The Grass Isn't Always Greener...

I got this idea from OldMDGirl, who writes a blog entitled The Long Road to Medical School. She made a list entitled "Career Preferences du Jour," which intrigued me because every time I go on vacation, my mind starts wandering about what I could do with my life if I weren't an anesthesiologist.

Her "Career Preferences du Jour":
#1 - Bench to Bedside Research in Field of Choice
#2 - Psychiatrist
#3 - Neurologist...
#25 - Pediatric Orthopedist...
#10,000 - Housewife
#999,999,999 - Stick needle in own eyeball
#1,000,000,000 - Ob/Gyn

I laughed out loud at that last one because I couldn't agree more. I am certainly not cut out for that medical specialty! (And though OldMDGirl came away from her anesthesia rotation too with, unfortunately, a very negative impression of the field, and she considers people around my age "really REALLY OLD" :(, we do agree on at least one other thing: one of my favorite books.)

If I had to pick another field within medicine it would probably be neonatology, to combine my love of infants with issues of critical care. But if I weren't currently in medicine, or had never chosen to pursue it, or were to drop it now and change, what would I do? Setting aside for a moment the fact that I have few if any other marketable skills? :)

Fantasy "Career Preferences" du Jour (somewhat tongue-in-cheek), after OldMDGirl

#1 - Chocolate taster - hee-hee!

#2 - Tour guide in Florence or Paris

#3 - Bookstore-café owner

#5 - Museum curator

#7 - Oboist - but I think I wouldn't in a million years have the talent or skill required
#8- Teacher

#9 - Ballet teacher

#10 - Housewife

#11 - Parish educational coordinator

#12 - Art Therapist

#20 - Lab tech

#25 - Food critic
#30 - Caterer...but I think the stress and organization that's part of preparing food for other people might take away my love of food
#50 - Wedding coordinator...but I dread making phone calls and would't love dealing with demanding family members
#999,999,999 - Do something self-injurious

#1,000,000,000 - Ob/Gyn

Hmm...I think I'm gonna have to stick to anesthesia for the time being...so I guess it's back to the O.R. on Monday!

_______________________________________________________

Addendum:

Did I do anything new during this break?

Answer: Why, yes, as a matter of fact.

-New sight: saw Lake Winnipesaukee from the top of the old Abenaki Fire Tower near Wolfeboro

-New movie: finally saw Almodóvar's film Volver starring Penelope Cruz and loved it so much I watched it again the following morning and added it to my "favorite movies" list

-New dish: made flan for the first time (food scenes in movies and books do that - I either have to try and make what I see, or eat it, or both...)

-New oboe piece: started working on a little Gavotte by Bach. My endurance has really suffered in these last few weeks of spotty practicing. I am paying for it now! Nothing like a little Baroque Boot-camp for us truants...

Excursions in Medical History: Brief Walk Through Medicine in Art

This coming August The Gross Clinic, painted by American master Thomas Eakins in 1875, will be exhibited at the Philadelphia Museum of Art until February of next year. Hat tip to Kathleen Stocker at A Repository for Bottled Monsters (a blog for the National Museum of Health and Medicine in D.C.) for the alert.

The New York Tribune described this masterpiece, which depicts American trauma surgeon Samuel D. Gross, as "one of the most powerful, horrible, yet fascinating pictures that has been painted anywhere in this century...but the more one praises it, the more one must condemn its admission to a gallery where men and women of weak nerves must be compelled to look at it, for not to look at it is impossible."

A lot of art depicting medical subjects is like this. It can be hard to look at and hard not to look at too. One of the scariest paintings I've ever seen is Sir Charles Bell's 1809 work depicting a patient suffering from tetanus. But there are other less gruesome examples throughout history, and I enjoy perusing them for the clues they provide about the history of medicine.

Here's the painter Goya getting some medicine from a doctor-friend (Self-Portrait with Dr. Arrieta, 1820).

In this painting on a Grecian urn from ca. 500 B.C., Achilles binds up Patroclus's wound from an arrow. With what? A swathe of linen? Would he have soaked it in something first, or applied a poultice?

Anatomic illustrations have a long and marvelous history, from Persian medicine centuries ago to Leonardo's famous drawings to today's med school anatomy "bible," the atlas illustrated by Netter. The National Library of Medicine has uploaded several pages from historic Persian, French, Dutch, German, Japanese, and Italian, anatomy books here and here for our perusal. Thanks, NLM!

Anatomy lessons were depicted by Dutch painters Mierevelt and Rembrandt, who portrayed Professor Nicolaes Tulp examining the flexor digitorum superficialis and Dr. Joan Deyman exploring the brain.

But to my mind Eakins' painting surpasses even these works by Rembrandt. There's something about The Gross Clinic that holds my attention - is it the way the light is striking Dr. Gross's forehead as well as the surgical field, or the way the "minor characters" have little stories of their own without distracting too much from the central focus of the painting? Is it the fact that here, clearly, the need for aseptic surgical techniques was unknown, whereas 14 years later, in 1889, when Eakins painted The Agnew Clinic, surgical gowns and sterilized instruments had become the norm, thanks to Lister? Looking through acts of medicine as portrayed by artists around the world (and throughout history) is like leafing through a family album, or trying to reconstruct stories for a family tree. It's nice to see how much we've grown...and humbling to realize how much farther we have to go.

More than Words

I'd met Angie a year ago, prior to a surgical procedure for which I provided her anesthesia. She and her husband are both deaf.

I was glad to see her again, this time under happier circumstances: the birth of their next child.

"How are you?" I gestured with my hands, pulling out the one ASL phrase I could always count on.

I added, awkwardly, "My signing is not better," then realized, Oh crap, how do you say, "since we last met?" At that time, the previous year, I had introduced myself, "I'm Dr. So-and-so," and it had taken me almost as many seconds as letters in my name to do the fingerspelling. So sad.

She smiled and answered through her interpreter, "No worries."

I have an "accent," I'm sure. A hearing person's accent, and a beginner's manual stutter.

Sometimes I wonder, is it annoying for someone who communicates in another language to have a non-fluent person try, or is it accepted in the spirit of fellowship in which the effort is intended? I guess it depends on the individual and the circumstances.

In any case, I was off the hook, for more than one reason: the presence of a terrific interpreter, and the need to get busy with my hands and prepare for the epidural placement.

Immediately I had an issue I hadn't thought of before: how best to position a deaf patient so she could still communicate. Lying on her side, she would probably find her interpreter easier to see, but one of her arms less mobile for signing. We opted to keep her in a sitting position and her interpreter seated on a footrest in front of her, in her line of sight even with her head bent down and her body curled up. Her hands and arms would be free to move with the caveat that she would have to keep them in front of her, away from the sterile field.

