Sunday, July 29, 2007

Would You Still Love Me If I Had No Face?


Chances are, if we were dating, and you were my boyfriend, and a pit bull or Rottweiler chewed my face off, you'd probably dump me sooner or later, even if you thought I was the most beautiful and special person you had ever known and you knew you'd never meet another person like me for the rest of your life.

Let's face it: faces are important.

Our faces identify us uniquely; so while "who we are" is not synonymous with "what we look like," people who can recognize me can point to my face, and say, "Yes, that's T."

We experience the world and the stories of our lives largely through our faces. A breathtaking mountain view, an achingly beautiful passage of music, a delectable restaurant meal, the smell of roses or chocolate or candles or wood burning in winter, a baby's head on your cheek, a lover's kiss, a laugh-so-hard-you-gotta-cry type of conversation with your best friend - all these things reach us through our faces.

We need our faces for a lot of important things. Food stays in our mouths instead of dribbling onto the table because of our facial muscles. People relate to us through our faces; our faces very often trigger our most important relationships and are instrumental in our continuing interactions. People understand us because we express ourselves with our faces as well as our voices. Our faces share our meaning, and our meaning is what we exist to communicate.

If you lost your face, in a way, you would lose your whole world.

But now surgeons can give you part of a face back. This morning the Boston Globe reported that Boston's own Dr. Bohdan Pomahac will begin to perform partial face transplants at Brigham and Women's Hospital. This is historic. There have been three other successful face transplants that I know of: two in France, one in China. A flurry of medical, ethical, and philosophical questions comes up each time the possibility of such a transplant arises.

Here's what I think would be great about restoring people's faces: the recipients could speak and eat properly again; they could participate in society once again without feeling so marginalized by their appearance; and they could remove some of the disfigurement that marred such a vital symbol of individual identity and that probably caused considerable psychological pain.

Here are the problems I have with the procedure: the recipient would have to remain on anti-rejection medications for life, which are not benign; if rejection occurred, the recipient would likely have to endure further disfguring surgery or a potentially grave illness; and the donor, as far as I understand from the case of Isabelle Dinoire, who received a partial face transplant in Amiens in November of 2005, would have to be a beating-heart donor, a situation which could be ethically problematic for some, especially those with ambivalence about the declaration of clinical death by brain death criteria.

Some people have also brought up identity issues - the psychological difficulty for donors' loved ones of having a portion of their loved one's face removed and placed on a stranger, and the challenge for the recipient of living life with an anatomically different appearance. To my mind these are outweighed by the potential medical risks to which the recipient is subjected.

Beyond these, I think this issue of face transplants calls each and every conscientious person to a reflective examination of his or her values, of what role the idea of self-acceptance should play in seeking treatment or healing for a devastating injury, and whether our criteria for accepting one another are themselves so acceptable. I don't have any answers; only questions. In fact I had a lot of tough questions swimming about in my head as I read about this stunning break-through. I've written down some of them, and while the answers may seem clear to some, I believe that clarity is contradicted by the disparity between our behavior as a society and what we say we believe or hold dear:

Why is having a mauled face so much worse than having a mauled limb, which itself can be physically and emotionally agonizing?

Why might agreeing to donate part of your face be harder than agreeing to donate your own heart - is your face more "yours" than your heart?

Does a human being have to look like a human being to have worth and dignity?

Does a sick and dying human being, or a malformed human being, or an "incomplete" human being, have less worth than other human beings? (History has shown the people can't even tolerate human beings of a different nationality or color, despite well-intentioned statements by many about the belief in every person's instrinsic value; what does that say about how we as a society assign worth?)

I have written before that the core of my faith is the belief that every person is precious. How well I live up to that faith, and how that fits in with the intricacies of the medical and sociological issues that are unfolding today, I can't say for certain. I guess I just have to keep learning as I go along.

Saturday, July 28, 2007

American Idyll


This was a perfect evening.

