Losing Patients

One of my friends lost a patient some time ago. It happened during the induction of anesthesia. Just as aviation disasters often happen during take-off or landing, operating room codes or emergencies often take place as anesthesia is being administered or terminated. His patient was terribly, terribly ill, chronically with diabetes, heart disease, kidney disease, and vascular disease, and acutely with other things. She had been through many operations already. He prepared the anesthetic with meticulous care, spoke to the patient's family about the risks, but despite all his efforts, his patient was too weak to tolerate this one last anesthetic. He labored for over an hour to resuscitate her, to no avail. It was the kind of case every anesthesiologist hopes never to have to face.

Unfortunately, it's also the kind of situation that comes to every anesthesiologist's table sooner or later, regardless of his or her skill and experience. My anesthesiologist friend asked me a very thought-provoking question after he told me about his experience. He asked, "Are you willing to continue in a career knowing that this will happen to you someday, if it hasn't already, and you're going to have to deal with it and live with it and not give in to grief and self-doubt afterward? Do you love this work and believe in yourself enough to keep going? Because if you don't, you need to get out now while you can."

These were sobering reflections. If I left my work as an anesthesiologist now, what would I do? Where would I go?

I can only imagine what he went through. The indelible image of his patient's face seared into his mind. The questions he asked himself.

• Did I do everything I knew how to do to care for this person?


• Was there something I missed, something I should have changed?


• What will happen now? Will the family blame me for the consequences of their loved one's frailty? Will I lose everything I worked for even though I did the best I could?


• If the hospital or the family wants me punished, how much punishment will be enough, since no punishment could possibly bring their loved one back?


• If someone else had been taking care of her, would things have been different?


• Even if I am a good physician, will this forever color people's ability to recognize that and their willingness to hear my opinions and advice?
• Whom can I talk to who would actually understand?


• Even if losing this patient wasn't my fault, will this churning of thoughts ever heal, this ache ever go away?

Doctors grieve. Doctors shed tears, seen and unseen, over patients, for many different reasons - at least, the ones who care do. I know this to be true. Seen it. Done it. But doctors also can't be debilitated by grief or doubt or regret for too long. Other lives hang in the balance. The question is, how do doctors heal?

___________________________________________________

Addendum 1/27/09:

Just read another brilliant post by Bongi of other things amanzi on the subject of post-traumatic stress in doctors who face the loss of a patient and had to reproduce its well-wrought final sentence here: "When we fall off the horse, most of the time before we can even shake the dust out of our hair, we are shoved back on and the horse is given a hard thwack on the rump." So true.

Happy Birthday, Little Sage

My son is 8 years old today!

To my great delight, what he wanted this year for his birthday was a stash of great BOOKS to read. Today he'll receive

Stoneheart by Charlie Fletcher - wherein a 12-year-old boy named George goes to the National History Museum in London and gets much more than he bargained for, like gargoyles and other statues coming to life, chases through the streets of an alternate London universe, a battle of good against evil...

The Battle of the Labyrinth by Rick Riordan - book four in the engaging Olympians series (he raced through books 1-3 about as fast as he got through all 7 Harry Potter books...)

Cornelia Funke's Ghosthunters series

Warriors by James Harpur, to feed his fascination for ancient civilizations.

The Last Dragon by Silvana de Mari, a classic "little underdog makes big" story.

Robots by Clive Gifford

The Mysterious Universe: Supernovae, Dark Energy, and Black Holes by Ellen Jackson.

and A Child's Introduction to the Night Sky by Michael Gifford, which is beautifully put together.

He'll spend the day at the beach with his cousin, then we'll go out to his favorite Chinese restaurant to enjoy scallion pancakes "that taste like actual pancakes," as he describes. Then perhaps we can play with his new Spongebob Legos or paper airplane kit and light up his new "Moon-for-my-room" at bedtime...

Ah, childhood.

***

I have been under some stress lately and have not blogged as much as I've wanted to, but I want to thank everyone who's been so supportive of all my endeavors. Special thanks to Ramona Bates, author of Suture for a Living, who passed along an "Arte y Pico" blog award to me today.

The rules of the award are as follows:

1.You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
5. To show these rules.

I hereby designate the following 5 blogs (in no particular order) as Arte y pico winners:

1. Orange Crate Art by Michael Leddy, because he helps people pay attention to language, and history, and literature, and NOTEBOOKS!

2. Eggbeater by Shuna Fish Lydon, because she is such a consummate artist whether she's holding a spatula, a camera, a pen/computer, or a good friend's hand.

3. POM by Dominican oboist Hilda Ramirez, for being an extraordinary musician, mother, writer, and now physician-to-be, and for being my own inspiration for starting a blog at all.

4. Anali's First Amendment, for the thoughtful way in which she sees - and helps readers see - the world and its little details.

and

5. Caroline's Crayons, for its refreshing artistry and ability to make anyone who visits feel like smiling, at least for a moment.

Thanks for the difference you make!

