The Edge of the Precipice

It was the second repeat C-section of the day. Both mothers had been obese. Both had had spinal anesthesia, the placement of which I had expected to be much more difficult than they'd ended up being. We were on a roll.

Then it started happening. That sinking feeling that something was just not quite right. Like when you're watching a film of someone climbing up a dangerous incline, and the camera zooms in on a pebble loosening from beneath a precariously placed foot, then catches the moment the foot slips on a rock and knocks the pebble down a dizzyingly steep ravine.

Obstetric anesthesia is like this. For the most part you're dealing with healthy young women having healthy babies, and it's generally a happy aspect of anesthesiology. But when things go bad, they're REALLY bad, so when you start to sense that they MIGHT go bad, you're on red alert until reassured otherwise. First there were mutterings about scar tissue. The two surgeons, my friend Keira and her colleague Marcus, both of whom were highly experienced, were having a tough time gaining access to the uterus. A lot of blood was collecting in the blood canister after being suctioned from the surgical field. In situations like this, we try to read each other's gazes almost telepathically, without help from the other expressive parts of our faces, hidden as they are behind surgical masks. We try to glean more from each other's curt words than is usually intelligible. We don't want to alarm the patient who lies awake on the table with her abdomen cut open, but we have to communicate with each other clearly and efficiently.

I put my face very close to the blue drape separating my cockpit from the surgical field. Keira looked at me and said, "Her rectus abdominis is totally stuck to the wall of her uterus." That one sentence summed up their situation with the swiftness and precision of her deftly wielded scalpel. There was so much scar tissue that body parts that weren't even supposed to be touching each other were fused together in a clump that had the potential to cause tremendous bleeding - more than the liter of blood that had already been lost.

Somehow they managed to dissect through the abnormal muscle and make the uterine incision to get the baby out...then they couldn't get the baby out. Marcus was pushing so hard on the upper part of our patient's belly that he might as well have sat on her. Keira was elbow deep in her abdomen trying to pry the baby out. She called for a suctioning device and applied it to the baby's head. Three times she tried to extract the baby, three times the baby would not come loose. At one point the suction device popped off with a jolt and spattered blood in multiple directions. Meanwhile I was talking to the mother, telling her she could expect to feel a great deal of pressure and tugging but should not feel sharp pain. I was watching her vital signs, pushing drugs to make sure her blood pressure didn't collapse, all the while hoping I wouldn't have to attend to a blue, lifeless infant when we finally did deliver the baby. I had visions of that ravine opening up below us all, ready to receive us as the rocks shifted out from under us and we finally plummeted out of control...

But somehow we kept it together. A glance here, a barked order their, few words but somehow a ton of communication among people who knew each other's language and signals well, from having worked the same beat together countless times. Keira widened the incision, tried again, Marcus pushed even harder, and somehow the baby's head finally appeared, then shoulders, then thankfully the rest of its greyish-pinkish body, ten fingers, ten toes, with a little whimper that enabled me to move on to the next set of tasks with some hope that all would be well. As soon as the baby was handed over to the pediatrician and nursery nurse I had another surge of busy work - oxytocin for the mother, antibiotics to hang, meds to manipulate blood pressure if necessary, blood loss and urine output checks - while Keira and Marcus began the daunting task of repairing and closing all the disorganized layers of tissue that had been like a forest of brambles in their way. The mother was doing well. The baby had had reasonably good Apgar scores and was whisked off to the nursery after a moment with the mother. The surgeons kept the bleeding under control and sewed the mom back up without incident.

I got to go home and go to my oboe lesson after that, and playing my scales and Gordon Jacob studies felt like dipping tired feet into soothing, flowing water. There's something therapeutic about breathing music into existence, and hearing one's breath emerge as a series of pure, almost imperturbable tones. And the great thing is, if I mess up with my oboe, I don't have to worry about killing anybody!

"Mawidge - Dat Bwessed Awwangement"

The hubby and I stayed up till 11 last night playing Cathedral. What a cooooooo-ooooool game!

In brief, for those who, like us, have been living "under a rock" the last 40 years:

-Player A has a set of light-colored medieval buildings of different shapes; Player B has a dark set.

-Player A starts by putting the cathedral, which is grey, down on a square grid. Player B then puts a dark building down. Players then take turns putting a single building down. The object is to put as many of your buildings on the grid as you can.

-If you can wall off an area of the grid with your buildings (without using the cathedral as part of your wall), that space is yours and your opponent can't put buildings in it. If either the cathedral or an opponent's building gets caught inside a walled-off area, the building is removed and the space it occupied is claimed by the player who constructed the wall.

-The excitement of the game comes from trying to claim real estate while preventing your opponent from doing so.

It sounds simple, and it might even sound relatively unexciting, but both our kids and we have been HOOKED by this game the last couple of days, snowed-in inside our cozy cabin with home-made chowder on the stove and mugs of cocoa in our hands.

