One of the Ones That Stay With You

"You're thinking of putting an epidural in a quadriplegic? Whatever for? It's not like he'll feel any pain."

I looked up from the chart in front of me. I had forgotten that the idea might be foreign to a non-anesthesiologist.

"Oh, it's not because of pain," I explained. "It's because I don't want him to have autonomic dysreflexia."

"Never heard of it," the preop nurse replied. "Will you explain it to me?"

At the time of this conversaton I'm scheduled to provide anesthesia for a man only slightly younger than I who broke his neck in an accident years ago.

For a patient with a spinal cord injury, I prepare for the worst. There are all sorts of challenges - maintaining a good airway and adequate oxygenation and ventilation; moving and positioning; and last but not least, the dreaded phenomenon of autonomic dysreflexia, in which surgical stimulation can produce out-of-control blood pressures and cardiac disturbances that can be life-threatening.

Options for prevention include trying to place an epidural or having the patient be under really, really deep - deeper-than-usual - anesthesia. I opt for the latter in the end, when the day of surgery actually arrives and I've had a chance to talk to surgeon, patient, and family. Though I am a little tense during the procedure, anticipating with each blood-pressure reading that it will be sky-high and I'll have to administer a blood-vessel-dilating drug from my pre-prepared arsenal of syringes and drips, everything goes just fine.

Such a patient can be medically challenging; but there are emotional challenges too, especially when the patient is so young. I think of all the experiences he has lost, that he must long for. I think of how unfair it must seem to see me walking toward him on my imperfect yet fully functional legs, breathing on my own, able to write in the chart, hold a phone receiver, hug my family. When I touch him to connect physically while speaking to him from the top of the bed as I wheel it into the O.R., I touch his head rather than his shoulder, because I know he can't feel my reassurance otherwise...and then I wonder if touch is reassuring or not for him. He doesn't seem to mind.

He is a pleasant-looking man with a nice demeanor, and if he had not been injured I can tell he would probably have had an athletic physique. In other words, a regular, healthy life. When we shift the blankets over his body I notice how thin he is, how atrophied his muscles, how stiff his limbs. He has a ventilator to help him breathe, but he has trouble breathing when he lies flat, so we raise his head. I don't want this man to have any discomfort.

The procedure is brief, and he does well. When I leave the hospital for the day he is smiling and talking with his family and his nurse. I admire his courage, feel a little shame at what I tend to take for granted, and am sad for what he has lost. The thought haunts me: he'll never be able to move. Maybe there are those who would be offended by this sadness, who don't want to hear me express it or don't think I should even have it. Americans seem to recoil with horror and resentment from anything that smacks of pity, whereas Filipinos see it as a virtue and a loving sentiment, synonymous with compassion. It doesn't matter how the sentiment is judged: I am sad. I won't forget him.

_________________________________________________
Illustration: a painting found in 1921 on a wall of the baptismal chamber of the house-church at Dura-Europos, on the Euphrates River in modern Syria. Dating c. 235, it is the oldest known representation of Jesus and depicts him healing a paralyzed man and and telling the man to rise, pick up his mat, and go home.

The Joy of Browsing: an anesthesioboist's quiet Saturday

Mm, browsing. It's one of my favorite things to do. I'll admit it: it's even better than wrapping Christmas presents. My "perfect date" would consist of terrific conversation, a delicious meal, and at least an hour in a wonderful book store BROWSING. I don't know why I find it so soothing, but I do. I love it. Calms my soul like nothing else.

No book store here, unfortunately - just rain, fog, a warm drink, and blissful seclusion in a cozy cabin for the weekend, but I have put my third Philippa Gregory novel down for a bit - a hard task - and indulged in a little cyber-browsing. Not as good as real-life browsing, but comforting in its own way.

I just had to share this delightful piece of stitching by a surgeon/fellow-blogger. I stumbled upon her blog when I checked to see if there were other people on Blogger who list Tuck Everlasting as a favorite book on their profiles:

Am I geeky to find this so adorably cute?!