Sweetie, Please Don't Go to Med School

It happens so fast. Yesterday she was happily hurling projectile poop at us as we changed her diaper. Today she's dealing with her first acne break-out. Yesterday he was literally a bouncing baby boy, using our laps as a trampoline while we held him under his arms. Today he's teaching us about solar flares and planetary orbits.

We have dreams for them. We dream that she'll be able to write and sing and act to her heart's content but not fall prey to the seamier side of theater life. We dream that he'll keep reading voraciously, participating in sports, and finding wonder in science in a way that gives him love of his work and confidence in himself. We dream they'll enjoy the work of their hands and/or minds and be pleased with the outcome. We dream they'll find love, the love of people who will know them truly well and appreciate how special they both are, and cherish them, and support them.

But there's something I do not dream for them, which the blog MothersInMedicine reminded me of today. I don't want them to become doctors. That is, unless it's really, really, really their hearts' deepest desire and they'll die of grief unless they do it.

In the post "Mothers, Don't Let Your Daughters Be Doctors," Fizzy captured my thoughts exactly from the time my own daughter was younger:

People ask me if I plan to encourage my daughter to become a doctor. At this point, I'd settle for her not coloring all over the walls, but my specific answer to that question is, "Absolutely not."

In fact, not only will I not encourage her to become a doctor, but I will actively discourage her from entering a life in medicine. I will tell her every awful story I can think of about the abuse med students, residents, and (I can only presume) attendings are put through.

Not all doctors feel this way. But many do, because they want their children to be appreciated rather than insulted, and to have a life. "But Mommy," my kids might say, "You have a life." Well, yes, I have a life now. I spend time with them now. But I missed out on so much that was precious before, and I still can't be with them as much as I'd like, during these, their too-transient childhood years. Today she has a break-out. Tomorrow she'll be in her college senior play. And the day after that she'll be on her honeymoon. I suppose for every woman who makes the choice to work outside the home as well as within it, this is the problem. We knew this going into that choice. We made the choice with our eyes open, knowing the consequences. That doesn't mean we have to like everything that we have to accept about this path.

I can only hope that despite my training and my job, they didn't feel neglected. I hope they felt I was there for them anyway. I hope they feel some of what this child-of-a-doctor wrote - that time spent with her parent was memorable and precious, and that some missed award ceremonies and school plays were forgive-able. I hope. I hope they know I wanted to be there, tried to be there, for everything, and that they were always, always present, front and center, in my mind and heart.

Do I regret choosing this career? No.

Do I like my work? Yes.

Would I be sad to have to change my work? Well, it depends on the alternative! I do feel there's a spiritual element to my reasons for having chosen medicine, so I wouldn't leave that decision lightly...

Would I do it all again? Hmm...probably not. I don't know that the exhaustion, emotional abuse, sleep deprivation, and indentured servitude would be worth repeating...for any reason...

But would I have changed the life I've lived so far in any major way? No. I treasure the life I've had and the family we've grown to be, together.

I just hope my children choose something else.

(Photos: One of my cuties feeding the alpacas at our friends' farm; and, me and the cuties enjoying the top of the Oak Ridge Trail on the grounds of Castle in the Clouds.)

Incident at the Ferry

We were standing on the dock on a glorious day - temperature in the upper 70's, sunny and clear, with a cool breeze over the water. The boat had just pulled in to receive passengers for a leisurely cruise across the lake. Families like ours stood with tickets in hand, looking forward to a beautiful afternoon. Restless with anticipation, children scampered in and out of the gift shop, stared longingly at the fried dough stand, or chased seagulls on the boardwalk.

Behind us and a little to the side there was a loud thump against the wooden boards of the boardwalk. I looked back and saw a youth sprawled face-down on the boardwalk, head turned to the left, arms and legs twitching very slightly. He couldn't have been in that position for more than twenty seconds. A small child near him was crying loudly.

Instinctively I took a step toward him but then stopped and let my mental voice slow my movements down: Is his airway clear? (Yes, for the moment.) Is his family around him? (Yes.) Do they look like they've seen this before or are they in a state of shock and panic? (The little sister was very upset, but the other family members were protecting the boy's head, moving bystanders away, and managing very well.) Do they need help, or would you just be in the way (as so many emergency medical personnel feel when doctors try to step in and offer assistance in a public place)?

I stood by ready to help if needed and kept watch, but I left the family alone. Once the episode passed (like, five seconds after I stepped forward to observe), the boy sat cradled in a relative's arms on the boardwalk looking dazed and very tired. Another relative replaced one of his hearing aids, which had fallen out when his head hit the deck. He had a mild abrasion right under his right eye. Dock personnel with walkie-talkies stepped in promptly to assist.

"What happened, mommy?" my son asked.

An elderly woman behind me was muttering, "At least it wasn't a seizure or something. Poor guy musta' gotten anxious and fainted." I whispered to my son, "Looks like he had a seizure, sweetie."

"Will he be ok?"

"Yes, I expect he will."

"Is he still gonna come on the boat?"

"Not today, lovey."

Very soon after we boarded, from the top deck of the boat, we saw an ambulance pull up to the depot to pick up the boy.