When The Hunk and I were playing it late into the night last night we kept trying to come up with strategies. "Being the 'light' player's a disadvantage!" I complained.

"You have to try to place the cathedral defensively."

"Defensively how? The board's totally EMPTY."

"I don't know...try different positions."

"But we've already tried every position!"

We both looked up at each other, had the same mischievous thought at the same time, and both started giggling like school kids.

He's right about "the secret of our marriage." Being able to laugh together is key. But I think our marriage has more than one secret ingredient. :)

***

During these few days off, a luxurious time to just relax and hang out with each other, I try to dispel thoughts of work as soon as they occur, but there are a couple of memories that have cropped up, I think, because I've had our 12th anniversary on my mind (it's next week). They are memories of couples I've seen in the preop holding area before one member of the couple goes in for surgery.

Patients surely form impressions of us clinicians based on those fleeting moments in the holding area. Likewise, we get certain impressions or "vibes" about patients and their loved ones, some stronger than others.

One vibe I don't like to get is the vibe of The Spouse Who Just Doesn't Want to Be There. This is the spouse who sits there looking lost or indifferent while the patient is tearfully asking questions or crying outright or frozen in an anxious silence. No physical contact, no reassuring looks or touches, nothing. The Spouse may not be indifferent; he or she may simply be very private, or feel nervous, or not know how to show support. But I've definitely seen partners who just couldn't care less, too. Not often, but it's disturbing every time.

The opposite is striking in a more pleasant way, and can be quite moving, but The Visibly Loving Spouse can be as uncommon as The Spouse Who Just Doesn't Want to Be There. There are probably many more genuinely loving partners out there than are obvious to the passing observer, but I recall one in particular whose outward expression of support I'll never forget.

A young woman was in the holding area waiting to enter the O.R. for a mastectomy to treat breast cancer. She was young and beautiful. Her husband was with her, holding her hand. They were pleasant with us despite the stress of their situation, patient with our repetitive questions. I finished my preop ritual and told them it was time for me to bring the woman inside. Her husband gave her a kiss.

"I love you," she said to him.

"I am in love with you," he replied, looking long and hard into her eyes.

Then we took her away.

Double Effect

I had to help take a life recently while on call.

A woman came into the emergency department with abdominal pain. An ultrasound revealed a tiny beating heart in her pelvis - in a fallopian tube, not in the uterus. An ectopic pregnancy.

These can be lethal.

Among three possible treatments for ectopic pregnancies - methotrexate (a drug to promote reabsorption of the fetus), salpingostomy (opening the fallopian tube to remove the "products of conception"), and salpingectomy (surgical excision of the affected fallopian tube) - only salpingectomy is considered morally licit by the Catholic Church, because the death of the fetus can be considered an unwanted but, unfortunately, inevitable by-product of a procedure done specifically to save the mother's life (rather than a direct consequence of the treatments, as it would be in the use of methotrexate or salpingostomy). Some might argue that this kind of hair-splitting is silly when the end result is the same, but I think the idea, for members of the Catholic community, is that intention really matters.

Aquinas first articulated this principle of "double effect" in his writings about self-defense: "Nothing hinders one act from having two effects, only one of which is intended, while the other is beside intention...Accordingly, the act of self-defense may have two effects: one, the saving of one's life; the other, the slaying of the aggressor...And yet, though proceeding from a good intention, an act may be rendered unlawful if it be out of proportion to the end. "

I am no theologian. I try to act according to my conscience and to be mindful of my choices. I wasn't thinking about Aquinas, or double effect, or any fancy ethical theories the night I gave this woman anesthesia for a salpingectomy. All I could think, as I held her hand and reassured her that she wouldn't be alone, as I watched her smile bravely but with small tears trickling into the corners of her eyes, was that I needed to execute an anesthetic that would maximize her safety and minimize her pain. The anesthetic itself went smoothly, no problems. But all through the case I kept thinking about those tiny tears trying not to spill down her cheeks, and I knew there was so very little that I could really do for her.

Just hours before, I had placed an epidural for a woman expecting her first child to enter the world that day. As the surgeon removed the small, dark-purple sac from our current patient's body, I winced thinking of the little life that was getting snuffed out. I felt sad, especially because I knew the mother was sad about it. Then I turned back to the mother and prepared her for her awakening.

Sounds in my Brain, Music in my Soul

Manuscript of the Exultet in Bari, Italy, c. 1030

Yesterday after some long tones and half-hole transitions I practiced my dreaded E flat major scale over and over and over again. I dissected it into little pieces and repeated those little pieces till my left hand was aching. I put it back together (still not perfect, or even good) and played it again, and again, never once getting it perfectly smoothly, but at least feeling less of a struggle toward the end.

Then I moved on to my Ten Little Studies by Gordon Jacob, of which I'm only tackling the first three for the moment, and whaddya know...they came out better than the last horrible, discouraging, frustrating, doubt-inspiring practice session I'd had. I need to warm up the way I did more consistently - something Kyoko's already advised me to do but which, like the impatient little kid that I am, I sometimes try to slide over.