Here's another picture I found on the enjoyable medical blog EverythingHealth, authored by Toni Brayer, M.D., which tells this story of a transplant surgeon who used a ping-pong ball (thinking outside the box!) to save his patient. As the Happy Hospitalist commented, that takes b... er, guts! If you're into medicine, Dr. Brayer's blog is a great one for interesting medical stories and news. I'll be eating more pistachios from now on... :)

One last picture, a sample from my daughter's birthday loot. I was reminded of it as I was browsing for ambigrams. Like me, my daughter absolutely loves notebooks and journals. She picked out this one the last time we browsed in a book store together. Turn the image upside down and you're still reading the same word. We couldn't resist!

It's still raining. I think I'll go generate some more ambigrams, or read some more of my book, or practice some oboe, or watch the rest of the Rock Hudson movie we were watching, or make some cookies...

*Sigh.* I love quiet weekends!

Anargyroi (a mini-excursion in medical history/legend)

Happy Feast of Saints Cosmas and Damian.

Factual details about their lives are largely lost to us, but according to legend Cosmas and Damian were twin physicians born in Arabia and brutally martyred in Syria (c. 287) under the persecutions of Diocletian.

One "miracle story" associated with them tells of transplant surgery: they grafted a leg from a recently-deceased Ethiopian onto a fair-skinned deacon named Justinian who had an ulcerated leg. This part of the legend is interesting to me for a couple of reasons - the idea of this kind of surgery even being contemplated in the third century, and the striking (and, to me, unexpected) juxtaposition of races in the story.

It was said that they were nicknamed Anargyroi, "The Silverless," because they didn't charge a fee for their services. In the Eastern Orthodox Church the term Hagioi Anargyroi, or Holy Unmercernaries, describes a special category of saints who perform labors solely out of love for God and humanity.

Cosmas and Damian are regarded as patron saints of physicians and surgeons as well as chemical manufacturers, pharmacists, hair dressers, hernia patients, and people desiring relief from pestilence. In Brazil they are also regarded as protectors of children and their feast is celebrated on its original date of September 27. They have been popular subjects in medieval and Renaissance art.

Not My Best Moment II: The O.R. as a Cultural Anthropology Lab

I have friends who are nurses.

I have friends who are surgeons.

I have friends on the housekeeping team.

I have friends who are physicians in other departments.

When we are acting in our professional capacity, we sometimes have to assume certain roles according to our expertise, with some roles more directive than others. In the lunch room, though, we're all Red Sox fans together.

Or I should say, almost all.

I've heard some disillusioning things about some of the nurses' attitudes to members of the housekeeping staff. Some of the nurses have told the night crew to stay away from the leftover coffee in the coffee pot. Others have warned the night cleaning staff not to trespass into the area behind the main O.R. desk, which begs the question, how then are they supposed to do their work and empty the waste paper baskets or sweep the floor in that area?

It sounds very much like the housekeepers have been spoken to as if they were children or chattel. I am sick at heart to hear about these things. One of the reasons I prefer life in America to life in the Philippines is that here, people aren't supposed to expect "lording it over others" to be acceptable, as it often is in countries like mine. Here the people we serve are not supposed to be our "betters;" they pay us, we work - it's a contractual rather than a feudal relationship that demands mutual respect of people's rights.

In theory, that is. But the sad truth is that there is classism here. There are people who look down on those who have less education, less income, or more menial work than they have. There are those who would refuse to recognize the intrinsic dignity of another simply because she's holding a mop rather than a scalpel.

One of those is the woman I once rebuked for behaving unacceptably during a crucial moment in the O.R.