After a pleasant afternoon playing at an arcade near Weirs Beach, we picked up a picnic dinner at the local dairy bar, then drove to Cate Park in Wolfeboro to hear Lance MacLean and the Moose Mountain Jazz Band give a a concert of dixieland music. The temperature was in the 70's, with a cool breeze blowing off the water, where a few boats were docked just in front of the bandstand. We strolled down the docks or lay on our colorful picnic mat just taking it all in. The ice cream shop down the little boardwalk was open for business - what summer night spent listening to a dixieland band would be complete without it? My kids danced happily without a hint of self-consciousness, which was delightful. The whole event gave me that cozy, small-town America, Norman-Rockwell-type of feeling. We were together and content, with good music to listen, good food to eat, and a beautiful view in front of us.

We take these freedoms and luxuries for granted so easily...yet what else can we say and do, but try our best to remember and express gratitude, and strive to share our blessings with others?

I have seen so much rhetoric in response to this world's "savage inequalities," to borrow Jonathan Kozol's phrase, claiming them as proof of God's absence, because a loving God "wouldn't allow" such injustice. I find this line of thinking weak and erroneous (not that theist rhetoric isn't full of weakness and error - it can be, too). I think people should stop blaming God for the world's problems and ask themselves what they have done to combat injustice.

I know that I for one have not done enough; as a good and wise man once said, the spirit is willing, but weakness hinders action. In my case those weaknesses are like the cumbersome lead aprons I wear whenever the x-ray guy enters the room to take an x-ray. They weigh me down, they're easy to hide behind, and I often keep the protection on when the need for it has passed, for no real reason.

When I kiss my children good-night a second time, after they've already fallen asleep in their beds, I think of these things, the joys and the challenges, and wonder how I can hope to teach them what's right, when I fall so far short of the ideals.




Friday, July 27, 2007

Cooking Up an Anesthetic

I have been on-call quite a bit this month. Today I am post-call and off for the weekend, ah...


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

Oscar the Grim Reaper Cat

A cat who can tell when you're about to die? Sounds morbid, but I actually thought it was kind of comforting. I love stories like this. It actually made it into the New England Journal of Medicine. All that and he's pretty cute, too.



Tuesday, July 24, 2007

Box of Dreams Arrives

I've been waiting for this package for almost a week.





When the UPS truck drove up around dinner time tonight, I jumped up and down like a little kid. My husband had to get the door and sign for the package.





I was on the phone with Hilda when I finally had the chance to start opening it.






My trial oboe! It's here! I hope I like it. But even if I end up sending it back, this is so cool - "trialing" an instrument. As if I had earned the privilege!





Now, how can one tell if it's a good oboe if one is an awful player? :)

So far it seems lighter and easier to get my fingers around, and hits highs and lows more precisely and consistently than my rental. It's a little brighter-sounding than my rental, too - less wanna-be clarinet or sax. Likin' it so far!

Epidurazilla

I couldn't go back to sleep after getting called to place an epidural for a laboring woman at about 3:45 this morning, , so here I am, walking down Memory Lane again. After a string of fairly gentle call nights, I was due for a busier one, and I got it. It's 5 a.m. I've had two hours of sleep.

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

The Problem of Prayer

"Those who believe they believe in God but without passion in the heart, without anguish of mind, without uncertainty, without doubt, and even at times without despair, believe only in the idea of God, and not in God himself." -Madeleine L'Engle


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 Gift of "Small" Moments


This weekend was truly lovely. We acquired two additional sons temporarily - our good friends had their wonderful boys, ages 10 and 13, stay with us while they went on a long-awaited trip - and as a bonus we also got to know their cute bronze-winged Pionus parrot (Pionus chalopterus).

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

Mirror, Mirror

If I could look like anyone in the whole world, I would want to look (and move) like Polina Semionova, one of the most beautiful ballerinas EVER. She's PERFECT.

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

On Suicide

I am very sad about the death of opera singer Jerry Hadley, who shot himself with an air rifle at his home in Clinton Corners, NY on July 10 and suffered severe brain damage. He was on life support at St. Francis Hospital in Poughkeepsie until July 16 and died yesterday.

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

The Purity Ring Thing


For the last couple of days I have been following news items about Lydia Playfoot, a British teen who lost a court battle for the right to wear her "purity ring" in school. I came upon the story quite by chance; I was on call overnight yesterday, and our hospital's default welcome page happens to be msn.com, which featured the story prominently in its news section.

Today I feel like opining rather than story-telling.