The epidural placement was an easy one. Easy enough to allow the labor nurse and me the opportunity for quiet conversation during the placement.

"Where did Angie and John meet?" I asked her. "She might feel a little pressure in her back now," I added, as an aside. The interpreter translated my question and my word of warning.

"We met at school," John signed in reply, behind her.

"You can really feel how much they love each other," I said, talking as much to myself as to the nurse and the interpreter. The interpreter conveyed my thoughts, which John would not be able to lip-read through my surgical mask. I started passing the catheter into Angie's body. It went in smoothly.

The labor nurse concurred. "Exactly. I felt it as soon as I walked in. Really felt it, in the air."

"Right? It's like something that wraps right around you right as you enter the room."

I finished taping the epidural catheter into place. It had gone without a hitch.

The labor nurse nodded. "A lotta love there. A lotta love. Not something you usually get when you walk into these rooms, lemme tell ya."

It was true. There was something special about the vibe in that room, emanating from this couple. Something palpably different from the feeling (or lack of feeling) you got in the presence of other couples. A warmth and tenderness that extended beyond them, easily.

I wondered if a lifetime of having to rely on means of communication other than speech had given these two wonderful people a special ability to communicate better in other ways, to transmit more than the average. We all marveled at Angie and John that night - at their kindness to us and each other, their radiance, the quiet joy and love they expressed, mostly without spoken words.

Sad to say, we're just as often discouraged as happy for the babies born to the families who usually come to this maternity ward. On this particular night, though, we knew we could rest easy and just celebrate - "no worries," as Angie had said. This baby was going to be way ahead of the game.

***

What I Want to Get Accomplished on this Break

1. Brush up on my sign language!

2. Brush up on my flagging Arabic.

3. Read the next book on my summer reading list.

4. Read the latest Oprah magazine, which has all the summer book recommendations.

5. Change nail color, just for fun. Or actually put some on to begin with...a rare event, because of work! Do something about eyebrows. Maybe even hair.

6. Watch reruns of 7th Heaven.

7. Try to make Stilton Cheese & Swiss Chocolate truffles (don't ask).

8. Get through a ballet barre, again.

9. Restore hibernating oboe skills!

10. Sleep. Sleep. Sleep. Sleep.

I think if I even get just #10 accomplished my life will be rejuvenated tenfold...

Summer Reading Time

I'm taking a little time off this week for a much-needed break way from the usual pace of work, putting dinner on the table, getting mundane errands done, etc. A pause at the Well of What's-not-bread-alone. A luxuriation in the things that nourish my spirit.

And one of those things, of course, is BOOKS.

I once entered a beautiful home and felt strongly that something was missing. The living room was lovely. The kitchen was a dream, spacious and attractive. There were lots of windows to let in natural light, morning and afternoon. But where were the...books? A well-to-do home with no BOOKS...?! I went back to my humble little house, looked at my book shelves, and thought to myself, now this, THIS, is a home. Nothing Architectural Digest would be interested in, but a cozy little place where my children and I can be enfolded in the aroma of bound pages and the vibe of stories all around us. It was the same feeling I'd get whenever I walked into a kitchen with fresh vegetables brimming over in baskets and saucepans filled with goodies simmering on the stove. I'd feel well-fed even before sitting down to the feast.

I've started my summer reading on this very day. I probably won't get through this whole list by autumn; work life always tugs me away. But I'd like to!

I start with Walking the Wrack Line by Barbara Hurd. This woman's prose is breathtaking, almost literally: the writing breathes, in and out, up and down, and its beauty does take the reader's breath away. It has rhythm and cadence, used wisely and naturally - as befits a nature writer, in the great tradition* of Annie Dillard or Loren Eiseley, and the literary and scientific writing of Lewis Thomas. It makes you want to read her words out loud and savor them in your mouth, be slowly transformed by the way they lap like waves at the edges of your mind. An example: "Underfoot that day was the usual medley of seaweed and shells, bits of plastic and driftwood, the ordinary ravel of wrack line every high tide leaves behind." Then, in the next paragraph,

Out in the harbor to my left, a dozen small sailboats practiced their maneuvers, tacking port then starboard in choreographed glissades of clean white triangles. Like sailors everywhere, they must have studied the jetty and shoals ahead and laid out a course to avoid them. Behind me, the narrow streets were crowded with sunglassed people who wove between slow-moving cars and children with ice cream cones. Wandering on the beach, I watched an object out in the waves, spent twenty minutes trying to figure out what it was. It hadn't bobbed so much as ridden, appearing on the top of a wave, disappearing behind it. Its rhythmic lift and sink had made it hard to identify - large fish? a log? a swimmer's rubber flipper? The closer it got, the flatter it looked, floating like something wooden, and by the time the skim of water twirled it clockwise and left it in the jumble of wrack, I could see it was a plank of some sort, a crafted thing, not a limb or something drowned, and then, finally, that it was a broken oar.

This passage is a microcosm of the process she as a writer and we as readers experience through this book - the gradual deciphering of a bit of knowledge or wisdom through ever-sharper observation of minute details, some beautiful, some astonishing, accumulating into a broader meditation on what washes ashore for all of us, "what might be rescued - from near destruction, from invisibility, from silence." I will finish this gorgeous book by tomorrow.

After Hurd's book I may stay near the water, so to speak, and turn to Exiles by Ron Hansen - a fictional exploration of the literary and spiritual struggles of Jesuit poet Gerard Manley Hopkins as he tries to make sense of the wreck of the steamship Deutschland, a vessel which had been carrying five young nuns who were bound for a new life in America because of Bismarck's laws against Catholic orders. I've been awed by Hopkins' poems since high school, when we read "As kingfishers catch fire..." (reproduced below). I never really thought about his inner life, though, and look forward to seeing an imagining of it, from an author who considers imagining an act of prayer, and who can use the words "anesthetic," "chamber pot" and "snowflakes" in the first paragraph alone.

As kingfishers catch fire, dragonflies dráw fláme;
As tumbled over rim in roundy wells
Stones ring; like each tucked string tells, each hung bell’s
Bow swung finds tongue to fling out broad its name;
Each mortal thing does one thing and the same:
Deals out that being indoors each one dwells;
Selves—goes itself; myself it speaks and spells,
Crying Whát I do is me: for that I came.