I felt very sad. I felt sad for the boy and his family, who deserved to be enjoying their afternoon on the lake every bit as much as my kids and my family did. I felt sad not to be at their side offering help and support. I felt sad knowing that even I had been able to do that, I had no power to really heal the boy.

Out on the water, the sunlight, wind, and waves were perfect. We had a smooth sail, and a cloudless sky.

'Tis a Gift to Be Simple: a soul-healing day

I believe there are places in the world that are healing places. Spaces that have a special energy about them - a spirit of calm and renewal that can enfold those who enter and banish troubled thoughts, at least for a while.

I am away from work for a week, and that's a good thing. Work has been stormy; even with time and space away, in sunny, breezy weather near mountains and a gorgeous lake, it's been hard not to be affected by the malignant energy churning around lately. But I'm here now, with the people I love most in the world; I'm going to try to take a real rest.

Canterbury Shaker Village, which we visited today, is a great place to find long-lost tranquility, especially on a clear summer day that's cool enough to feel like fall. (See here for some beautiful black-and-white photographs of the place.)

We tried some home-made bread in the kitchen, and were reminded that the daily work of keeping a home can be a form of prayer.

We danced in the chapel, men and boys facing women and girls.

We admired artifacts that showed the Shakers' inventiveness and ability to unite beauty with usefulness.

We heard the touching story of Alberta Kirkpatrick, the last person to be welcomed to the Canterbury community as a child and raised there. She had had such terrible experiences in other foster homes that at the age of eleven she was suicidal. She described seeing her Shaker foster-mother-to-be running to meet her for the first time and dispelling all her fear and self-doubt by embracing her with genuine warmth and unconditional love. She felt that her self-concept was reborn, created anew, at that moment.

We were impressed by descriptions of the community's diligence, efficiency, and extraordinary organization. Clothes were labeled with building numbers, room numbers, and initials so they could be promptly returned to the right place after being laundered. Tools from a common list were likewise labeled so they wound up back in the appropriate drawers. Everyone, young and old, was expected to work hard - "Hands to work and hearts to God" - to create and maintain their little piece of heaven on earth, their village.

We walked the beautiful grounds and rang the bell at the school house. My daughter tried her hand at weaving. My son climbed the ruins of the long barn. We learned about some herbs commonly used by the Shakers (I didn't know lavender could be used as a moth repellent!). We learned the origin of expressions like "Sleep tight" and "Knock it off" (which shaker women would call out if the laundry got tangled up and the leather conveyor belts had to be knocked off their pulleys temporarily, to halt the work and allow them to undo the mess).

I especially enjoyed seeing the infirmary, which had an apothecary, a few patient bedrooms, one room devoted to assisted living of the elderly, and even a rudimentary operating room where village women would assist visiting surgeons - even give anesthesia! The placard outside the room said, "Shaker sisters assisted in surgery as 'scrubs' or 'etherizers.' "

It was a healing place.

Back home I was inspired to make an apple pie, much to my children's delight and satisfaction. There is nothing quite like the feeling of seeing your children eat well and feel content during and after a meal. It's one of my greatest pleasures in life. It's those simplest of pleasures that bring heaven a little closer to earth, I think, lending the work to create them a special beauty and dignity, tedious though some of the steps may be.

"Do all your work as if you had a thousand years to live and as if you were to die tomorrow." Mother Ann Lee.

Playlists

Yes, I was one of the curious ones that was wondering what Michael Phelps listens to on his iPod (photo: Getty Images). What can I say? I'm fascinated by the way people choose music, and why. Why, for instance, does Phelps listen to

-Eminem

-Li'l Wayne

-Jay-Z

-Young Jeezy

-Outkast

-Usher

-Twista and

-G-unit

before racing? Is it because rap music energizes him, motivates him, gets him "pumped up?"

And for any of us who have made playlists - why do we make them, and what makes us choose the music we choose? Does the music help us perform better at a particular task? Do we feel more energized, motivated, "pumped up?" Is it because we're telling ourselves a particular story that can be expressed in part by our own, individual soundtrack?

Chris, an American surgeon deployed to Iraq, explains why he chose the songs he did for the playlist on his O.R. disc - besides the study that showed it makes surgeons more efficient when they get to choose music to play, and (arguably) the O.R. staff happier: "Not only will this disk keep me in my game during the operation, it prevents me from falling asleep and sliding under a truck on the drive home after the operation at 2am."

Chris's O.R. Playlist:

Blur: Song 2

Green Day: American Idiot

Offspring: Come out and play

Violent Femmes: Blister in the sun

Clash: Rock the Casbah

Drowning Pool: Bodies

Marilyn Manson: Beautiful people

Alice Cooper: Feed my Frankenstein

Garbage: Supervixen

Cracker: Low

Smashing Pumpkins: Bullet with butterfly wings

Stone Temple Pilots: Flies in the Vaseline

Nickelback: How you remind me

Pearl Jam: Daughter

Fatboy Slim: The Rockafeller Skank

Lit: My own worst enemy

Butthole Surfers: Pepper

Linkin Park: In the end

Cypress Hill: Insane in the brain

Seven Mary Three: Cumbersome

Wheezer: Hash pipe

P.O.D.: Alive

Sublime: Santeria

One of the surgeons I work with has very similar proclivities. He'll throw in a little Evanescence and Disturbed - and turn it down without complaint when I need to concentrate on something crucial. He'll even play Sting's Desert Rose just for me because he knows I love it. My favorite ophthalmologist will have only classical...and enjoys playing this game of seeing if I can identify whatever piece happens to be on the radio at that moment.