In my opinion, it takes great courage for an adolescent to stand up sincerely and vocally for her beliefs when those beliefs are not shared by the majority of her peers (or for that matter, the adults in her society). Any young person who tries to do good and encourages people, by word and example, to respect of self and others, should be applauded.

Some people have criticized Lydia for "making such a big deal" out of a little ring, saying that she can still speak out about abstinence with or without an article of jewelry on her finger. I agree with the latter statement, but I also know that symbols can be exceedingly powerful, and the ring may in fact be a very big deal for her, regardless of anyone else's opinion of it.

Whatever one's personal view of fornication may be, from a medical and psychological standpoint the following, in my opinion, may be reasonably inferred:

-if every single person waited till marriage to participate in sexual intercourse, the rates of sexually transmitted diseases and unwanted / unplanned pregnancies would likely be vastly reduced;

-if every single person waited till marriage to participate in sexual intercourse, the emotional pain, confusion, or disappointment often associated with dating relationships would likely be mitigated.

As far as I can tell, most things that are considered "wrong" within certain faith systems involve hurting oneself or one another. I believe most religions that have what, by most modern American standards, might be considered "conservative" norms regarding sexual morality probably have people's best interests at heart. Simply put, we're supposed to take care of ourselves and avoid hurting each other. Thus mocking, disdaining, or categorically criticizing these norms, without giving their underlying foundation of care for the human person its proper respect, is, in my opinion, an uneducated, arrogant, intemperate act.

That said...

I think a private school is well within its rights to prescribe a dress code for its students and can, at its discretion, in light of a regulation against jewelry that applies to all students, ask that students refrain from wearing symbols of their beliefs that are not strictly required by their belief systems. I believe it wrong, however, for a school to favor certain articles over others - cross necklaces ok, but bracelets not, head scarves ok, but gowns not, etc.

I am also a little wary of the exaltation of the word and concept of "purity." By implication people whose behavior has failed to meet certain standards can be considered "impure," tainted, sullied, stained, dirty, inferior...you get the idea. This mode of discourse equates a person's worth with his or her "purity" - already a fallacious equation - and predisposes to a great deal of judgment that, in theistic belief systems, should supposedly be left to God.

There are belief systems in which even the merest physical contact with "contaminated" objects and individuals elicits more aversion than a scrub nurse's horror of a medical student accidentally touching a sterile drape. But I like Jesus's take on purity politics: it's not what touches you from the outside that makes you impure, but rather what's in you that defiles you (Mark 7:15). It's all about what's going on deep down - you may act morally, but are you really moral in there, in your mind and heart? Haven't I smiled at people but resented them or disparaged them in my mind? Well, yeah, and shame on me; isn't that about as impure as it gets?

Jesus also said "blessed are the pure in heart." This isn't to say he thought we could all casually copulate with anyone just because we were "good on the inside" and felt like it. On the contrary, he said people should keep not only their hands etc. off each other's spouses, but also their very thoughts. He wasn't stupid. He knew it was normal for the mind to wonder and wander...but he taught active rather than passive morality: work to curb selfish impulses; make acts of love, and a life of love, a conscious, continuous choice, starting with what's inside of you and proceeding accordingly.

What I would love to see in our world of many beliefs and belief systems is this: virgins who don't look down on unmarried non-virgins, and non-virgins who don't look down on virgins. I would love to see a world, in fact, that's cleansed of any kind of "looking down," that's spiritually wearing a ring inscribed with Luke 6:37 - Do Not Judge. That would be a purer world indeed, one in which the "lions" and the "lambs" really could lie down beside each other free of all domination and fear.

Tuesday, July 17, 2007

The Limits of Viability


21 weeks, 6 days.

As far as I know, this is the gestational age of the youngest premature infant to have survived beyond birth. Amillia Taylor (not the infant picture here) weighed only 10 oz and was only as long as a pen.

This makes my 32 weeks back in the early seventies look like term.

***

The story I'm about to tell may elicit a strong reaction from some. I need to retell it because I it's an experience that has stayed with me, and the telling of it helps me understand, gradually. I don't want anyone to infer any opinions or judgments on my part; I'm not interested in sharing opinion right now. Just telling a story.