This same woman, Nurse X, yelled at my friend on the housekeeping staff, let's call her Z, to get her cleaning supplies cart out of the way while a patient was being wheeled out of the O.R. I saw the incident. The cart was not in the way to begin with. Nurse X took Z by the shoulders and shoved her to the wall, crashing her into the cart in the process, causing the cleaning water to spill into the corridor and Z to nick her shin. Nurse X roughly manhandled Z, who is small, in a way she would never dream of doing to a man "of rank" in the hospital.

It happened so fast. I was so shocked I didn't know what to say, then it was over and people went back to the hustle and bustle of O.R. life, and I got pulled away to take care of some medical thing. Later I kicked myself for not saying something - for being a weak leader, and succumbing to Bystander Effect - then rationalized my shocked silence by telling myself that Nurse X would have made an ugly, unprofessional scene right there in full view of other staff and patients, and it would have been fruitless to allow a scene to be made. But I should have done more. What's that famous line - "All that is necessary for evil to triumph is for good men [and women] to do nothing."

I talked to Z afterward to see if she was ok, and she was not. Later that evening Z's supervisor approached me to ask about the incident and I spewed my guts out, not just about the horrifying incident but also about the stupid coffee pot thing and the behind-the-desk rule. But I don't think that "testimony" will do enough, and I went to bed that night knowing that in a very real way I had failed a friend.

Mark 4:39

Today is my daughter's birthday.

She is eleven. If she had been a rich Tudor girl, as in the impossible-to-put-down books I am reading now by Philippa Gregory, we'd be gearing up for a wedding next year or the year after, to some faraway nobleman who would spend his life treating her like property and cheating on her with countless mistresses.

As I brushed her hair this past weekend - we were on Martha's Vineyard with family friends - I thought of generations of women who have been brushing their daughters' hair for hundreds of years before me. The brush almost tugs her closer to me with each stroke - a wistful rhythm. It's an act that seems to expresses this tender, almost plaintive thought: stop a moment, my lovely girl; don't grow up too fast; enjoy this time to yourself, this untroubled time without complications or worries or major responsibilities, this fledgling time to be you and be entirely lovable and free.

I talked to her of our good fortune: we are women in a society in which we are free to choose to be wives or not, mothers or not, with opportunities to educate ourselves, vote for our leaders, work at professions of our own choosing. She would not be riding off to some stranger's court next year to be wedded and bedded at a horribly young age.

Yet centuries of disregard for women don't fade all that fast. Just today I had to draw a thoughtless nurse aside for speaking to me in front of a patient in a way I truly believe she wouldn't have with a male physician.

Then I had to let it go, fast. I had a patient who was afraid to the point of tears. With her I was gentle, I hope, and reassuring. She nodded as I described things, showed relief when I explained things, clung to my hand when I rested it on her arm.

I was pulled away again for some other unpleasant business, and I had to put the harder face on, the one that has to take charge and get things done right. Then back to the patient, and more reassuring murmurings, more of what I hoped were kind words that built trust, and soothing moments. Then the procedure began, and again, there was a need for firmness - my more business-like side, as I tried to convey important directives and elicit competent, efficient work from the team I was working with. Then it was time: the patient awoke, surprised it was all over, refreshed. Again a hand on the shoulder. Everything's all right. You're just waking up. Procedure's all done. You did great. Tears of relief. A smile. A squeeze of my hand.

Hard. Soft. Hard. Soft. So it goes all day, every day. Compassion in the interstices, between moments where I have to take a stand, or take charge of something, or direct someone, or all the above.

We're tugged in so many directions. I think of trees pulled about by storm winds or rain. How can I teach my daughter to stand firm in this whirlwind world, to bend but not to break, to be firmly rooted but pliant, and most important of all, to use her health and her gifts to bear good fruit? I want her to be happy and safe. I want her to stay energetic and free. I want her to feel satisfied with her work but not to get too physically and emotionally exhausted. All day at work as I travel from patient to patient, task to task, she is in my thoughts, like a song in the background of everything I do and try to be.

What can I teach her about how to cope with wave after wave of demands on her attention, her time, her energy?