I've had a medicine-oriented playlist that captures for me what I can't put into words about my job. It includes

Smash Mouth: Walking on the Sun (don't ask me why - maybe because it was on an episode of E.R. once)

Marc Cohn: Healing Hands

Queen and David Bowie: Under Pressure

the Harvard Opportunes' arrangement of Maria McKee's Breathe

the song Credo from Elizabeth Swados' play Missionaries

P!nk: Just Like a Pill

Leona Lewis: Bleeding Love

Tracy Chapman: The Promise

Five For Fighting: 100 Years

and a whole bunch of Rent songs - One Song, Glory; Life Support; Will I; and Without You

And I remember on my last day of residency I had a celebratory CD I blared in the O.R. as I was setting up the anesthesia stuff in the morning. I addition to Under Pressure, My Sharona was on it, as I recall - just loud and "obnoxious" enough to "get it all out."

What does an oboist choose for work-out music? Hilda, a.k.a the Dominican oboist, who has renamed her blog POM (physician-to-be/oboist wannabe/mommy), works out to Julian Oro Duro and Banda Gorda. I have 80's nostalgia on my work-out list - Janet Jackson's Miss You Much - but my daughter, very much a child of this generation, enjoys it too.

When I want to relax and let oboe music wash out my tired spirit, I turn to this playlist:

Albinoni: Concerto à cinque No. 2 in D minor (for oboe, 2 violins, viola, cello & continuo)
Zipoli: Adagio for Oboe, Cello, & Strings
Marcello: Concerto in C minor, 3rd movement
Bach: Concerto for Oboe and Violin in D minor
Schumann: Romance No. 2, Op. 94
Vaughan Williams: Concerto for Oboe and Strings
Saint-Saens: Oboe Sonata in D major
Fauré: Pavane, Op. 50
Poulenc: Sonata for Oboe and Piano, 2nd movement
Stravinsky: Pastorale
Menotti: Shepherds’ Dance

Aaaaaaaaah....music really does change everything.

Tales from St. Boonie's: Olympic Dreams

As evening approached the recovery room was down to its last patient. The patient's blood sugar post-op was alarmingly high, and I was working with the on-call nurse to change some orders, order labs, and make sure we didn't have florid ketoacidosis on our hands. The rest of the nurses were just about to leave for the day but had gathered around the computer behind the desk in the recovery room. Occasional murmurs of admiration arose from among them. I went to the desk to look at a blood gas (normal, thank goodness) and asked them what they were looking at all huddled around the screen.

"Oh, nothing...just Michael Phelps' iliac crest. And some cute tattoos."

"Iliac crest my foot!" I teased. "I think I know you guys a little better than that. Are you sure you don't mean his anterior superior iliac spine?"

I went around the desk to sneak a peek.

Oh, that wasn't his iliac crest they were looking at. Or his anterior superior iliac spines.

"Whoa, that's actually his inguinal canal, y'all," I said, dramatically hiding my eyes in mock modesty. "And Trudi, what's your lovely French-manicured hand doing on his rectus abdominis?!"

"Lemme tell ya," said one of the nurses, "We'd be happy to take care of his inguinal canal or his rectus abdominis in this recovery room any time!"

(Photo credit:
https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7gAFotWK82eRtrX0P6TB1NUo0yAVE11AuNkft8Bu0YbGY-hIZDmdTFQKwPFIYyaTs_xu5eBsjthK4zSr7zgJ5JGi_4dUtIbNErjvwRVnAPV6-u9drKSoXtaZIOhE9LHd9zbtXuyiZsbDu/s1600-h/phelps.jpg)

I had to laugh with them. "I'd just be happy if I could eat that much every day - three fried-egg sandwiches AND a 5-egg omelette AND french toast AND chocolate chip pancakes AND grits for breakfast alone? And an ENTIRE BOX of pasta for lunch AND for dinner, each? Sheesh!"

"I don't think I could burn 12,000 calories in a year, much less a day," another nurse chimed in.

Fun aside, I have an Olympic favorite myself. I love Shawn Johnson. She is to gymnastics what I want to be in medicine: consistent, reliable, stellar, down-to-earth, and able to stay calm and grounded under pressure, and really deliver when her gifts are most needed. I think this picture epitomizes her grace and poise and her ability to enter that zone where no one can ruffle her. (Photo credit: http://www.gymnasticsmedia.com/Gympedia/tabid/332/topic/Shawn+Johnson/Default.aspx).

My favorite gymnast from the last Olympics, Catalina Ponor, had it too. I don't know what their secret is, how they enter that sacred zone of strength and courage, but that's exactly where I need to be when I'm at a patient's side in the O.R., especially when the going gets rough.