In my third year of medical school, during my rotation in OB/gyn, a couple was admitted for termination of the woman's pregnancy. The fetus, whose age I don't recall exactly but I believe was somewhere in the teens (for weeks of age), had Down Syndrome. I remember very little about the tasks I was asked to do outside the couple's room - perhaps a little shuttling of pain medication or fetching a sheet of paper for the residents involved more closely with the couple. Their privacy was maintained as much as possible.

A few images are branded into my mind from that day. I remember catching a glimpse of the couple just after the termination was completed, when the door swung open so the fetus could be brought out of the room. The man had his head on the woman's and they were sobbing quietly together.

A little later I remember passing the cleaning supply room and noticing that the fetus had been placed in there, for whatever reason. I asked one of the residents if it would be all right if I looked in on the fetus. Permission was granted and I went. I could not tell if the fetus was male or female - externally this was not yet visible. But I recall being able to see the heart beating through the chest wall, and feeling a mixture of disbelief, confusion, and helplessness because it took such a long time for the heart to stop.

***

During my intern year I had an unplanned "take your child to work" day because a snowstorm closed my daughter's day care center and she had to get dropped off at the hospital, where I was doing a rotation in the neonatal ICU. I thought it was kind of cute that she went on rounds with us in the less restricted unit, and thankfully the NICU attendings thought so too. She took it all in stride - the incubators, the eye covers on some of the tiny babies to protect them against the treatment lights for jaundice, her mom in a big blue gown and mask about to do a spinal tap or place an umbilical line. The attendings took turns playing with her and taking her to the cafeteria. It was the one time the high-stress environment of the NICU felt a little brighter for me.
***

I wish people wouldn't pass judgment on parents who ask for everything possible to be done to save their children.

I wish people wouldn't pass judgment on parents who ask that their children be left in peace if resuscitation appears futile.

I wish there were easier answers to the question of what is futile and what isn't.

***

Many thanks to Brian Hall for making the first image above publicly available on Wikimedia Commons, where the second image can also be found.

Sunday, July 15, 2007

National Ice Cream Day

I've been taking a mental poll recently of most-talked-about subjects in the O.R. (not pertaining to patient care or medicine). So far the top three items seem to be

3. The Red Sox / celebrities / other news items
2. What to do when we're NOT in the O.R.
1. FOOD.

We spend an inordinate amount of time thinking and talking about food.

***

Happy National Ice Cream Day, everyone!

After the last couple of posts, I need to write about something a little frivolous. Like ice cream.


On our recent vacation I noticed that on the two occasions we visited Ben and Jerry's for ice cream, we all chose the same flavors for ourselves.

Me: Chocolate Therapy
My husband: Crème brûlée
My daughter: Lemonade sorbet
My son: Vanilla with Gummy bears

So I thought, can I read ourselves into those flavors at all? ("If you were an ice cream flavor, which one would you be?")

My son is definitely vanilla with gummy bears. Sweet, reliable, tried and true, with a sprinkling of fun and some delightful, hidden treasures, spiritually and intellectually.

My daughter could be lemonade sorbet - sweet but a little tangy, too, slightly off-beat but with a style of her own, yummy and refreshing all in all. I think the best metaphor for her, though, would be rainbow sorbet, with its exuberance and festiveness.

My husband does happen to be French (or at least, half-French), like crème brûlée, smooth and sensual but also comforting. But the "fancy" name fails to convey his earthier side, the part of him that would build a log cabin for his family by hand if he had the time and resources.

As for chocolate therapy, perhaps it's too dark, multilayered, and mysterious to represent me, but I'll take it anyway. In truth I'm probably more like one of my other favorites, cookie dough.

My husband and I are as different as chocolate and vanilla, but Cookies & Cream is an ice cream flavor we agree on. How fitting - a marriage of both chocolate and vanilla, complex in texture, gritty yet oh-so good.

John Harrison, the official taste tester for Edy's Ice Cream (where can I get a job like that?!), was on the radio last Friday morning talking about his invention of Cookies & Cream ice cream (a claim disputed by Blue Bell Creameries and also by the dairy plant at South Dakota State University). He said if it hadn't been for a hail storm that wiped out a pre-purchased crop of peaches that the ice cream company was going to use for a peach ice cream, they might never have taken his Cookies & Cream concoction off the back shelf of the freezer and trialed it.