Í say móre: the just man justices;
Kéeps gráce: thát keeps all his goings graces;
Acts in God’s eye what in God’s eye he is—
Chríst—for Christ plays in ten thousand places,
Lovely in limbs, and lovely in eyes not his
To the Father through the features of men’s faces.

I'm intrigued by descriptions of Sebastian Barry's book The Secret Scripture, a novel about a 100-year-old mental patient who starts to reflect on and write about her past and hides her manuscript beneath the floor boards of her room. Meanwhile, a doctor is in the process of reevaluating all the patients in the ward - including her - to see which ones might be released back into the world...

After hearing last Sunday about how Francis Xavier Nguyen Van Thuan spent nine years in solitary confinement, often in the dark, because of his faith, I really want to read his books The Road of Hope: a gospel from prison and Testimony of Hope, a course of spiritual exercises he was invited to offer the Roman Catholic Curia. In it he expresses the desolation he felt during his ordeal and how he found hope in the depths of darkness and despair. How does anyone endure such a thing and emerge still capable of love and joy, as he did? Some people remain open to these gifts in unbelievable ways...

A Death Retold is long and dense, so it's probably not a realistic goal to for this summer, but I want to try. It recounts the tragedy of a botched transplant in an undocument Mexican teen immigrant and discusses the social and ethical issues in our tiered health care system, as well us in transplant medicine in general, brought to light by that terrible case. It sounds like a story that weaves together a lot of compelling fields of inquiry - medicine, sociology, ethics, and history.

Last but not least, every year I try to read or reread at least one "classic." Last summer when I was on my René Goupil mini-pilgrimage I came across this eerily relevant passage from Death Comes for the Archbishop and decided I had to get reacquainted with Willa Cather's work:

Before him, on the grey floor, in the grey light, a group of bright shawls and blankets, some fifty or sixty silent faces; above and behind them the grey walls. He felt as if he were celebrating Mass at the bottom of the sea, for antediluvian creatures; for types of life so old, so hardened, so shut within their shells, that the sacrifice on Calvary could hardly reach back so far…When he blessed them and sent them away, it was with a sense of inadequacy and spiritual defeat. -Death Comes for the Archbishop, Part III, Chapter 3.

That's my ideal reading list for this summer. I know I'll get through Walking the Wrack Line, and soon. As for the rest...they may get supplanted by other discoveries along the way, or put off for another time, but the desire to spend time with them is certainly there!

I welcome other suggestions too, so please let me know if you're reading anything good!

________________________________________________________

*Addendum: Toward the end of Hurd's book she mentions valuing Annie Dillard and Loren Eiseley. What a relief to know she wouldn't have minded my placing her in their company!

SurgeXperiences 124: Season Finale

Welcome to the last edition of this season's SurgeXperiences blog carnival!

The loose theme for the collection was "Secrets and Surprises" - what season finale would be complete without a few of those?

Yet there's another ingredient that no real season finale would be complete without. It's The Unanswered Question. The Unsolved Mystery. Unfinished Business. Arguably it's why any of us keeps returning to any realm of inquiry or learning.

The world of medicine abounds with unanswered questions. While they might not show up here in the form of a conventional "cliffhanger ending," they're here all right...lurking behind the answers to other questions, the often-untidy "resolutions" to stories, and in situations that remain unresolved altogether and that keep us wondering about doctors, nurses, patients, the O.R., the characters in the vast series of episodes that comprise life in medicine today.

So without further ado I give you Secrets, Deep Dark Secrets, and Surprises.

Secrets

Aggravated Doc Surg has written several truly enjoyable posts about hospital life behind-the-scenes. Read here about the five people you DON'T meet in the hospital, usually, but should still appreciate, and here and here about how doctors REALLY feel about JCAHO, the folks that go around making surprise visits to hospitals and subsequently determine what should be changed about them and whether they should even stay accredited. I confess to enjoying Doc Surg's satirical and sardonic bent in the latter.

In this post, Dr. Bates at Suture for a Living navigates the sometimes-tricky situation of meeting a patient outside the expected setting.

And speaking of the expected setting, what goes on, exactly, in the O.R.? Katy at her engaging blog Funny Girl once invited folks to go ahead and ask, through her comments section, and graciously, she answered.

She also writes of a recurring anxiety dream that materializes in her sleeping mind once in a while in response to her work as an O.R. nurse. We all know about those recurring dreams. Being late for class, or showing up without your homework, getting lost on a familiar route, or teeth or hair falling out in public, or missing some other crucial necessity at the most inopportune moment. Dr. Bates shares a very interesting dream one of her patients had regarding her upcoming surgery. It doesn't matter which side of the surgical drapery we're on. Those secret concerns come out at night for our brains to play with and puzzle over.

That is, if we care enough to take responsibility for the work. Buckeye Surgeon describes the issues involved in being the kind of surgeon who takes this "You operate, you own it" type of resonsibility for patients. The discussion generated in the comments section is enlightening.

On a lighter note, if you missed my recent post on the yuckiest things I can think of from hospital life, here it is in all its repugnant glory. I pair it here with a post by Oystein Horgmo, our Sterile Eye, about "Inner Scents." Enjoy.

In a well-written post I consider one of the most important in this collection, Dr. Bruce Campbell, ENT surgeon and author of the blog Reflections in a Head Mirror, discusses the perils of losing the capacity for empathy during one's medical training, while in his beautiful and bittersweet post on empathy, Dr. Sid Schwab reflects with both hope and perhaps a hint of sadness, "If empathy can be learned, I'm not sure it can be unlearned."

Deep, Dark Secrets

Photo: Premier secret confié à Vénus by François Jouffroy, photographed by Christophe Moustier

If you haven't visited Respiratory Therapy 101, please do - it's a wonderfully-written window into the world of respiratory therapy and critical care medicine. And while you're there, check out this post about little human touches in the ICU, and what a mixed blessing they can sometimes be, along with the thought-provoking comment from RogueMedic that follows it.

The Sterile Eye gets a pretty intimate view of some patients who often end up in surgical ICU's. He shares his work with us in this post containing sarcoma videos.

If a life in medicine shows us anything it's that there is just so much pain in the world. We could all probably make a list of the worst stories we've ever heard / seen / been involved with, and I even wrote a post once entitled "The Worst Story I've Ever Heard." But there's never only one such story, and certainly not just within the confines of our hospitals, as Bongi painfully recounts.

There's less dramatic, silent suffering too - amorphous, almost like a vapor you can smell but not see. Elusive pains like those fomented by doubt, distrust, suspicion, ill-repute, as Sheepish describes in The Paper Mask.