I have never been good at sports, but there are certain skills athletes have from which people of all professions can learn. An athlete, from the Greek word athlos, or contest, is one who competes; medicine requires a kind of mental and spiritual athletics, in which one enters a life-long contest against wounds, illness, and death as well as against one's own deepest weaknesses - the impulse to hide from others' suffering, to judge others, to get impatient, fearful, fatigued, or cynical...all the things that are like a kind of lactic acid build-up for the mind and heart. I think it's worthwhile to set aside moments to enjoy and marvel at the Olympics even when closer to home there are pressing priorities. Our young heroes have the power to inspire, and that periodic inspiration may be the just the boluses of energy we all need to keep our own torches lit.

"Hit the Road, Jack, and Dontcha Come Back No More, No More, No More, No More..." (just kidding, of course)

Let me say this, first: the dividing line between mostly procedure-oriented physicians and mostly thought-oriented physicians, or however you want to label the two, exists, certainly in the minds of students choosing specialties and insurance companies reimbursing them, if not anywhere else.

Let me also say this: doctors who excel at procedures are often great thinkers and "empaths" as well, while doctors who excel at evaluating and relating to their patients may also have technical skills that would inspire admiration in any specialist.

And of course in either "group" there are those who stink at one or the other, or both.

One reason anesthesiologists take pride in their profession is that in the de facto divide between the surgical/procedure-oriented specialties - general surgery, orthopedics, urology, et al. - and the medical/"thinking-and-relating" specialties - e.g. internal medicine, pediatrics, family medicine - anesthesia requires of its members a high level of competence in both procedural and cognitive medicine.

When someone I'm supervising gets over-anxious about a patient's recent upper respiratory or gastrointestinal symptoms right before surgery, to the point of unnecessarily alarming the surgeon by saying that the patient's going to either die on the table or postop, it's up to me to spend time with the patient taking a proper history, doing a physical exam, and assessing the patient's appearance and lab studies in order to make a final, well-thought out judgment on the issue.

When a surgeon appears under-anxious about EKG changes on a patient who's recently reported more episodes of windedness, and wants to proceed with an elective operation anyway, I'm responsible for evaluating the patient's condition and making the final decision about whether to proceed with the case, often to the surgeon's (and patient's) great disgruntlement.

When someone deteriorates in the recovery room, I have to figure out what's wrong and what to do about it. When the ICU calls with an airway or hemodynamic issue, I'd better show up with some ideas as well as practical skills. When a surgeon brings me a patient with a tumor right on his vocal cords or a 24% ejection fraction and asks me to induce anesthesia without killing the guy, it's my job to make it happen.

I have to know about babies, the very elderly, pregnant women, and athletic adolescents. I have to know about brains, hearts, kidneys, livers, and lungs. I have to be able to place intravenous lines, epidurals, and spinals, and intubate difficult airways. I have to know how to protect and save people's lives when they seem to be actively trying to die on the table, or when they're trying to bring new life into the world.

Of course, if you've been kind enough to have been reading this blog since its inception, you've already seen me vent about all this. So why am I once again rallying to my profession's defense?

Because today after spending several minutes interviewing a patient - let's call him Jack - during a preop evaluation, listening to his concerns about various pathologic conditions, and answering his questions as thoroughly as I could, the patient ended the conversation with, "Well, at least your job is one of the easy ones."

Excuse me...WOT?!!

"In what way?" I asked, smiling as sweetly as possible.

"It's one of the 'ROAD' specialties. You've 'hit the ROAD.' "

I think my face must have looked blank, or at best, quizzical.

"You know - ROAD, R-O-A-D?"

Still blank.

"Radiology / ophthalmology / anesthesiology / dermatology. The specialties all the students are trying to get into now, because of the pay and the lifestyle."

Lightbulb. Ding-ding-ding-ding.

"Ooooooooooh, road. I get it now."

Hmm...you forgot emergency medicine. I hear that's pretty flexible too.

"It was in the paper a few weeks, or maybe it was a few months, ago. 'Doctors hitting the ROAD.' "

"Hmm...Well, I can see why students would be attracted to a flexible lifestyle, and to anesthesia once they get to know it. It's a GREAT specialty. But I wouldn't call it an easy one. I've heard some anesthesiologists say they don't think what we do is all that hard. But I actually think it can be VERY challenging."

"Really? Why?"

One. Two. Three. Breath. Four. Five. Six. Seven...

"I think it can be really tough sometimes to protect someone's life. We have to think fast and act fast, and make judgment calls that can be hard. I think everyone finds it highly stressful at one point or another."

"Oh."

We exchanged some concluding pleasantries after that. I was barely listening by then. I kept thinking of how I ended up choosing this specialty - of the twelve-year-old boy I mask-ventilated for the first time, and how at that moment I knew I wanted to be doing that for the rest of my career. I wasn't thinking of salaries or lifestyle at all at that moment. I was thinking of how much I loved the actual work.

I bid the patient farewell as I put his chart away and turned to go back into the O.R. He thanked me for my time, then hit the road.