For dessert I worked on a transcription of the flute Intermezzo from Bizet's Carmen because I thought I deserved a little "Shugah...oh, honey honey." The task was way over my head but there was no one else in the house to hear the slaughter, so I had a grand old time.

***

I'm working my way through Oliver Sacks' latest book, Musicophilia, about musical enigmas in the lives of patients with neurological anomalies. So I've had "music and the brain" on the brain, so to speak. And what I want to know is why, oh why, do I love perfect fifths and harmonic minor scales, or pieces constructed around them?

Did I live in a biblical or medieval era in a past life, or something?

Is my brain just innately partial to a raised seventh degree?

Is everyone's?

Do I love the oboe because it's particularly beautiful playing pieces built on a harmonic minor with lots of perfect fifths thrown in?

I first learned about harmonic minors at a very young age. I think I was still living in the Philippines, taking piano from Mrs. U, so I was younger than nine. They have stirred something in me from the first time I learned to recognize and play them. They sounded exotic but familiar, ancient, mysterious; they spoke to some place deep inside me even at that young age.

In college the choreographer for the jazz dance company I was in created a piece to Peter Gabriel's "The Feeling Begins" from Passion, his soundtrack for The Last Temptation of Christ. "Biblical" sounds galore. Harmonic minor music saturating my every move, until I felt totally submerged and transported, connected to a different time and place. What is it about the stuff that does that to me?

I was just reading an old Scientific American article entitled "Music and the Brain," by Norman M. Weinberger, from a 2004 issue. I learned the following interesting things from it:

-People were already playing on bone flutes about 30,000 years ago.

-The brain doesn't have a discrete music "center" per se; music stimulates many areas of the brain, and does so differently depending a person's learning and experience.

-Harmony and timbre are processed in the right temporal lobe.

-Brain cells' response to a given tone is modified by that tone's location within a given melody; the response is different if the tone comes first or is found in the middle of a rising or descending passage of music.

-"When a symphony's denouement gives delicious chills, the same kinds of pleasure centers of the brain light up as they do when eating chocolate." That explains a lot.

-A person with bilateral temporal lobe damage may be unable to recognize music, or distinguish between two very different melodies, but may have normal emotional responses to a piece of music because her frontal lobes are intact.

This kind of science is fun to read about. But it doesn't solve the deepest mysteries that I often wonder about.

Every Lent/Easter season I think a lot about this because there is an ancient piece of music - from somewhere in the 5th-7th centuries - that is sung once, and only once, each year, at the Easter Vigil, and I look forward to this short-lived moment of pure beauty and mystery every year. The Exultet. I am deeply, inexplicably attached to and moved by the Exultet, so much so that when the music director at our current parish composed his own version three or four Easters ago, as talented a musician and composer as he is, at first I felt a little crestfallen...

...Until I heard him sing it. The church lights had been darkened, and inside that cavernous space, the Paschal Candle was lit in the distance, reminiscent of the appearance of light in the Genesis account of creation. The light spread from one parishioner's candle to another, slowly illuminating the church one person at a time, then he sang, and it was as if all the centuries between the time of early Christianity and ours had evaporated. He built his Exultet around a harmonic minor, and used some Middle Eastern instruments and a low, Gregorian-type of hum from the choir in the background, and it was almost a mystical experience. I still love the traditional Exultet, but MB's has taken the piece to new heights musically, and I have to admit I think I love his even more, which I never would have thought possible. His Exultet has now replaced the traditional one at our parish, and he has also composed a set of psalms along the same musical themes to carry us through the rest of the Easter Vigil. I think this annual ritual is the richest liturgical experience we experience together.

I don't know what areas of my brain light up like genesis Light when I hear MB's Exultet, or why it causes the kind of mental transfiguration it does, but I know that it's for musical experiences like these that people hungrily seek, listen to, and play music, for which we seem naturally anatomically, chemically, and electrically made. Even in times of despair and devastation, music is with us, keeping our spirits alive just as food does our bodies. I was listening to NPR today and heard Reuben and Black Nature, musicians of the Refugee All Stars, talk about how music kept them going in the refugee camps after they fled the civil war in their native Sierra Leone. Music is in our blood, or brain cells, our genes, our tiniest molecules, in the deepest parts of us that these physical elements can't even begin to encompass or represent, and I, for one, am truly grateful.

Battlefield, Ballet Theater, Hospital, and Church

(Photo credit: Plasma being given to a wounded GI in the Philippines, from the exhibit Battlefield Medicine 101: From the Civil War to Vietnam Photo Gallery, found on the National Museum of Health and Medicine website)


Battlefield, ballet theater, hospital, and church. What could these four possibly have in common?

A LOT!

