with other people. Plus, since by our own admission we in the group would only be too happy to attain even a shred of mediocrity, there's no pressure - we can all be mediocre together! (Actually, not everyone's technically a beginner...we have a very accomplished flutist who taught herself how to play the violin, so she's a "beginner" violinist but lovely on flute!) Hmmm...Something to think about...