When bad things, really bad things, happen to good people on both sides of the drape - the caregivers and the patients - there are several ways to respond. Denial. Rage. Hiding or giving in to despair. Or you can do what this outstanding individual did, generously and courageously and with consummate integrity, and try not only to become a better person and physician but also to transform the systems around oneself for the better.

And groups can do the same. Here Paul Levy writes about M&M, morbidity and mortality conference, during which docs discuss adverse events behind closed doors and try to establish ways to prevent future errors or disasters. Far from being a dismaying and dismal post, this narrative leaves us with a sense of hope that we can and will do better.

Surprises

This surprised me: a patient writes, "Interestingly...I owe my blogging hobby to being stented," referring to the placement of a stent into an obstructed ureter. Glad to have a patient's input in SurgeXperiences!

I was also surprised to see some insider info and an entreaty from a Beverly Hills plastic surgery blog about how the stars should just quit trying to make their lips bigger!

The Repository for Bottled Monsters highlights the "clearest pictures ever taken" of human ovulation as it is occurring.

Next, some stories that I found both refreshing and refreshingly well-written. Quietus Leo describes how one of his patients finally came to give herself a much-needed rest, even from the preparations for the highest holy day she traditionally honored. Sid Schwab writes about fainting. TBTAM who writes The Blog that Ate Manhattan relates a lesson from Italy about caring for aging parents.

A Little Summer Reading

I'd like to close the carnival with some posts to keep us thinking for the summer. Dr. Bates at Suture for a Living gives us useful information about dog bite prevention here. For practicalities involving medical practice, visit Ian Furst's writings about a simulation regarding wait times, and Sid Schwab's (and many other doctors') concerns about appropriate reimbursement. Dr. Schwab also offers a sampler of great posts from his blog for our ongoing perusal as we look forward to the season premiere of SurgeXperiences Season 2, to be hosted by our very own carnival founder, Monash Medical Student Jeffrey Leow.

To be continued...

Excursions in Medical History: Cataract Surgery

Warning: this post may contain some graphic images and descriptions. Viewer discretion advised.

I'm going to try producing a new series here this summer: Excursions in Medical History - an occasional, brief stroll through the annals of our collective clinical past. A kind of "History of Medicine 101."

Photo: Dr. Rizal Treating His Own Mother, Romeo Enriquez, 1960. Courtesy of the National Historical Institute, Manila, the Philippines. Adapted from JAMA.

Because I've had the luxury of being "in eyes" - that is, providing sedation for cataract surgery - not once but twice this week, I started thinking a lot about cataract surgery. What's a cataract? It's a clouding of the crystalline lens in the eye, so named because in antiquity physicians conceived of the clouding material as something that cascaded into the eye.

Some people who haven't undergone the procedure get a little alarmed when I inform them that they'll be awake for the entire surgery, and I don't blame them - who wants to sit there under a giant drape while a masked figure in blue scrubs pokes into your eyeball with a sharp object?

(Taken, with permission from the patient, off a video monitor of cataract surgery at one of the hospitals I serve.)

But the truth is, I have never seen any patient experience pain or distress during cataract surgery. The ophthalmologist numbs the eye completely, with drops of local anesthetic and perhaps a regional block (retrobulbar or subtenons). The anesthetist may give a little sedation through the I.V. And that's really all you need! The incision is tiny - two or three millimeters, tops. The surgeon might occasionally ask the patient to look in a certain direction, or tilt the chin a certain way, the patient says, "Ok," and the surgery progresses - the clouded lens is removed and replaced with a new lens.

Not so back in the day, oh, maybe 2500 years ago. As the American Academy of Ophthalmology recounts, the earliest form of cataract surgery was couching, a procedure described in 5th century B.C. Sanskrit manuscripts. This involved displacing the lens away from the pupil and into the vitreous cavity. Centuries later discission, or needling to break up the cataract into pieces, was practiced. In the mid-1700's Jacques Daviel of France and Samuel Sharp of London began surgically removing the lenses from their patients with "the services of a strong assistant...to hold the patient's head still." Local anesthetic drops would not ease the pain and terror of the procedure until 1884.

Which brings me to José Rizal, my country's national hero, whom I've mentioned briefly before and whose birth anniversary was just yesterday. Rizal was a real Renaissance man - poet, novelist, polyglot, political activist, physician (click here for a wonderful article from the Archives of Ophthalmology by Tracy B. Ravin, M.D. on Rizal's medical training). He studied ophthalmic surgery in Madrid, Paris, and Heidelberg, then brought his skills and other talents back to the Philippines, where he practiced from 1888-1896. People would sometimes travel for miles, through heat and dust and mosquitoes, to receive treatment from him.

After his execution by firing squad for "rebellion" against Spain, Rudolf Virchow (of "Virchow's triad," the first triad I ever learned in medical school) gave a speech in his memory at the annual general meeting of the Berlin Society for Anthropology, Ethnology and Pre-history. Another statement by Virchow seems a fitting reminder of what Rizal's life represented: "Medicine is a social science, and politics is nothing more than medicine on a larger scale." Rizal embodied the old adage about the pen being mightier than the sword and used his gifts as a physician-writer - a good eye and an intelligent use of language - to try to bring about social change, political action, respect for human rights, and freedom for all in his homeland. I am reminded of one last quote, from The Word as Scalpel by Samuel William Bloom: “If words, the main substance of human relations, are so potent for harm, how equally powerful can they be to help if used with disciplined knowledge and understanding? And where more certainly does this simple truth apply than in the making of a physician?”

The Ad Hoc Anatomist

This will only be amusing to medical people, I suspect, but I had to document it here because it totally made my day.

This weekend a friend and I will be hosting a wedding shower. The bride will be starting medical school this fall, so I devised a (tamer) version of the traditional "Pin the Member on the Male" game: Pin the Anatomical Label on Michelangelo's David. Or maybe we'll make it a matching game of some sort.

Anyway, the labels I made were

1. Acromion
2. Anatomical snuffbox
3. Bundle of His
4. Corpus Cavernosum
5. Foramen of Luschka
6. Inguinal canal
7. Lumbricals
8. Pterygoid hamulus
9. Lateral meniscus
10. Ligament of Treitz
11. Sartorius
12. Soleus.

I asked The Hunk to do a "dry run" and apply the labels to my David xerox, to see if the names were too recognizable to the medically uninitiated. Here's the result (by permission):




So now the inguinal canal is somewhere in the head. And ya gotta love the soleus at the solar plexus, and the Ligament of Treitz where a knee ligament might be. But for me what tops the whole list, hands down (so to speak), is where he put that bundle of his...