I started reflecting on this after I visited the current edition of SurgeXperiences, a blog carnival hosted this week by Chris over at Made a Difference for That One: a Surgeon's Letters Home from Iraq (I hosted the last edition a couple of weeks ago). He centers his collection adroitly around "the love-hate relationship between surgery and war," and offers this introductory thought:

"What I realized most as I reviewed the excellent submissions this week, is that surgery, both for the patient and the surgeon, is very much like war. There is an urgency to fight against a foe who may kill if left unchecked. Both are activities with high contact and there will be blood. Both are better, far better, when over."

I don't know a whole lot about the military, but I'm pretty familiar with the ballet world, medicine, and my dear old ecclesia. Here's what struck me as comparable features among all four of these seemingly disparate arenas:

1. Training: those 10 or 15 years you spend preparing to participate fully. It's often hard and painful and can feel incredibly unfair. But what doesn't kill you makes you stronger, right...? (I dunno - I actually have a bone to pick with that idea, because I've seen it make people morally weaker or emotionally scarred, too, in some cases...)

2. Hierarchy. Many Americans or folks with egalitarian sensibilities might chafe at operations conducted, and in fact reliant upon, a fairly rigid hierarchy. But though I strongly believe all people have equal dignity and equal rights, their unequal abilities / education / training / experience make hierarchies useful when used properly, without abuses of power or disregard for people's intrinsic worth.

3. Inside jokes, jargon, language, customs, rituals, and familiar experiences. I'm a "native speaker" in three out of the four cultures, but I can see how foreign each of them must look to those who are just "passing through," and how possessive the "natives" can be of their special knowledge of the world they inhabit.

4. Near-total outpouring / investment of onself required - and, on a related note, "the show must go on." It can't stop because you're tired or uncomfortable or emotionally stressed. You're needed for a purpose higher than satisfying your own needs. I'll admit I've often resented this. I once heard the O.R. nurses complain bitterly (and with good reason, I thought) about a time when they were called to work on the obstetric floor because the obstetric nurses were "de-briefing" all day over a traumatic loss that they hadn't even directly been involved with. For most combat medics, docs and anesthetists, surgeons, residents, performers, etc. there's no "de-briefing" allowance. If you're needed, you go to work, even if you've just seen or experienced something traumatic and wanna curl up under a blanket and cry for a while. Sorry. You're needed elsewhere and you gotta put aside your needs and your feelings (what business do you have having THOSE anyway? That's "weak!").

Just the other night I had to re-intubate someone for respiratory insufficiency in the PACU under stressful circumstances, with the next surgeon chomping at the bit wondering when we could start his case, and when I finally got the patient all settled in the ICU the phone rang with the surgeon (actually, a cardiologist who, unlike most surgeons who take about half an hour to place a pacemaker, often takes two to three hours) wondering when the heck we could get started. It was 7:30 p.m. All I wanted to do was go home and cry out some of the tension and fatigue, but instead I had to go back to the main O.R., smile, and greet the next patient as if nothing had happened (Bongi at Other Things Amanzi writes about a similar phenomenon of having to be all bright-eyed and bushy-tailed for the next person after you've told the last person the worst news she's ever heard). This is one of the things I find challenging about my job (besides the fact that you never know what's coming and that possible disaster's always looming around the corner): the fact that you have to commit to be strong for others regardless of how bad you feel inside, and perform at your peak no matter what, no excuses. It's a little unforgiving, but I also do believe doctors, medics, and most nurses have to try to be at their best all the time while they're working, because people's lives are at stake. So, no "de-briefing" for us - that has to wait until we get home. If we ever do, that is.




***

The "outpouring" of care does have its rewards, of course. I am on call for four days straight this weekend and this morning had the chance to help a young boy through a procedure to reset his broken forearm. Boy in tears in the preop area, then father in tears, then mother in tears, but in the end all went well, and it was one of the smoothest anesthetics I've given a child that age in recent memory. Child woke up fully in the PACU sleepy but comfortable and calm. One can't ask for more than that.

Did have a chance to come home for a little while...just in time to wave goodbye to my family as they drove off for a school vacation week ski holiday without me. With any luck I'll be able to join them some time next week...maybe "de-brief" a little...

Valentine's Day - Ugh

I've never liked Valentine's Day. When I was younger I was insecure beneath what I felt was societal pressure to be special to someone other than my immediate family. Now that I'm older and happily married, VD, as I like to call it, seems doubly trite. There's only one VD I can say I loved and will always remember: the night my husband showed up to the hospital in a tux bearing a rose, because I was on-call. He was gorgeous. I had palpitations.

In the spirit of laughing at myself for despising Valentine's Day for so many years, I dug up an old poem I wrote during a post-break-up period in college. It's not a great poem, but I had a great time writing it.

Stuffed Pepper Spell: a love poem / anti-sonnet

She chops an onion tearlessly and chants,

"His nose. His eyes. Appendages. His chin."

The pieces drop and crackle in the pan;

The garlic seethes; tomato and breadcrumbs dance.