This story reminded me of a saying that was passed down to me during my training and that I often repeat to students: luck is more important than skill! :)

***

Another "list of the week," in honor of National Ice Cream Day: My Favorite Ice Cream Flavors:

10. Toasted coconut ice cream from Main Street Sweets in Tarrytown, New York tied with Philippine ube ice cream (ube, pronounced "oo-beh," is a purple yam - VERY purple)
9. Ben & Jerry's cinnamon bun ice cream.
8. Chocolate chip cookie dough ice cream.
7. Mango ice cream if made with Philippine mangoes, which are the best in the world.
6. Selecta mocha ice cream (in the Philippines).
5. Hazelnut ice cream, especially the nocciolo gelato you can get in Italy.
4. Ben & Jerry's Chocolate Therapy - anyone seen this in grocery stores? Ate it in the parlor...
3. Häagen-Dazs Tres Leches ice cream - is this gone?
2. Häagen-Dazs limited edition strawberry shortcake - bought it once, then couldn't find it again; love their limited edition Belgian chocolate, too
1. J.P. Licks Oreo ice cream.

Saturday, July 14, 2007

If I Had Been a Spider During Residency...

People have asked me how I deal with the sleep deprivation that's sometimes part of my job, and was a chronic, recurrent, unrelenting element of it during residency.

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

(This) Sux


In November of 1993, thanks to the FDA, the package insert for Succinylcholine (or if you're British, Suxamethonium, or if you're most anesthesiologists and emergency physicians, just Sux) was changed. The new label stated that the drug was contraindicated in children and adolescents "except when used for emergency tracheal intubation or in instances where immediate securing of the airway is necessary."

This means if we give Sux to children, we had better have a darn good reason for doing so, like, "the kid's gonna die before my eyes unless I give it."

I gave it to a 5-year-old.

First day back after a vacation, first case of the morning at the "main" hospital my group serves.

I came in to set up my drugs and equipment in the morning as always - first a suction, laryngoscope, and machine check, then drug preparations. For children I whip out my little home-made table of specific doses, intravenous and intramuscular, for specific drugs by child's weight. I look at the weight that corresponds to my patient at that particular time and memorize the doses for the most crucial drugs. I draw up these "rescue" drugs before the case and place them in syringes that are always within my reach. Then I put a few bottles of candy scent in my pocket, go out and see the kids, and ask them which scent they'd like their "magic air" to smell like when it's time for them to breathe the magic air that will make them sleepy.

My little 5-year-old patient was going to have her tonsils out. She had little braids and a wiggly tooth. She had a little white sheep named Little Bear who had a little lamb.

Everything was going just like every other anesthetic for a tonsillectomy; she breathed her bubble-gum scented magic air, she went unconscious, my wonderful O.R. nurse was getting an IV, everything was going according to plan...

Then it happened. One moment I was giving her manual breaths through a mask snugly held to her face; the next moment, after a couple of coughs, she stopped breathing and I could not, try as I might, squeeze any more breaths into her little lungs. Her saturation dropped, 99%, 90%, 85%, 77%...in a matter of seconds it had plunged to terrifying. Mask ventilation was futile.

I asked my O.R. nurse to grab the Sux syringe next to me and push 2 milliliters of it into the IV she had just placed, and I asked a second nurse to call other anesthesiologists stat to the room for extra pairs of hands. Help arrived in a matter of seconds; by then I had an endotracheal tube in place and was ventilating the child again, and her saturation came back up rapidly to 100%. My colleagues, Maddog and Fred, drew up and gave one or two other protective drugs while my hands were full, saw that the kid was stable, patted me on the back, and took their leave.

It happened so fast. It took me maybe half a second to think, "Oh, crappe,* I need Sux" and another half-second to say, "Get that Sux and give 2 cc's of it now." But in that one second, if you were to project my thoughts on a screen slow-motion, I think you'd read something like this: This is laryngospasm. I can't believe this kid is actually laryngospazzing on me. Or could it be bronchospasm? No history of asthma...What else makes someone desaturate fast? Airway obstruction? So-called chest wall rigidity? Masseter spasm? But the IV's barely even in; we haven't given something that would cause that. Well, we're about to...Is that really the heart rate? Could be worse I guess, she's only bradycardic by five-year-old standards; if she were an adult she'd be fine. What if she goes into hyperkalemic cardiac arrest when I give the Sux? Or malignant hyperthermia...but how likely is that? She's more likely to stay desaturated (and croak) from no airway than to do all that...Still, I hope she doesn't have pseudocholinesterase deficiency, or an undiagnosed myopathy that would predispose her to cardiac arrest...Here goes...