Not Even the Most Frustrating Conversation Of the Week, But Unbelievable Nevertheless

(Reconstruction of an actual phone conversation overheard at the main O.R. desk.)

Doctor In Charge of Administrative Stuff (DICAS): Who writes the orders for blood transfusions in the O.R.?

O.R. Nurse: No one.

DICAS: You mean blood is getting hung with no orders?!

O.R. Nurse: The anesthesiologists give it. They don't write an order for it.

DICAS: Why not?

O.R. Nurse: Because it's part of anesthesia care. They ask for it. We get it. They give it.

DICAS: Who actually hangs the blood?

O.R. Nurse: Anesthesia. It's their decision, based on preop crit, blood loss, and vital signs.

DICAS: Well, as of today, they're going to have to write an order for that.

O.R. Nurse: But who would they write the order to? It's just like when they give fentanyl or pressors - it wouldn't make sense for them to write themselves orders to give a medication every time they assess the vital signs and decide the medication is warranted.

DICAS: That's not the same thing.

O.R. Nurse: Of course it's the same thing!

DICAS: No. Blood transfusions can kill people.

O.R. Nurse: The drugs they use can kill people too! And who's supposed to pick up the order?

DICAS: I don't give a sh___. That practice is going to change as of today. If there are no orders written, then there's no way of knowing who's responsible for giving the blood and causing the reaction.

O.R. Nurse: Of course there is! The anesthesiologists document it on their record! They sign the blood sheet!

DICAS: No, they don't. I have a medical record right here...(leafs through record to find blood administration sheet...remains silent for a moment. We imagine it's because he's gazing at the anesthesiologist's prominent signature on the blood administration sheet).

Anesthesiologist (from the sidelines): Remind him that life-threatening transfusion reactions occur in, like, 1 out of about 250- to 600,000 patients REGARDLESS of who orders the blood transfusion, so creating a measure for the purpose of assigning blame is an ignorant and asinine thing to do.

DICAS (on phone, to O.R. nurse): What is your name, exactly?

O.R. Nurse: Brillia. Brillia Sensemaker.

DICAS: Well, Brillia, I'm going to take this up with the Vice President.

Vice President (minutes later, on the phone): So, why aren't orders written for blood given in the O.R.?

O.R. Nurse: Because it's part of anesthesia's care. The doctors make the decision to transfuse based on what the patient needs right at that moment.

Vice President: Don't the nurses then carry out the decision?

O.R. Nurse: No. The anesthesiologist hangs the blood after a nurse double-checks the label with him or her. It wouldn't make sense for the anesthesiologist to write an order to herself for something she's decided to carry out.

Vice President: Hmm...you're right.

O.R. Nurse: (Catches anesthesiologist's eye, thinking they've gotten somewhere).

Vice President: But it's going to change anyway. DICAS wants an order written every time blood is transfused in the O.R.

O.R. Nurse: An order to whom? To self?

Sigh. Why is it that people who have no understanding of what goes on clinically in the O.R. are allowed to make dictatorial decisions about the O.R.?

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For another great peek into the headaches of being unjustifiably strong-armed by the administrative side, please see this well-done post at Dr. Val and the Voice of Reason.

To Write or Not To Write: a question for doctors who blog

Just as the medical blogosphere is burgeoning with opportunities for health care workers to draw back the curtain and demystify what goes on behind the scenes in medicine, and how people who work in medicine approach certain situations and decisions both intellectually and emotionally, the naysayers are criticizing this growing transparency and even implying that doctors shouldn't be free to express themselves, to have a voice, to tell their stories.

But as Dr. Mary Johnson, a pediatrician in Asheboro, NC, once wrote on her blog, "I live in America. I did not leave my right to have an opinion at the door when I got my medical degree."

Physician bloggers, including me, got shaken up when Robert Lindeman, a.k.a. Flea, had to quit blogging because of the way he was "outed" during a malpractice trial. Interviewed later about the ordeal, Dr. Lindeman reflected, "Writing as a physician is a dangerous activity, and that’s a shame. That’s a message I’d like the folks to know. For physicians, writing is dangerous and there is something really messed up about that."

For those of us who love writing and who love medicine, these are painful words.

Dr. Johnson aptly points out elsewhere in her blog that we shouldn't let our voices be silenced by others' fears:

I have noted in the past that most medical bloggers do so anonymously. Provided they change the names and blur the locations in order to protect both the innocent and the guilty (not to mention, dodge those snarled privacy laws) . . . and as long as they don’t tell too many people who they really are . . . they generally can get away with discussing their days . . . their patients . . . their opinions . . . with the wit and wisdom and insight that can only be borne of the experience of actually being a doctor.

The public really needs to hear this stuff. In this era of “Walmart medicine” and a "me-me-me-now-now-now" society that expects the state-of-the-art best (not to mention good outcomes no matter what) for next to nothing (and OBTW, society's members will sue the doctor's pants off if they don't get it), this kind of thing needs to be part of the discourse.

Amen to that.

I know this:

• I know I am not truly an anonymous blogger - no one is.
  
• I know I need to protect people's privacy and am committed to doing so.
  