She turns the salsa music up and joins

them, checks the oven, seasoning the rice

with cumin, thyme, plus one last special spice -

the quasi-homicidal Leaf - and grinds

some sunflower seeds: a final ritual.

The doorbell rings. He's actually on time?

Come in come in sit down ex-boyfriend mine

You must be hungry (I know you so well)

Aromas waft, the kitchen timer bings,

And she, with clink of cocktail glass, just winks.

No worries - I never actually tried to poison anyone with laxatives or anything, and not only did I end up getting back together with this guy...we've been married for almost twelve years!

Happy Valentine's Day, everybody!

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Ooooooooooh, I just couldn't resist this tasty little addendum with many thanks to Suture for a Living and Street Anatomy for the heads-up:

BLEEDING HEART CUPCAKES, from the book Hey There, Cupcake! by Clare Crespo.

Recipe at YumSugar. Enjoy!

Seven Wonders of the Anatomical World?

I'll admit right off the bat that I don't have seven in mind right at this moment. I'll work on that list and be happy to take suggestions. Right now the one anatomical marvel that's on my mind is the one that protected hockey player Richard Zednik's brain yesterday when his carotid got sliced open* accidentally by teammate Olli Jokinen's skate blade when Jokinen took a spill. The circle of Willis.

The circle of Willis is a ring of connected arteries that supply blood to the brain. When the ring is intact, injury to a blood vessel on one side can, up to a point, and depending on the injury, be compensated for by the blood coming up to the brain from the other side and traveling around the circle of Willis. It's how people who have severe occlusion of a carotid due to atherosclerosis can still get some blood up there.

You know you've spent too much time in hospitals when the first thing you notice about people is their veins and what size IV would fit in them and the first thing that comes into your mind when a hockey player takes a skate blade to the neck is, "OMG is he okay?! Good thing his circle of Willis is intact!"

I'll try to list seven other "Wonders of the Anatomical World" here but if anyone thinks of any that I've spaced out on (beside obvious wonders like the brain), please feel free to chime in. I could probably come up with a whole other list...

7. The trabecular structure of bone.

6. The fine muscles of the hand.

5. The larynx (I'm an anesthesiologist - I have to love the larynx).

4. The ductus arteriosus (and I'm gonna cheat here and include the fetal circulation in general as well as the placenta)

3. The His-Purkinje system (cardiac conduction fibers)

2. The chemoreceptors in lung vasculature that cause blood vessels in the lung to dilate in response to oxygen, when all the other receptors in the body cause constriction.

1. Tiny sensors and transmitters: the cochlea and ossicles in the ear, and rods & cones in the retina (actually, the whole eye is pretty amazing)

_______________________________________________________

*The Canadian news video I had originally linked to has been removed. This is some American footage. I can't believe he got up and skated halfway down the rink and was able to get to the trainer, and I'm so glad he got help right away. I wish Mr. Zednik and his family well and bow my head in admiration toward Dr. Sonya Noor, who performed the repair, and all the docs, nurses, and techs at Buffalo General Hospital who helped take care of him.

Texas Produced ONE Bright Light, At Least*

Alvin Ailey. He was a genius.


Went to see the company's last performance in Boston this season and came out of it, as always, in total awe.

Their latest T-shirt shows words like power, passion, strength, spirit. These words capture only fleeting glimpses of what this company is. I would pay money just to see these dancers walk across the stage, in all their muscular glory and spiritual abandon, as they do so gracefully in Ailey's enduring masterpiece Revelations. In this ballet even when they hold still it's breath-taking. And when they move, Lord...they show us the epitome of what human movement can be.

*Sigh.* This is the only company in the world that can make me feel for a moment that I missed the boat...that I should have tried harder, persisted with the dance training, if only for a slim chance to be near this kind of greatness, touch the hem of it. Ailey started the company in 1958. Four years later it was already being recognized as a national treasure: the company was chosen to tour Asia and Australia as part of the John F. Kennedy's "Special International Program for Cultural Presentations." Fifty years later it is the BEST dance company this country has to offer, I think, and has been for years.

One of my colleagues, an orthopedic surgeon I enjoy working with, once expressed surprise that I should look upon another profession, especially an artistic one, as potentially more fulfilling than the work we do to serve others in medicine. I can't explain it. I remember that when I danced and danced well, really well, I felt as if I had pushed past certain human limits and liberated the part of me that knew how to take flight, to connect with others and with music, with stories our human words can't fully express, and turn my breath and muscles into channels for some divine energy nothing else could capture.

So when I watch these perfectly beautiful, strong, powerful passionate men and women up there doing just that, I do feel a great deal of longing. One of my teachers at the Joffrey Ballet School once went on TV and described me as someone who had "the soul of a dancer." In many ways I feel like I let some of these amazing teachers down choosing a different road. But I also truly feel I'm living the life I'm supposed to be living, with the soulmates by my side, husband and children, that I'm supposed to be living with. I'll just have to be a doctor's body carrying a dancer's soul, I guess!