As soon as the Sux went in, her entire body including her airway relaxed perceptibly under my hands and I was able to intubate her and secure her airway. All I can say is, thank goodness the FDA didn't outright ban this drug. It may be dangerous for a few in rare cases but when you need it, you need it badly.

She did beautifully the rest of the case. Then I was able to move on to the adult patient I had to intubated blindly because a plum-sized thyroglossal duct cyst was obscuring my view of the vocal cords...and after that I almost got the man whose every organ had something wrong with it (heart didn't work, pancreas didn't work, kidneys didn't work, lower esophageal sphincter didn't work, peripheral nerves didn't work, brain was kinda on-the-fritz too...), except my colleague George was on late-shift and wound up taking the case...

Somebody please tell me why I shouldn't quit my day job and move on to something that doesn't entail being responsible for other people's lives...

_____________________________________________________

*"Crappe," according to Wikipedia, is a Middle English word meaning " 'chaff, or grain that has been trodden underfoot in a barn' (c. 1440s), deriving ultimately from Late Latin crappa..." The other word, meaning excrement, is slang derived centuries later by Americans. I admit I actually was thinking the latter at the time, but I can't bring myself to use it in writing.

Wednesday, July 11, 2007

Mea culpa, mea culpa, mea maxima culpa: Confessions a Working Mom

I spent the last two days of my vacation doing some stay-at-home mom things - drop-offs at day camp, making lunches, tidying up a little, running errands. I loved it. I didn't miss work one bit, though surprisingly I didn't have my usual Sunday Night Syndrome before returning to work (though technically my last vacation night wasn't on a Sunday anyway.)

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.

Colbert v. Dawkins

I just had to post this link to the hilarious video clip of Stephen Colbert interviewing Richard Dawkins about The God Delusion. I laughed and laughed and laughed...

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

Celsius 233


Thanks to fellow-blogger Angie for alerting me to this list of reasons to whip up some chocolate therapy (enumerated by Robyn Jackson at the University of Dayton Erma Bombeck Writers' Workshop):

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.

*Sigh.*

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."
2. To Kill a Mockingbird by Harper Lee.
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.
***
There are three artistic works that are not books but that affected me so profoundly I was practically trembling when I experienced them. To be fair I need to mention those too:

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.
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Figured out how to embed the Lacrymosa video:

Sunday, July 8, 2007

L'Insegnamento Medico Alla Moda

In 1720 composer Benedetto Marcello (whose oboe concerto in C minor is a well-loved part of the accomplished oboist's repertoire) anonymously published a satirical pamphlet entitled Il teatro alla moda - Fashionable Theater. In it he criticizes contemporary trends in opera by constructing a handbook of sorts for various participants in opera production.

The pamphlet suggests that the modern composer should have no knowledge of proper music theory; that virtuosi should be illiterate and don't need to have good pronunciation or comprehension of the words they sing - the better to perform "ornaments, trills, appoggiature, very long cadences,"* etc.; that the modern Poet "should not have read and should never read the ancient Authors, Latin or Greek. And this is because the ancient Greeks or Latins have never read the moderns;" and the mothers of female singers should mouth the words with their daughters at every audition, prompt them with the appropriate ornaments and trills, and lop at least a decade off their virtuose's ages whenever asked.

I read some of Il teatro in the original Italian, and I have to say, it's pretty funny. But I'm sad that Marcello included a caricature of Vivaldi on the cover of the pamphlet, and that the pamphlet is in fact a response to, and harsh critique of, Vivaldi's style. Benedetto Marcello wrote such a lovely oboe concerto (as did his older brother, Alessandro Marcello); I hate to think such a talented composer might also have been a sneering jerk.

Yet I can't pass judgment, because of what I'm about to do.

I'm about to start...in quizzical memory of Benedetto Marcello...and with tongue firmly planted in cheek...

L'Insegnamento medico alla moda: Fashionable Medical Education, being a compendium of safe, easy, useful and necessary Advice given to attending physicians, residents, medical students of both sexes, premeds, spouses of the above, & other People belonging to the World of Medicine.