• But I also know that STORY MATTERS. Ultimately, for me, story is the whole POINT of writing, and, arguably, the very way in which we define ourselves and forge our connections with one another - even in medicine, where taking a good history, learning a patient's story, is one of the most important steps in the healing process.

The authors of the article "Online medical blogging: don't do it!" (published in the journal of the Canadian Medical Association) assert, "Telling personal stories about individual patients poses the risk of eroding the public's trust in the particular physician involved, as well as in the relevant department, hospital and university, and in physicians in general." What a limited and limiting understanding of the powerful positive role writing about one's experiences can play in medicine. So many visitors who have been kind enough to leave comments here on this blog have described just the opposite phenomenon: an increased trust in, and understanding of, physicians due in part to a particular story related here. Who better than the surgeon himself to describe what it's like to be feel almost inexpressible sorrow over an outcome, or to convey, as this surgeon did, the momentary intimacy of an office visit in which compassion for a patient's physical and emotional lesions, and the willingness to become part of another's story, transform a mere "encounter" into something much greater?

To the authors of that journal article, I must say that perhaps five or ten years ago a discussion of whether or not doctors should blog might have made sense, but considering the plethora of truly remarkable, valuable, fruitful, and praiseworthy blogs out there by now - open your eyes and take a look, please - I think the horse has left the barn.

I'd like to thank Melissa Healy of the L.A. times for featuring Notes of an Anesthesioboist on today's roundup of "Medical Blogs For Doctors and Patients Alike."

Other medical blogs included on her list were
From Medskool
Emergiblog - "The Life and & Times of an ER Nurse"
GruntDoc by former Marine infantryman and physician Allen Roberts, an ER doc in Fort Worth
Blogborygmi by Dr. Nicholas Genes, an ER doc from Mount Sinai Hospital in New York
Edwinleap.com - "husband, father, physician, writer"
DB’s Medical Rants maintained by Dr. Robert M. Centor, an internist at the University of Alabama School of Medicine
Dr. Val and the Voice of Reason
Kevin, M.D. by Nashua, N.H., internist Kevin Pho
MedGadget
Medpolitics
California Medicine Man, by Dr. John S. Ford, assistant UCLA professor and an internist at Harbor-UCLA Medical Center
Fingers and Tubes in Every Orifice.
Ob/Gyn Kenobi
Mothers in medicine
Codeblog
Musings of a Distractible Mind by Dr. Rob, a primary care physician in the Southeastern U.S.
Head nurse
Urostream
Clinical Cases and Images
Medical Jokes, Cartoons, Videos
Placebo Journal Blog -"Medical Humor With a Purpose," by family practitioner Dr. Douglas Farrago of Auburn, Maine. (Thanks to you, Dr. Farrago, my husband will never look at a cast iron stove the same way again...)

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Addendum August 25, 2008:
Here's an article on the website of the American Medical Association on physician blogs: http://www.ama-assn.org/amednews/2008/09/01/prca0901.htm#1 . There seems to be an underlying assumption about what blogs should be - tools for dissemination of information by "professionals" with proper "citations" only, whereas blogs are clearly different things to different writers, including journals, art exhibits, family albums, etc. The genre is fluid and undefined; it can be personal, not professional. Not all physicians who write blogs are writing in their professional capacity as physicians. I think Dr. Rob stated it brilliantly: "Physician blogs should not be seen as an attempt to replace other sources of information, but instead as a new kind of medium -- a view into the minds of the rank-and-file members of medicine."

And via KevinMD on August 26, 2008:
Here's another site that expresses my view pretty well, which is that in this country that glorifies the First Amendmet, my right to write whatever I want should be respected, not abrogated: http://www.medrants.com/index.php/archives/3718

More links on the subject here - specifically, on the story of a Scottish doctor suspended for something he wrote on a doctors-only blog forum - found on September 2, 2008: http://thebrownstuff.blogspot.com/2008/08/story-here.html
http://thejobbingdoctor.blogspot.com/2008/08/suspension-and-resuspension.html
http://ward87.blogspot.com/2008/09/reinstate-dr-scot-jnr-support-free.html
http://doctorbloggs.blogspot.com/2008/08/harassment-and-bullying-in-nhs.html
http://witchdoctor.wordpress.com/2008/09/01/the-highlands-in-the-eye-of-a-storm/

Addendum 9/30/08:
http://www.scalpelsedge.net/2008/09/theres-something-about-med-blogging/

Addendum 4/21/09:
http://casesblog.blogspot.com/2005/08/simply-fired-how-not-to-blog-about.html

How a Plate of Broccoli Got Me Thinking About God and the Whole Evolution v. Intelligent Design Debate

Am I a Creationist or an Evolutionist?

Frankly, it's easier to declare what I am not. I am not a fundamentalist Christian or a person who espouses a strictly literal interpretation of any religious text.

Right now I certainly can't claim to be an atheist or a strict materialist either. Some of the most arrogant, obnoxious, disrespectful fundamentalists I have ever read or heard speak have been atheists. I do, however, accept the Theory of Evolution as the best explanation we have for our observations of living things.