It comes to me: I will have to teach her, by example if not by word, to reach for stillness, again and again. When I return to it, sometimes it's for just a millisecond. A pause before inserting an I.V. A putting aside of annoyance at a fellow-doctor's lack of consideration or a nurse's thoughtlessness, in order to lay a hand on a patient and hold still for a second. I hold still. My daughter and me brushing hair during a weekend retreat: another moment of stillness. It's a rhythm, a habit, but one that takes practice, one easily forgotten. I flutter around, busy, sometimes frenetic. But I have to go back to that stillness, even draw other people into it if I can, or I absolutely cannot cope with all the tugging. I have to "rebuke the waves," and try to tell myself, "Peace! Be still!"

Be still. Young people so often underestimate the value of that, the gift of that. Everything now has to be high-stim, instant gratification, always on-the-move. My kids are no different. They are sucked in along with all their friends, into the maelstrom of entertainment and activity that their generation craves. But there is something in mindful stillness that none of those delights can match.

Somehow I will have to teach my children this if I can, and hope that it's of use to them as they grow (too fast!) and discover (wonderfully!) who they are.

[Cross-posted in slightly different form at MothersInMedicine.]

In fact, Gwendolen, not intending it...had offended her hostess, who, though not a splenetic or vindictive woman, had her susceptibilities...*

Red pulp. Malpighian corpuscles. Trabeculae and sinusoids. Great words associated with a great organ: the spleen.

This past week I provided anesthesia for an emergency splenectomy. You'd think after giving anesthesia so often it would be old hat, but whenever I help get a patient through a tough operation safe and sound, I always feel deeply grateful.

Here, I was grateful that the difficult A-line went in, finally (thank you, Saint René!). Grateful that precautions I took in anticipation of the surgeon's incision, which revealed over two liters of blood in the abdomen from the patient's ruptured spleen, enabled the patient's vital signs to hold steady. Grateful that when I transported the patient to the ICU still intubated and with blood pressure medication infusing continuously, she was in stable condition, and I felt I could reassure the family - a large, warm family that filled the entire waiting area. Grateful that one family member felt comfortable enough with me to give me a hug afterward.

But a couple of hours afterward when I stopped by the ICU again to check on the patient, things were not as I had left them. I was upset. I disagreed with some of the steps taken by the physician now-in-charge. I always find it difficult to know how to handle such situations. Too many cooks can often spoil the soup, and I hate it when someone tries to backseat drive with me / read over my shoulder / hover. It's also a delicate matter to challenge the physician in charge when their decisions are technically not incorrect but I perceive them to be less effective or aggressive than my alternatives, or they're just not what I would have chosen.

There's often not just one right way to do something in medicine, but the physician running the ICU that night was clearly a think-about-it kind of person rather than a do-something-about-it-right-now kind of person, and I wanted to do something RIGHT THEN to fix the patient's vital signs - to temporize, at least, and protect the patient's organs while more goal-directed measures were being set up. I hate to say it, but I hovered. I hovered and hovered, ready to muscle my way in to protect my patient if need be, but eventually she stabilized and I felt I could leave once more.

*Sigh.* You can feel good for a moment in medicine but never for too long before something takes you back down.

***

In French, spleen "refers to a state of pensive sadness or melancholy." In case it hasn't been clear from my recent posts, I think I have been a bit "splenetic" of late.

Maybe some Baudelaire will be cathartic (various translations here):

Spleen

Quand le ciel bas et lourd pèse comme un couvercle

Sur l'esprit gémissant en proie aux longs ennuis,

Et que de l'horizon embrassant tout le cercle

II nous verse un jour noir plus triste que les nuits;

Quand la terre est changée en un cachot humide,

Où l'Espérance, comme une chauve-souris,

S'en va battant les murs de son aile timide

Et se cognant la tête à des plafonds pourris;

Quand la pluie étalant ses immenses traînées

D'une vaste prison imite les barreaux,

Et qu'un peuple muet d'infâmes araignées

Vient tendre ses filets au fond de nos cerveaux,

Des cloches tout à coup sautent avec furie

Et lancent vers le ciel un affreux hurlement,

Ainsi que des esprits errants et sans patrie

Qui se mettent à geindre opiniâtrement.