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*Tongue was firmly planted in cheek when I wrote the title. I know there are a lot of great folks from Texas.

Blowing Through Cylindrical Objects Can Be Good For You

"Attention all personnel. Attention all personnel."

The hospital operator's voice on the overhead paging system pulled me awake out of a weird dream early this morning.

"Code Blue, CCU. Code Blue CCU."

I looked at the neon red digits on the bedside clock. 4:40.

I made my way to the CCU and looked for signs that it was a real code situation. The back door of the CCU swung open after I punched in a numerical code, and I saw a family member leaning on the nurses' desk. Beyond him, a curtain was drawn across the entrance to one of the bedside areas. I could see numerous pairs of feet under its bottom fringes as well as the bright red, metallic outline of the code cart.

I slipped into the area behind the curtain, now crowded with clinicians in scrubs and white coats. An elderly woman lay on the bed, her torso uncovered, a tangle of wires attached to her chest. The respiratory therapist was mask-ventilating her at the head of the bed. I squeezed past them toward the person keeping the code record, identified myself as the anesthesia attending, and offered help if needed.

"Oh, thanks for coming, doc, but she's a DNI."

"A DNR?"

"No, a DNI - no intubations. We can do the 'R' part. Thanks anyway. We got it covered."

"Allrightythen," I said.

On my way back to the call room I stopped to chat with one of the nurses.

"So, how does that work?" I asked her. "People want to be resuscitated but not intubated? Isn't oxygenating and ventilating them a key part of the resuscitation?"

"Yeah," she said. "But people think they can just get CPR and shocked by a defibrillator, and maybe some drugs, and come back. They don't understand."

"Hmm," I said, going through, in my mind, an imaginary resuscitation without a secure airway. Not fun. And possibly less effective.

"People don't want to be hooked up to machines for a long time," the nurse continued.

"I can certainly appreciate that. But it just doesn't make sense to me to eliminate the very first step, the least violent step."

It wasn't that I wanted to be needed at that code. Frankly, I was happy to be ordered back to bed. But something bothered me. The discrepancy. In the past I've often seen DNI/DNR orders together. I haven't often come across DNI/R's. If people wanted part of a resuscitation but not all of it, it made me feel there was something half-hearted going on. Did the patient really want to survive, or want to be let go, to be allowed to die in peace? Did the patient and family really know what a resuscitation involved? It wasn't always clear. It's much easier, naturally, when people voice a desire for all or nothing.

"Isn't airway management one of the fundamental components of a resuscitation, if your goal is to 'succeed' in being resuscitated?" I asked the nurse rhetorically, knowing I was preaching to the choir.

"I know, believe me, I agree. But people just don't understand. They want resuscitation to be easy and the outcome to be rosy."

I've mentioned before that I dislike DNR's in the O.R. but appreciate them in the ICU. I have to amend that. I appreciate DNR's in the ICU but dislike DNI's.

I'm hoping chamber orchestra will meet tonight despite a little snow. I need to spend some time obsessing about a different kind of tube altogether! :)

***

Our chamber conductor just sent me this wonderful superbowl ad / video about oboist and football star, Chester Pitts. It's so uplifting! Best ad of all time! And Ephraim Salaam is ADORABLE. See, blowing through cylindrical objects can really be good for you... :)

Ash Wednesday Musings by a Hungry Disciple

Photo Credit: Judean desert by David Shankbone

I was just reading an old blog post about ballet shoes and found this thought: "I'm sure every art or profession has its share of rituals created by its practitioners. I've seen tennis players with their racquets and doctors setting up their central line kits get pretty particular about what they do with their instruments and how they do it. I think ritual even at its most mundane is valuable. It sets a rhythm. It defines the mind's foci of attention. It enacts meaning and infuses physical acts of work with the desires that underlie the work."

So when the hospital chaplains toured the PACU today placing ashes on patients' and clinicians' foreheads, I received my share, Catholic agnostic though I may be (and ironically, at times actually somewhat more observant than my truly faith-filled husband - perhaps precisely because I find ritual to be very grounding).

I must seem a bundle of contradictions, faith-wise. What am I, spiritually speaking? A theist who's skeptical about the miraculous? An atheist who prays? A reluctant yet enthusiastic believer? A Christian who's not a Christian? A faithful unfaithful Catholic? A person who believes every act can be a prayer, every moment a moral choice between love and un-love, but who also finds the whole idea of spirit and spirituality challenging? I think I might be all the above. Reluctant. Ardent. An agnostic who wants the Shroud of Turin to be authentic. A believing nonbeliever who talks to saints.

***

Here are some Ash Wednesday FAQ's I've encountered over the years:

Is the whole ash thing a sacrament? Not officially, no.

Is Ash Wednesday a "holy day of obligation?" No. But interestingly, a lot of Catholics who miss their "obligatory" holy days show up to church on Ash Wednesday.