:)

Whose Gifts Will We Accept?

"Am I gifted?" asked my seven-year-old son tonight, looking up from his bedtime reading.

I looked at his adorable little face, totally innocent, asking an honest question with the tone of one who really is simply wondering what the term could mean.

I wanted to exclaim, "You're TOTALLY gifted - are you kidding?!"

But I restrained myself a bit. "Your father and I certainly think so. Why do you ask?"

He pointed to the inside flap of the book he had just started reading. The Mysterious Benedict Society by Trenton Lee Stewart. "Because it says here on the jacket, 'Are you a gifted child looking for special opportunities?' "

I tried to offer, again, a more measured reply. "I definitely think you fit the bill."

Actually, you're a little genius! A brilliant, talented, beautiful, loving, gifted little boy who's already changed the world, just by being present in it! And even if we were the only ones who could see this in you, by golly, it would still be fundamentally TRUE! Isn't that GREAT?!

I added, "I think all children are gifted in some way."

He nodded. But I think he could sense my undercurrent of adoration.

***

Several years ago I heard a radio ad advertising a summer program for "gifted" or "exceptional" high school students at some Ivy League college. It extolled the virtues of such a student: intelligence, motivation, leadership, etc. And all I could think was, what if someone doesn't WANT to be a "leader?" What if someone with a lot to offer the world wants to offer it in some other way - by working hard behind the scenes, or in a group, or by listening and generating positive change in quiet, "ordinary" ways? Isn't such a person as much of a gift to society as a more visible figure? Why are we so utterly clueless about understanding an individual's worth?

I've always wondered - having seen a "prestigious" educational system from the inside - how, for instance, an institution dedicated to TEACHING can view as "worthy" only the most obvious talents and stars, when teaching in principle should be about bringing learning opportunities and stimuli to those that need or hunger for them, regardless of their advantages or disadvantages. I like Jesus' attitude to an analogous process, and his response to the intellectuals and elitists that criticized him for it: "I have not come to call the righteous to repentance, but sinners - and they may even enter the kingdom of heaven before you."

I have done a lot of thinking about this because while I can be a capable leader when necessary - for example when I need to take charge of a clinical situation at work, and use my help and resources efficiently - I much prefer being a helpful cog in the machinery. In this society, which exalts the "assertive" type, my quieter leanings have in the past been viewed disfavorably in certain settings. I think it's one of our culture's biggest mistakes: to dismiss, fail to acknowledge, or totally miss out on the gifts people have to offer simply because their personalities or personal inclinations don't project an image of stardom.

If I had started my music career playing a group instrument instead of a solo instrument, I think I would never have left music for a time the way I did. I MUCH prefer being second oboe to first. I LOVE being alto instead of melody in choir. So when I found this quote by Leonard Bernstein, I was thrilled: "I can get plenty of first violinists, but to find someone who can play the second fiddle with enthusiasm—that’s a problem. And if we have no second fiddle, we have no harmony.”

We have no harmony. Maybe people should consider listening a little more closely to those "second" voices...the non-soloists that give the music its rich layers of sound and meaning.

yes I said yes I will Yes

Happy Bloomsday! (Click here for an engaging post on the subject.)

Last February The Hunk and I celebrated 12 years of legal marriage. This month we celebrate 12 years of sacramental marriage. We like this two-anniversaries-per-year thing.

So because love is in the air on Bloomsday, I thought I'd treat myself to a re-read of one of my favorite love poems ever, a sonnet by Irish poet Micheal O'Siadhail (MEE-haul o-SHEAL, or o-SHAY - I've heard it pronounced both ways and don't know which is correct).

I first heard his work during a C.S. Lewis Foundation workshop at Cambridge University in 1994. He totally ROCKS. To hear a podcast of an interview with O'Siadhail, click here.

while you are talking

While you are talking, though I seem all ears,
forgive me if you notice a stray see-through
look; on tiptoe behind the eyes' frontiers
I am spying, wondering at this mobile you.
Sometimes nurturer, praise-giver to the male,
caresser of failures, mother earth, breakwater
to my vessel, suddenly you'll appear frail -
in my arms I'll cradle you like a daughter.
Now soul-pilot and I confess redemptress,
turner of new leaves, reshaper of a history;
then the spirit turns flesh - playful temptress
I untie again ribbons of your mystery.
You shift and travel as only a lover can;
one woman and all things to this one man.

- Micheal O'Siadhail

*Sigh.* I am a hopeless romantic.

***

Every anniversary I try to reflect on why our marriage has lasted so far. We share few interests. We have little in common academically or culturally. But we seem to work because of a few big things and a whole lot of little things, among them (and not necessarily in any order)...

HARD WORK and GENEROSITY

-letting each other's lives and hopes matter to us; interest in how each other's day went even if it involves things that don't in and of themselves interest us

-frequently (read, constantly) expressed affection
-consistently expressing delight when we see each other after an absence - like, at the end of the work day

-basic courtesy: still being polite when we miss each other's calls, courteous when we ask each other to run errands, and sympathetic when the other has a bad day
-at least one compliment each day, both ways
-knowing that if we can't do for ourselves, the other will help us, with compassion (like, I want to be sure my daughter asks herself of a potential life partner: Will he help you on and off the commode if you break a leg or a hip, or help you shower if you injure an elbow or a shoulder? Will he keep to you if you're injured, mutilated, paralyzed, burned? Click here for a well-written, sobering post from RT101 which asks the question, how far do you take "for better and for worse?")

KINDNESS and PATIENCE

-tolerance of imperfection (which he has needed in spades)
-loving admonition of each other's faults and trust in the other's continued respect when on the receiving end of those admonitions

TEACHING, LEARNING, & MUTUAL ENJOYMENT

-shared values/faith

-shared laughter

-ability to be happy/content when alone / independent (though admittedly happier when the other is present)

-security, and in fact happiness, in the face of the other's successes

-capacity for stimulating intellectual discourse or downright silliness, depending on the moment

-still flirting years later

Thank you, sweetheart...

Father's Day Thoughts from Behind the Blue Drape

As an anesthesiologist I am privileged to witness some things that few people, except in the most intimate of times, have the opportunity to see.

One of those things is a father's tears.

When do men stop crying, or feeling natural about crying openly? I've been trying to figure that out as I watch my little son grow not-so-little any more. As a baby he cried when hungry or uncomfortable. As a toddler he cried when he lost something or broke a toy or couldn't find one of us. Now, as a young child, he cries when frustrated or disappointed or afraid or hurt. He also cried when Mimi died at the end of La Bohème. Much like his older sister. No gender difference at all, yet.