Some excerpts:

Medical Students, say a fond goodbye to your spouses, your children, your hobbies, your wallets (figuratively speaking), and your beds (quite literally). You will probably never see them again.

Residents, especially those engaged in surgery or anesthesiology, should have themselves permanently catheterized so as to be able to void bladder contents at appropriate times rather than waiting the requisite 6 or 8 or 10 or 12 hours for their cases to be done.
Female residents, please prepare and practice the sweet smile you're going to show daily to patients who address you as "Miss," "Nurse," or "Kid" despite the name tag on you that clearly says DOCTOR on it.

Attending physicians, be sure to expect your students to know everything there is to know about medicine prior to their having been taught any of it; expect them also to read your mind and know exactly what you want without your giving a lucid explanation or clear directions; never offer clear directions, or guidance of any kind, or if you do, do so grudgingly and with an air of exasperation or contempt; don't forget to contradict the attending physician who was teaching before you, so as to confuse your trainees utterly and make them appear incompetent to the next person; and finally, never, ever, ever, ever allow the on-call residents to sleep. Ever. And make sure they have to work like oxen the following day, especially if they are residents in cardiac surgery or neurosurgery.

Spouses should take a vow of long-suffering patience and self-sufficiency in addition to all that love, honor, and cherishing they promised before they realized what they were getting into.

Nurses in the recovery room or ICU, be sure to brow-beat the residents from the moment they drop off the patients to the moment they finally take their leave and run to the rest room or drinking fountain. Some exceptions apply...

Fellows and senior residents: lord it over any one less senior than you, fix the schedule so it favors you and nails everyone else, bad-mouth the attendings above you and the juniors below, and avoid doing work of any kind.

Heehee...I know, I am SOOOOOOOOO bad...but I'm not really this cynical, honestly. For the record, during my training I did know attendings who were good teachers and clinicians, nurses who were kind and helpful , surgeons in various subspecialties who were gracious and respectful, and senior residents and fellows who exemplified everything I hoped to become as a physician. But after all these years, a girl can take things a little less seriously, lighten up, and let off a little satirical steam, no? :-)
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*translations are from the wikipedia article about il teatro alla moda.

Friday, July 6, 2007

You Are What You...Have?

What makes us human?

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

Brief Oboe Update


Yes, I've been practicing even on vacation. It's hard to find a good time and place in a hotel, but I managed to practice every other day last week, and a little more this week at our cabin.

Jesu, Joy of Man's Desiring is actually getting a little faster. I now have recognizable trouble spots I can work on amid more fluent runs, instead of every measure being one messy trouble spot.

I can sight read most things I like out of our church hymnal - D and G major better than E flat or F# minor, not surprisingly.

I can play Gabriel's Oboe all the way through.

But I'm unhappy! Why? Because I sound like !$^&*@#!!

No, it's not my reed. No, it's not my trusty little student oboe. It's ME. If Mr. Kolyenkov from the play You Can't Take It With You were my teacher, he'd be pulling my husband aside and saying, "Confidentially, she stinks." I feel like my whole family thinks it sounds awful but they just feel sorry for me and don't say anything. *Sigh*

I won't have another lesson with Kyoko till August. Then I have to go on this trip with my husband's family...then what? Should I just keep taking lessons even though I feel like I'm gonna sound like stink for the rest of my life? Poor Kyoko...

Racist Cookies? (a follow-up to yesterday's post)


I remember these cookies (image used by permission). In 1999 the Philippine government protested their name and the reference to them as "brown on the outside and white on the inside." I've also seen a petition on the net against purchasing or eating them, though it should be noted that not everyone takes immediate offense at the name.

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.

I was horrified but not surprised when, on my husband's first visit to the Philippines (we were not yet married at the time), a matriarch in my family exclaimed in English, upon meeting him: "A foreigner!" Then, in Spanish "Va mejorar la raza" - [if you marry him,] he'll improve our race. What an ignorant thing to say - and the worst part about it is if it had been pointed out to her as such, she probably would have said, "Why? I'm just speaking the truth." Good thing my husband was well-educated about colonial history, post-colonial culture, and the related social issues, thanks to his studies and travel experiences.

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.