Why smudge black ash crosses on your foreheads anyway? Because we love symbolic expression of mystical realities. That's all - no magic, no voodoo, no special power. Just connection to ancient biblical heritage - i.e. many references to marks on foreheads throughout scripture - and to ritual reminders of spiritual work that needs to be done, to identity and meaning that need to be constantly renewed.

Why "celebrate" something so depressing as Lent? It's a liturgical season that echoes the 40 days Jesus spent praying in the desert, the "desert times" in all our lives, and the barren winter of ordinary time that leads to the rebirth of spring. It's also the big preparation time for the holiest remembrance of the year, that of Christ's death and resurrection. I love marking time with the liturgical seasons; they create a rhythm to the year of faith-practice that just sweeps you along on a journey from an infant's very earth-bound birth in an obscure village to a cataclysmic, mystically transforming event for one man and, many believe, for all.


But I have to admit I've never really LIKED this particular season, Lent. It has always seemed so gloomy. I don't like morose approaches to faith and life in general. One of my colleagues said to me light-heartedly today, "To dust I shall return? No way. I'm going to have myself cryogenically frozen!"

I don't think Jesus spent his 40 days in the desert beating himself up over past mistakes or nurturing in himself a sense of unworthiness, shame, or fear. I don't think this is what he was about or what Lent is meant to be, but in the past the season has often been described to me as a time to reflect on sinfulness and the need for repentance. I think of it as spiritual work-out time - like the sometimes hard and painful but ultimately health-building, strengthening, wonderful exercises dancers do at the ballet barre. I have found that retreats - stepping back from material cares and mundane concerns into silence and sacred space - can make that spiritual work really fruitful, but silence and sacred space are really hard to come by these days, making the demarcation of sacred time even more valuable.

I think Jesus spent his time in the desert in deep connection with Spirit and world. I appreciate what Bruce Feiler said in his program Walking the Bible, during which he visited the awe-inspiring Sinai Desert: "In the desert you are between being in extreme places, having extreme emotions, and opening yourself up to spiritual ideas that never existed before. That's why the desert is such a powerful place. You're pushed to the limits of your capacity and you crave nonhuman, nonrational support -- that is, God...That's what Jews, Christians and Muslims all have in common: a single man goes out into the desert and has a transforming experience."




***

For my fellow Catholic-geeks (reluctant or ardent, or both) out there: here's a Lenten Meme I found on other blogs while hopping around the Net this evening. Enjoy! :)


What is your favorite Sorrowful Mystery?

Aw, man, a Sorrowful Mystery? A favorite one? Isn't that, like, a contradiction in terms? Oh, all right...The Agony in the Garden. Jesus at his most human: feeling alone, praying his heart out, stressed out enough to show hematidrosis, yet in the end choosing to trust in God completely...

What is your favorite Station of the Cross?

Veronica wiping Jesus' face. Yes, it's a fictional incident (most likely - or maybe it's based on an incident like it and got passed down through oral tradition). But I love it. I love the healing element, the laying on of tender hands on suffering face, the courageous love of it. I love the whole "left-his-face-imprint-on-the-cloth" legend. I love its narrative cousin, the story of the Shroud of Turin. I know, I know - the shroud's a medieval hoax, right? Well, I love it. It's just so coo-ool. What can I say.

Do you fast during Lent?

I try to observe the Ash Wednesday and Good Friday fasts but don't always do so well. I understand that there's something instructive about experiencing hunger...but it can also be impractical...

What is your Lenten resolution?

I don't recall being brought up with the idea of "giving something up" or even encountering the idea till I moved to the United States. The custom is similarly unfamiliar / absent on my husband's French side of the family. What I'd like to try this year is to recuperate some of the education I had years ago about my faith, maybe be a more rigorous apologist for those convictions that I do hold dear within the framework of my faith.

Do you use Holy Water during Lent?

I've only ever conscientiously used holy water once in my life - so no, not typically.

How many times to you go to Mass during Lent?

Weekly, as is our family's practice, but we also try to engage in Holy Week pretty actively and have a liturgically rich Triduum.


Wishing everyone who enters the season of Lent a good "desert time..."

__________________________________________________

Addendum 10/4/08:

"I guess if introspection is your thing, then the desert is the place for you." -Anthony Bourdain

Blog Carnival: surgeXperiences #114

Welcome to this edition of surgeXperiences, a blog carnival about...guess what...surgical experiences! (By coincidence, it's Carnival Day in Brazil - Happy Carnival to those around the world celebrating!)

I've chosen the above painting by Gauguin as an organizational aid for the carnival. Where Do We Come From? What Are We? Where Are We Going? (1897–1898) was painted in Tahiti and is now at our very own Museum of Fine Arts here in Boston, as far as I know. Without further ado, let's take a stroll through the questions Gauguin poses in his title!

Where Do We Come From? A few glimpses of our training...