But at some point men learn to suppress the tears. Are the feelings underlying those tears blunted too? Perhaps sometimes, but I would bet not. Does this transformation - would some call it maturation? - happen some time in puberty or adolescence, when it's "cool" to be all grown up, in control, unruffled by trouble, when strength and control are understood as prerequisites for manhood?

The most genuine men I know, and the most admirable, are those who have the courage to share their feelings, even their tears.

I recently brought an autistic boy and his father into the operating room for tonsillectomy. I always warn parents ahead of time that as the anesthetic takes effect, they might see some abnormal-looking movements, rolling of the eyes, and finally the body going totally limp, all of which can be disconcerting if unexpected. When I talk to the kids, I bring my face, often my whole body, down to where we can be eye-level with each other, and I sometimes let them and their parents hold the face mask ahead of time, explaining to the kids that it's a magic mask that can make them feel sleepy.

This particular boy and his father did beautifully, and the induction of anesthesia was smooth. As the boy went limp I had the nurses help me take him off his father's lap and lay him gently on the operating table. I positioned myself with my left hand on the oxygen mask and my right on the ventilator bag and invited the dad to kiss his son's left cheek while I turned his head. The father bent down and kissed his boy, and as he stood up to go, tears welled up in his eyes and started flowing down his cheeks. I thanked him for helping us and promised I would be right by his son's side.

When I was at Children's I was asked to take care of a young girl from a different country, one for which I had a preconceived notion in my head. My prejudiced expectations were that men from this particular country would value female children less than male children and would not be outwardly expressive of their affections with their relatives, male or female. I had a stereotype of misogyny and reduced emotional expression stuck in my mind.

I met with the girl's family to explain the anesthetic and her expected post-op course. Her parents listened quietly, nodding once in a while. I reassured them that we would take good care of the girl, who was about ten or eleven. As I turned to leave, her father started to cry.

"She will be in good hands," I said to him.

He nodded, unable to speak, his face crumpled with grief, as the tears streamed down his face.

"Thank you, Doctor," his wife whispered, also appearing distraught, on the verge of tears.

Bless these fathers, and all loving fathers who through their tears make such a difference and change the world.

***

I'm starting a list of memorable fathers in literature. Here's what I have so far:

Atticus Finch in Harper Lee's To Kill a Mockingbird (of course!).

Reb Saunders in Chaim Potok's The Chosen.

The father whose child is a patient in Mark Helprin's short story Elisha Hospital.

The Chinese father in Mark Salzman's memoir Iron and Silk whose love for his daughters has to be expressed in stolen moments.

King Lear.

The Man in Cormac McCarthy's The Road. (Suggested by Kathleen on the comment board.)

Hector in the Iliad.

Paraskevidekatriaphobia

Okay, I almost have to be a believer now.

Friday the 13th is BAD luck!

Either that, or my former "white cloud" for call nights has turned into a decidedly black one (in medicine we often describe people who always have quiet calls as having a white cloud and those who are constantly hammered on call as having a black cloud).

Actually, I haven't believed in "good luck" or "bad luck" since childhood; I believe we create our own "luck." But this was not only another one of those up-all-night calls but also a call during which there seemed to be more equipment mishaps, paperwork losses, and communication flubs than usual!

My colleague Maddog (moniker his choice) once had a memorable Friday the 13th case: a midnight penile fracture in a 280-pound patient incarcerated for some scary crime or other. Maddog was calling him "Hannibal Lecter" and said anyone near him would have felt like potential snack food. [Photo credit: Geneva Foundation for Medical Education and Research.] It just went downhill from there for Maddog. [Click here for a urologist's tidbit about penile fracture.]

During the day today I was in the O.R. off and on for about 12 hours.

Then there was a call from the E.R. doc who called to ask if I could stand by and assist while he tried to intubate a near-300-pound patient with a suspected medication reaction. The patient was so large she appeared to take up the entire exam room. Already this sets off alarm bells in an anesthesiologist's mind: obesity triggers concerns about difficult airway management, difficult IV access, difficult spinals and epidurals, and potentially difficult managemet of various medical problems. When we anesthetized the patient and placed her supine on the stretcher the middle of her belly was a spherical mound that practically obscured my view of the nurse on the other side of the stretcher. When I saw how much soft tissue there was around the neck I began to dread hearing the E.R. doc say he couldn't see the vocal cords, but he did a nice job with the intubation. Whew! [Some descriptive elements of this case have been altered. This photo and the next are from http://commons.wikimedia.org]

Then there was the mother whose premature fetus was presenting a nerve-wracking fetal heart tracing. We watched over her for hours, prepared to do a crash C-section but dreading the delivery of a premature infant at a hospital with neither a neonatologist nor a neonatal ICU. Fortunately she stabilized enough to be transported to the closest tertiary care center.

Then there was the last epidural I placed. Usually I can place epidurals reasonably quickly. That last epidural, though, was CURSED. The procedure itself wasn't the problem; the problem was unforeseeable, uncontrollable equipment issues. The first epidural catheter I passed developed a kink that prevented me from injecting medication through it. The second one hit a blood vessel and was thereby rendered un-usable as well. I went through three catheters before breaking this streak of misfortune. This is almost UNHEARD-of.

Then I was up till 3:30 in the morning doing ob/gyn cases - for a patient who had had a miscarriage, and another woman whose labor had stalled and needed her child delivered by caesarian. I went to bed at 4 a.m. thinking, thank the Lord, I can get at last get a little sleep before I switch to being on call for the other hospital...but at 4:30 the beeper jolted me out of a just-acquired, much-desired sleep with the most annoying page in recent memory.

Nurse: Hello? Is this Dr. Z?

Me: No, it's Dr. T from anesthesia.

Nurse: Oh...um...I'm just calling because Dr. G from your department changed an epidural order to a rate of 10 mls per hour.

Me: Ok.

Nurse: I just wasn't sure if that meant the infusion rate or what.

Me (crazed with sleeplessness): I would assume so - it does say "rate," right?

Nurse: Um...right. Actually the problem is the order was written at 3 p.m. but the nurse from the afternoon shift never picked it up.

Me (confused): Ok. And?

Nurse: Well, the nursing supervisor told me to call Dr. Z.

Me: I thought the order was written by Dr. G?

Nurse: It was, but she said to call Dr. Z.

Me: Dr. Z's not here. She's not on call. What does the nursing supervisor want, exactly?