— Et de longs corbillards, sans tambours ni musique,

Défilent lentement dans mon âme; l'Espoir,

Vaincu, pleure, et l'Angoisse atroce, despotique,

Sur mon crâne incliné plante son drapeau noir.

Or, if you're a wine connoisseur, maybe a little glass of this - Lord Byron supposedly called it "a medicine to drive out spleen" - is just what the doctor ordered (photo credit):

The Merry Drinker writes, "Chasse-Spleen is made up of 73% Cabernet Sauvignon, 20% Merlot and 7% Petit Verdot, fermented in stainless steel and cement, then aged in oak for 12 to 14 months. The 2003 is bluish-purple, with a strawberry jam nose. Its tannins are still a little harsh – unavoidable in a wine built to last – but they do not impair the pleasure, which is intense. The taste is scrumptiously full and meaty, the finish good and persistent."

The finish good and persistent. I'd drink to that, but chocolate's more my style... :)

*from George Eliot's Daniel Deronda

Lament Over Education; or, I'm Going Through a Little Blue Period of Sorts...

I have become convinced that (perhaps unbeknownst to itself) this country doesn't give a flying frigging rat's patooty about education.

Worse: I think a lot of people here actually see being educated as a negative - at best, an "elitist" goal; at worst, a useless endeavor; and somewhere in between, an embarrassing obligation.

Someone please tell me I am wrong and am just going through a little slump triggered by thoughts of being on call every other night at the end of next month. Please. Someone please reassure me that all the propaganda about reading to our children isn't just empty hypocrisy in light of how little we end up reading as adults.

Here's what's behind my momentary cynicism. American politics, for one thing. And for another, American pre-medical education. Both worlds, incidentally, highly competitive, centered around defeating opponents and making oneself appear irresistible despite the reality of one's qualifications. And both worlds ones in which a solid grounding in the humanities AS WELL AS the sciences - in other words, a well-rounded education - seems grossly undervalued.

Let's leave politics alone right now; there's no shortage of verbiage on it all across cyberspace. But what of becoming a doctor?  What of pre-medical education?  Why are we still wondering what that educational path should consist of, after discussing it, criticizing it, revamping it, defending it, and criticizing it yet again, for the last hundred years?

I believe all doctors should be well-educated people who appreciate the value of a truly liberal education. But a lot of doctors echo in spirit what one thoracic surgeon once said when the patient was surprised to learn she hadn't read an author that the patient had been discussing with me as I placed monitors before administering the anesthetic. The surgeon said to the patient, a little acridly, "No, I was busy reading things that would actually be helpful to you." I wanted to make a little sound of incredulous protest but I held my tongue. I was surprised, though, by the intensity of my own resentment of her remark. I felt personally affronted.

Let me tell you, my having had to learn organic chemistry has NOT been helpful to my patients, and I've forgotten it all. All of it. Hours of effort, sweat, and tears - gone. Calculus is NOT helpful to my patients either (though I did use some arithmetic once trying to calculate how much bicarb to give somebody in an extreme state of acidosis). The work in medical school is do-able for anyone who is reasonably intelligent, interested in the material, and willing to work very, very hard. It was certainly easier than organic chemistry for me, and more relevant...though a lot of what we learn in medical school never, ever comes up again in clinical practice (unless you're an anesthesiologist; then it comes up every day). Whatever you end up choosing, though, chances are having gotten an A in orgo was no more predictive of your being a good doctor than getting a B or a C, and getting a B or a C no less predictive than getting an A. 