I sometimes enjoy the debate between rational empiricists and people of faith. It can be like watching that last tournament between Nadal and Federer. Whether you were rooting for one or the other, watching the volleys was fun.

Here are a few "volleys" I consider weak arguments for either side:

• There's a watch here, so there must be a watchmaker somewhere.
• God must exist because there's so much beauty and goodness in the world.
• God must not exist, or must not be a loving God, because a loving God wouldn't allow so much pain and suffering in the world, especially by innocent people.
• God must be an UN-intelligent designer, or there must be no designer, because so many "designs" in nature are suboptimal - a perfect God would design a perfect world.

I don't believe that last idea holds or is necessarily even logical. But just for fun, what are some of those design flaws?

Well, for one thing, I've always thought the need to eliminate waste was a royal pain in the...well, you know, a big annoyance. Not to mention gross. That's it! Dirt must be proof against the existence of a Creator! NOT. But it would be nice to be energy-effiicient enough not to have to deal with it.

Then there's childbirth. Have you SEEN how big some babies' heads are?! I don't care HOW stretchy a woman's birth canal gets during pregnancy. Having to push a watermelon out through a STRAW is just plain WRONG! And back in the day, before C-sections, it could KILL people.

And there are other "poor" designs in that area - the features that predispose to ectopic pregnancy; undescended testes; descended testes leaving behind the right mix of ingredients for future hernias...

For that matter, let me extend my thoughts to ovulation itself. Think of all the problems of the world that could be solved if women could ovulate at will. No pesky menstrual periods. No unwanted pregnancies. No overpopulation.

Then there are all those animals (including us) with "useless" or downright maladaptive parts (which I read about on wikipedia, with many more described in Robyn Williams' book Unintelligent Design: Why God Isn't as Smart as She Thinks She Is) - ostrich wings, giraffes with several feet of extra recurrent laryngeal nerve, babies with malformations or metabolic defects, panda thumbs which aren't really thumbs, armpit sweat glands, the appendix, and every anesthesiologist's favorite: the shared passageway for both food AND air. Gotta love that stroke of genius.

So how is it that I got to thinking about all this at the local Chinese restaurant, where I ordered a steaming plate of Yu Shiang Broccoli, cooked just right so the stems were still crunchy, the green was still bright without a hint of overcooked brown, and the sauce neither too spicy nor too garlicky?

Taste. I began to realize how maladaptive one's sense of taste can be, yet also what a prominent role it can play in human experience.

Even if you're an eat-to-live type of person, you can't tell me that you think raw veggies are the greatest pleasure known to humankind. But surely if "nature" wanted us all to be healthy, we'd have evolved, or been created with, taste buds that sent signals to our brains along the lines of, "That flax seed is SOOOOOOOOOOO much yummier than chocolate," or "Mmm, green leafy vegetables instead of ice cream - sign me up!" Alas, my taste buds, at least, would pick chocolate over flax any day.

Which brings me to my plate of broccoli. I start to think of all the sodium in the soy sauce bathing each little cooked-to-perfection crown. Not to mention the added sugar, just enough, that makes it taste so goooooooooooooood. Then there's the added oil, though thankfully this restaurant isn't too heavy-handed with that. And I love it. Every bite. Darn my maladaptive sense of taste!

Sigh...the gift of taste definitely has its dark side.

But to my mind it also hints at a few things, like a clue to a bigger mystery.

I think it suggests we as creatures are meant for enjoyment. Happiness, not misery. At the hospital even patients who can't really eat well are sometimes prescribed soft foods by mouth simply for quality of life, for the pleasure of eating. We have become creatures with a capacity for pleasure, for play, for laughter, for enjoyment. Whether or not you believe there's a giver, that's a gift.

Secondly, I think we are meant to learn stewardship. Existence gives us certain natural human rights, but with them a certain inalienable responsibility for the times and spaces in which we participate in that existence, including our bodies, our planet. I know I'm not supposed to let my taste buds run the show, and that's something I'm constantly having to work on. Stewardship can be hard when one is a total foodie!

Finally, I think we are meant for development. The very path we take from embryo to adult seems an incarnation of this intellectual, and some would add spiritual, destiny. We're supposed to evolve within our lifetimes, as the universe is meant to do during its lifetime. We are supposed to deal with imperfection, and thereby to LEARN, grow, and strive for perfection.

This is why I think any arguments for or against religious concepts made on the basis of the world's imperfection are intrinsically flawed. It's NOT supposed to be perfect here; this "site" is under construction, and it's up to us - not some invisible, intangible God - to put our hands in the earth, with all its grit and dirt and hidden dangers and treasures, and do the work of constructing it. The work of perfecting it. The work of creation.

SurgeXperiences 203

SurgeXperiences 203, a surgical blog carnival, is up at Other Things Amanzi, a blog authored by Bongi, a surgeon in South Africa. Many thanks, Bongi, for including me!

Check out past editions of SurgeXperiences here.

The next edition will be hosted by JeffreyMD on August 17. His theme will be "My First Time." Submissions are due by August 16 and can be made here.

Finally, and most importantly...HAPPY BIRTHDAY, MOM! :)