Nurse: Well, we have a policy that any time there's a medication error, the doctor has to be notified.

Me: I look again at the clock. Quarter to five. So, the order was written during the previous shift?

Nurse: The 3 to 11. I'm on the 11 to 7.

Me: That's almost over.

Nurse: Well, it took us a while just to figure out what happened. When we finally sorted it all out my supervisor said to call you.

Me: Why? I'm sorry. I know I'm sounding a little frustrated. Please don't take it personally. It's just that I've been up since 6 o'clock yesterday morning, and I'm not fully understanding the situation. I'm just trying to understand what you need from me.

Nurse: According to the rules we have to make sure the doctor is aware of all medication errors.

Me: I see - "M.D. aware." So, a NURSING error was made - one of the nurses failed to carry out a written order - and now thirteen hours after the order was written, which means the NEXT DAY, you're calling a doctor who has never seen the patient, heard of the case, or been involved with any of the orders? I'm still a little unclear as to what exactly you want me to do.

Nurse: Well...Do we still carry the order out now?

Me: Is the patient in pain?

Nurse: Yes.

Me: Then I don't see any reason why Dr. G's written order shouldn't be carried out, as written, the way it should have been YESTERDAY.

Nurse: Um...Can I write a note that I talked to you about it?

Me: Close eyes. Count to three. You could certainly document it this way: Attending physician aware of egregious nursing error made by day shift nurse and recommends now following-through with the order.

Nurse: Actually, Dr. Surgeon is the attending.

Me: Four. Five. Six. Well, you could word it like this: attending ANESTHESIOLOGIST aware of blatant negligence of day shift nurse and approves of following other attending anesthesiologist's orders. Has Dr. Surgeon, the attending surgeon, been notified that HIS patient hasn't been given her pain medicine?

Nurse: Um, yes, he's aware. I told him when we had to notify him that the post-op antibiotics he ordered weren't given either. But he's not in charge of the epidural orders. I'm supposed to notify the doctor in charge of the epidural orders.

Me: Taking a deep breath. Trying not to burst into tears with exhaustion and frustration. Would it make it easier for you if I came to re-write the entire order set from scratch? Maybe I'll just do that, since I've given up all hope of ever going to sleep tonight.

Nurse: Oh, that would be great. Thanks! Sorry, we just have to follow the policy.

I restrained myself from muttering, Oh, of course - God forbid there should actually be any THOUGHT going on.

Once again, I am unable to maintain complete outward sweetness when totally exhausted and suffering from a pounding headache. *Sigh.*

To her credit, the night nurse didn't take my crabby mood personally after I apologized if I was coming across as a little curt or frustrated. Actually, we even shared a good laugh over the absurdity of the whole situation, and she gave me some Tylenol for my head.

Tales from Saint Boonie's: Gross, and I mean GROSS, Anatomy

I apologize in advance for this post.

If you are faint-of-heart when it comes to disgusting stuff, please bail now. Do NOT keep reading.

But if you don't mind a glimpse into a few little nitty-gritty secrets of life "behind the scenes," or at least behind the drapery - the non-glamorous side of medicine that most people don't get to know or hear about - welcome back to St. Boonie's.

Why do I have to write about this? Because I almost threw up in the O.R. today - I mean a real, honest-to-goodness near-HURL event. And over something that wasn't even that bad. I am going soft at St. Boonie's.

Like the average health care worker, talking about physiological processes or anatomical features over the lunch table doesn't bother me much. I have to admit, though, that I've never been the truly steely, never-ever-grossed-out, could-eat-lunch-next-to-a-bowl-of-innards type. I do find some aspects of my job...a little unpleasant.

Blood I can do. Organs I can do. But certain other things, I absolutely cannot deal with without that insect-like tickle in my throat that portends some projectile stomach contents. Most sights fail to shock me. But sights coupled with certain sounds - the rupture of a pus-filled abscess, or the crack and crunch of a joint - or even worse, certain SMELLS - the cheesy stink of a pus-filled abscess, or any hint of the feculent or fecal - push me right up against my ghastly limit.

Without further ado, the Top Ten List for the month of June: Top Ten Grossest Things I Wish I Had Never Heard About, Seen, or Smelled in the O.R. and its Environs.

Runners-up:

-Feculent matter in an orogastric tube. Anesthesiologists often insert tubes into the esophagus to help empty the stomach of its contents. In one patient having urgent bowel surgery this action produced five liters - that's twenty cups - of pre-poop poopy stuff pouring out through the tube and into the suction canisters. I couldn't help letting a verbal "Eew! Eew!" slip out now and again as the stuff was coming out. The surgeon was amused, good-naturedly enjoying my lack of enjoyment a little too much...

-Mucus wads

-Gangrenous toes

-Desquamating skin.

These aren't super-pleasant but after several hundred exposures you kinda get used to them...

10. Vaginal delivery. There, I've said it. I know I'm supposed to LOVE childbirth. I respect the process. I love children. I think motherhood is sacred. Babies are totally precious. But vaginas...Let's just say I was not meant to go into ob/gyn. I consider myself a supporter of women, women's rights, and women's dignity, and I find the idea of bringing a new human being into the world from one's own body glorious, but the actual event is...kinda messy and yucky and stressful. Vaginas all stretched and torn and bloody from pushing a seven-pound human being out make me wish I hadn't gotten out of bed in the morning. I could do my very own little vagina monologue about it (and actually did once, much to the amusement of the labor and delivery nurses and docs, who obviously aren't bothered by them at all), but I'd be wincing the whole time. It's my deep, dark secret. I find birth amazing and wondrous but at the same time, truly at the same time, a little dreadful.

9. Foreign body trapped in rectum. According to one of St. Boonie's most senior surgeons, these show up a LOT in St. Boonie's emergency room. I've only had to provide anesthesia for surgical removal of one once since I started working there, and that was enough lost innocence for me. Call me sheltered...

8. Nasal polyps. I've never enjoyed observing surgery that occurs above the level of the shoulder. ENT surgery often gives me the heebie-jeebies. But a half-cup of polyp removed from one nostril and a third of a cup from the other nostril of a person suffering with these polyps for a decade because her primary care physician didn't think they were a big deal, despite the fact that they had totally distorted her nasal anatomy and she had to breathe through her mouth for years? That's just unreal.

7. The Bezoar. A couple of thankgsivings ago CNN and The New England Journal of Medicine made the "hairball case" news with the headline "Doctors untangle the strange case of the giant hairball." Please don't eat your own hair, or someone else's. Please. It's not pretty. It's...well...sh___...oh, never mind.