Don't get me wrong; I believe a strong education in science is integral to medical study and of vital importance regardless of one's chosen profession.  But encouraging intense focus on hard sciences, for a secondary goal (admission to med school) rather than for the sake of science itself, to the exclusion of the humanities, selects for a very particular (competitive, self-interested, often arrogant, and at times, decidedly un-empathetic) type of student - often, for students who get really good at shutting themselves up in rooms with their noses in textbooks away from the rest of teeming, suffering humanity. 

Authors Jeffrey Gross, Corina Mommaerts, David Earl, and Raymond De Vries couldn't have painted a more accurate picture when they wrote in their paper for the journal Academic Medicine,

"The requirements established by medical school admission committees and the courses and tests used to weed out those who are not qualified to become physicians do more than lay the groundwork for the rigors of medical school - they also create a premedical student culture with a distinctive set of norms and values.  One does not have to believe in the existence of the premed syndrome - excessive concern with grades, extreme competitiveness, and lack of sociability - to acknowledge that during the premedical years, students learn more than information from their textbooks and teachers."

If medical students end up forging effective relationships with members of suffering humanity, understanding the ramifications of their patients' conditions, and negotiating the often complex journey from clinical evaluation to clinical decision, it's not only because of those hours of isolation spent memorizing facts that they won't be applying in the practice of their art anyway. It's because they learned, in the course of their journey into adulthood, how to participate in story and relationship - how to understand, evaluate, discern, and communicate. The ones that aren't afraid to touch their patients on the first day on the wards already have something that can't be taught - but that can be learned.

I'm with Lewis Thomas: let's stop encouraging the formation of stereotypical "pre-meds" (carbon-based life forms) and start going for real people (flesh and blood and, if we're lucky, soul). He wrote, "I have a suggestion, requiring for its implementation the following announcement from the deans of all the medical schools: henceforth, any applicant who is self-labeled as a premed, distinguishable by his course selection from his classmates, will have his dossier placed in a third stack of three. Membership in a premedical society will, by itself, be grounds for rejection."

Huzzah, I say. Let's do it. Then maybe after another hundred years there will have been enough talk and revamping of medical education that we'll actually be nurturing physicians-to-be who, instead of making "strategic" pre-med choices to project the best "image," will be making genuinely self-edifying choices to be the best human beings they can be - and thus the best doctors.

Computer Woes

My laptop died.

A couple of days ago a repository of memories, messages, knowledge, and creative efforts, working just fine; now, a silent, dark, lifeless THING that won't turn on. I cannot begin to express my anxiety and grief.

To add insult to injury, let me quote what a few fellow-bloggers have said about the "New Sitemeter," which is unreadable, unusable, inaccessible, and basically useless:

"the new sitemeter rolled out today and my first impression is: i hate it."

"The new Sitemeter is much much worse."

"New Sitemeter is much less usable than the old one."

"I hate the New Sitemeter...Just another complicated, obfuscated, hard to use system."

"The old Site Meter was simple and elegant. The new Site Meter is clumsy and awkward."

"A total debacle. Take something simple to use and render it incomprehensible."

"I hate hate hate hate the new Sitemeter."

and, in my opinion the most accurate assessment of all,

"The new Sitemeter is a STINKING PILE OF CRAP."

I agree with all the above, with Stephen Green's Open Letter to the "shameless sodding shiftless saps" at SiteMeter, and with everyone on the Google Blogs search results for "the New Sitemeter." Everyone hates it. Everyone's jumping ship. The question is, what is everyone thinking of using now? Statcounter?

I am bummed. I am on-call. It's been rainy. My computer doesn't love me any more. Waaaaaaaah.

Where's that piece of chocolate I saw just a moment ago...

________________________________________________________

Update, c. 8 p.m. on 9/24/08 - I guess the SiteMeter people got wind of how everybody feels about the "new" version and are retreating. Too bad a lot of users are by now completely disgruntled. I'm even annoyed enough to resent the fact that they don't seem to know or care that "customer's" is not the plural form of "customer." What can I say - my grammar antenna gets a little hypersensitive when I'm irritated. Character flaw.