Bongi at Other Things Amanzi recalls how a surgeon in training was expected to tough things out.

At Bright Lights, Cold Steel, lightsnsteel gives us a vivid example of how tough that training could get.

"You gotta walk before you can fly." Don'tcha hate that? :) An orthopaedic resident reflects on how being a stellar surgeon starts with being a good assistant.

This med student's impressions at Denialism during his first week on surgery rotation generated a huge controversy at a New York Times health blog!

But of course, different students have different impressions and experiences, as Aaron the "sneaky dog" notes on his blog.

And finally, a captivating story from the training experience captured by a true "fly on the wall," the astute and observant medical videographer, Sterile Eye.

Who Are We? Meet the surgical team...

We, the surgical team, are composed of surgeons, anesthesiologists & nurse anesthetists, scrub and circulating nurses, scrub and anesthesia techs, assistants, residents, and medical students.

I loved Aggravated Doc Surg's playful post about medical words - we gotta know our stuff, we team members, but really, what IS all that gobbledygook?

Doc Surg also describes how great the enjoyment of the work of surgery can be - can we say, pancreatic cystgastrostomy, everyone?

And speaking of love of the work, Dr. Sid Schwab, one of the best surgeon-writers out there, writes about an amputation and reveals how even in the face of a tragic clinical situation, the pleasure of doing the actual work can prevail.

Hard-earned knowledge also helps us do our job well. Dr. Bates, author of Suture for a Living, gives us an informative article on an overlooked but very important body part.

Buckeye Surgeon points out how the challenges of working and making decisions in the community can differ from those of working in the hallowed halls of academe in this post about an urgent operation to remove a child's spleen.

What about the rest of the team?

Makeminetrauma over at intraopOrate introduces us to the world of the surgical first assistant and reminds us all not to assume things are as easy as they look in this post about laparoscopic gastric bypass surgery.

At Livin' Large, Unsinkable MB compares her job as a circulating nurse to that of a familiar face to those of us who grew up in the 70's...

And I couldn't resist inserting my old diatribe "Have You Hugged Your Anesthesiologist Today?" from months back, about what anesthesiologists do. Go, team!

Where Are We Going?

Some people think the growing interest in alternative medicine is a step in the right direction, while others decry the dangers that may lurk therein for unsuspecting patients. Whether or not we fear urban legends come true (anyone seen the film Awake yet?) or scoff at what we see as quackery, the alternatives will always be fair game. Psychic surgery? Is it a joke? Some people claim they've benefited from it. What about gallbladder flush? Sid Schwab weighs in with some strongly worded thoughts.

We have even more urgent and complicated challenges for us in the realm of ethics and morality. We face difficult questions, small and large, on a daily basis in the operating room. Should we suspend DNRs? How do we balance the information a family wants to know versus what they need to know? Should we even do a case in someone whose illness is clearly not salvageable? How about...should we use our expertise to participate in killing people? Terry over Counting Sheep offers a lucid post on the subject of lethal injection. And this heart-breaking, beautifully written post from Dr. Schwab about the death of a child reminds all of us that moral courage in the operating room covers not only decision-making before and during a procedure but also one's demeanor, sentiment, and behavior in its aftermath.

Then there's technology. Hundreds of years from now I bet people will look back on 20th- and 21st- century surgery as comparatively barbaric. But we're making progress. Minimally invasive techniques are all the rage. Off-pump cardiac surgery has been made possible by special stabilizing machinery. We can regenerate heart tissue, transplant faces, separate the conjoined. We are developing robotic techniques - I think I mentioned once that one of my most memorable cases involved the robotic removal of a boy's uterus. But what about robot rounds? I'm not sure removing the human factor is ALWAYS an improvement...

In fact, snazzier doesn't always mean better. Once again, a word from Sid about "bugs" in the O.R. and how a little common sense can be all the technology you really need - and how the body's capacity to repair itself can often outdo the high-tech stuff.

Last but not least, speaking of clean O.R.'s, I'd like to end the carnival with a link to this tribute about one more often-overlooked member of the team that helps the O.R. run smoothly. Thank you, Barb!

Thanks to all who submitted posts for this edition. I wish I could have used all of them! I'm taking the liberty of linking you to one last one from Sid, about scrubs, one from Aggravated Doc Surg, about how we should be careful how we read studies, and a humorous one from amanzimtoti that lightened up the mood a little. They made for good reading but I couldn't fit them into place under my Gauguin schema.

Tune in next time, February 17, when Chris from Made a Difference hosts surgeXperiences #115!

To quote one of my favorite childhood TV shows, this edition of surgeXperiences has been brought to you by the letter

"Where have we come from? Where are we going?

What is the meaning of our lives? We can’t comprehend.

So many pure souls under the blue circle of sky

Burn into ashes! But tell me, where is the smoke?"

-From the Rubaiyat by Omar Khayyam, translated by Dmitri Smirnov