6. Belly button escargot. This is is what got to me today. When someone comes to the hospital for abdominal surgery, once the anesthesia's on board, the circulating nurse cleans the abdomen with a surgical prep solution. Part of this cleaning procedure involves inserting a long cotton swab into the navel to remove whatever detritus resides therein. Today the nurse removed a two-centimeter clump of curled-up I-don't-know-what from the patient's belly button, and I almost lost it. Here's a tip (no pun intended): before you have surgery, please, please, for the love of all that is good, do a little navel care when you shower...

5. Bug crawling toward the light...out of a patient's ear. When I was doing pediatrics my biggest dread was to shine the light of an otoscope into a kid's ear, look into the lens that magnifies everything in there so it looks gi-normous, and see a scary, multi-legged, wing-flapping BUG trying to beat its way out of there...or succeeding! With a tremendous sense of gratitude I can say that the worst unexpected thing I ever found in a child's ear canal was a small, pink, Barbie stiletto.

4. Chunks of body dander on the sheet after a patient moves to the operating table. A lot of disease processes cause poor integumentary health. The results can be very visible, with mini-clumps of total-body dandruff of different colors and textures dotting the bed linens when a patient is moved off them. It's not the patient's fault, of course, but I do get very queasy when I catch a glimpse...

3. Poor hygiene in a ~300-lb person (in anyone, really, but morbid obesity really makes it worse...). Sometimes, and it's not always the patient's fault, the intertriginous areas get very difficult to clean, and people unfortunately get a whiff of poop-stink that smells like it's been sitting in a tight space for a week...or greasy-hair smell...and again, you're left with that awful pre-vomit tickle at the back of the throat...the attempt to smile and talk despite the fact that you're trying to hold your breath...the distraction of wondering what all that black stuff under the person's fingernails is... or why the alcohol swab turns from white to dark BROWN when you prep an area of skin for an I.V....

2. Fecal impaction. This is the reason I abhor the use of the word "impact" as a verb. It reminds me of the time one of the ob/gyn docs had to take a gloved hand and scoop, I mean scoop, gobs of poop out of someone's bottom before he could begin an acetic acid procedure to assess the woman's cervix...

1. Pus. Even the word grosses me out. One of our surgeons once drained a cup of pus from a lanced rectal abscess. It came out in cheesy green and white globs while tendrils of odor wound their way through the room as if searching for people's nostrils and the backs of their throats. The worst pus specimen I've encountered, though, was an excised empyema, or lung abscess. It was the smell of death itself - a piece of carcass made of blackened infected tissue decomposing in that unfortunate patient's lung. I seriously think I turned green and almost passed out.

Sorry, everybody. Please forgive me. I had to get that off my chest. So to speak.

_____________________________________________________
Update, August 15, 2008: Please check out Dr. Bates' posts on maggot therapy. Eeeeeeeeeeeeeeeew! (Yet, strangely fascinating...)

It's That Time Again!

Tonight I was honored once again to be invited to host the SurgExperiences blog carnival for its final edition of the season, SurgExperiences 124, to be posted on June 22. I am considering the theme "Secrets and Surprises," but the last time I thought I might have a theme, the collected works morphed into something else - so again, the "theme" isn't written in stone!

SurgeXperiences is open to all (surgeons / nurses / anesthetists / RTs / first assists / patients / hospitalists / fascinated observers / med students / friends, relatives, and spouses of aforementioned, etc.) who have a surgical/anesthesia/critical care blog post or article to submit.

The deadline for submissions will be midnight on June 20th. Please submit your posts here or email me directly at anesthesioboist@gmail.com with a link to your post.

SurgeXperiences 123 is up at Quietus Leo's blog, The Sandman. Click here for a catalog of past surgXperiences editions. If you'd like to host a future edition, please contact Jeffrey Leow.

See you at the carnival!

Keeping the Faith

Espresso depresses me.

I mean that quite literally.

I don't mean it simply makes me jittery, the way an ordinary cup of coffee might (actually, it would take two or three). I mean I am one of those people whose adenosine receptor subtype (1976T/T, I believe) causes an intense anxiety response to high doses of caffeine, with a concomitant anxiety-induced (transient) depression.

I've never had a panic attack or anything, but I've found the aftermath of a strong cup of coffee extremely uncomfortable. The other day I had an espresso-based drink and hours later found myself tossing and turning in bed with dark thoughts, irrational fears of doom, and visions of worst-case scenarios churning about in my head. This has happened before with espresso, but thank goodness not with regular coffee.

How do I deal with such dark moments, whether drug-induced or "real?"

I take a lot of deep breaths, then I try to reflect on the figurative "center" that holds me together. I turn to faith.

Let me define what I mean by "faith," since it can be so easily interpreted to mean "religion," which is not what I'm referring to right now. I believe every person has faith. Tell me you're an atheist, and I'll say you still have faith. I define faith not as a set of beliefs to which one adheres but rather as a way of seeing the world and living one's life.

When I turn to what I call my "faith," instead of trying to find answers, I return again and again to questions which have a way of restoring focus, insight, mindfulness, and peace. My favorite set of questions comes from James Fowler. In his book Stages of Faith: The Psychology of Human Development and the Quest for Meaning, Fowler presents the following questions he used in a workshop he was leading in Asheville, North Carolina:

What are you spending and being spent for?

What commands and receives your best time, your best energy?

What causes, dreams, goals, or institutions are you pouring out your life for?

As you live your life, what power or powers do you fear or dread?

What power or powers do you rely on and trust?

To what or whom are you committed in life and in death?

With whom or what group do you share your most sacred private hopes for your life and for the lives of those you love?

What are those most sacred hopes, those most compelling goals and purposes in your life?

Fowler wrote, "No easy set of questions. No simple game of value clarification. I congratulated myself on my cleverness in coming up with such a probing workshop opener. Then it hit me. How would I answer my own questions? My sense of cleverness passed as I embraced the impact of the questions. I had to pull my car over to the shoulder of the road and stop and for the next forty minutes (almost making myself late for the workshop) I examined the structure of my values, the pattern of my love and actions, the shape of fear and dread, and the directions of hope and friendship in my own life."

As I reflect on questions like Fowler's, I step back into a quiet spiritual space that allows me to examine the path I'm taking, my place in my own world, and see if I can be at peace with it. If I find that peace, I've also found freedom, because fear loses the place I've momentarily granted it in my life. At least, until the next time I stray off the path...!

Photo credit: Latte art by JMPerez, via Wikimedia Commons ShareAlike license.