T.'s 250th - My First Retrospective

Welcome to my 250th post!!!

I thought I'd wax nostalgic and celebrate by culling together some of my most Anesthesioboistic old posts. Hope you enjoy this little side-trip down memory lane.

Posts that give a little glimpse into the "real me" - or should I say, the "real T.?"
T. Unmasked (just a bit): the Interview
My Favorite Things
Valentine's Day - Ugh
Midlife Already? A Look Back at my Education
Cadaver Poem
Mushroom Love
yes I said yes I will Yes
"Mawidge - Dat Bwessed Awwangement"
The Closest I May Ever Come to Discussing Sex on this Blog (Unless You Count the Mischievous Inside Joke In That Mawidge Post...) - Still Rated PG
Success is a Neon-green, Glow-in-the-dark Monkey Around Your Neck and a Squishy Yellow Duck in Your Arms
ABC's for today

Memorable Medical Moments
Wound Care
The Last Day
Wide Excision
The Rounding Orb
A Wish for Divining
Tales from Saint Boonie's: Songs in the O.R.
On Seeing and Being Seen: a meditation on the social psychology of medical intervention
(This) Sux
Shock Therapy
Amputation
Job (a story for Veteran's Day)
Heart Room

What You Get Is What You See

Pain and Suffering II: a confession

Declaring Death, and Life

The Limits of Viability
Father's Day Thoughts from Behind the Blue Drape

Other Reflections on Medicine
To Write or Not To Write: a question for doctors who blog
The "F" Word
Losing Patients
Sign Here, Please
The Deep Satisfaction of Demonizing Our Doctors
Excursions in Medical History: "Doctors Wanted - No Women Need Apply" - And Yet, We Did
Tales from Saint Boonie's: Gross, and I mean GROSS, Anatomy
Why The O.R. is NOT a "Meat Market," Grey's Anatomy Notwithstanding; and, Looking a Patient in the Mouth: What's That About?
Excursions in Medical History: Brief Walk Through Medicine in Art

You Are What You...Have?
Would You Still Love Me If I Had No Face?
Have You Hugged Your Anesthesiologist Today?

On Being a Mom
What's a "High-Payoff" Kid?
Whose Gifts Will We Accept?
Commotion of the Heart
Birthday Cake with a Side of Deep Thoughts
Confessions of a Worried Stage Mother
The Gashlycrumb Tinies Come Haunting Again
Sweetie, Please Don't Go to Med School
Reed-Making Tips, Time Capsules, and Trampoline Secrets
American Idyll
Optics, Acoustics, and Matters of the Heart, Not Necessarily in that Order
Mea culpa, mea culpa, mea maxima culpa: Confessions a Working Mom

On Faith
Keeping the Faith - questions to ask oneself
Ash Wednesday Musings by a Hungry Disciple
Pentecost Thoughts
"We Can't All Be Mother Teresa" - Or Can We?
The Problem of Prayer
God on the Brain; the Brain on God
Gabriel's Oboe / The Mission Revisited
Nulla Per Orem (Or, Anesthesia 1, Theology 0?)
How a Plate of Broccoli Got Me Thinking About God and the Whole Evolution v. Intelligent Design Debate
Fusia Podgorska and the Milgram Experiment
René
à la Recherche de Saint René
The Purity Ring Thing

If You Don't Like Your D, Don't Go to C

Christmas Star Light
Faith, Children, & Some Big Questions - one of my earliest posts

Food, Glorious Food
Oboe Consolation Pudding
Pasta Puttanesca (at bottom of post)
Sweet Potato Pie
Ful
On Filipino food: see here, here, here, and here.
On Gastronomic Delights in France
Paul Levy, How Could You Do This To Me?! :)

Books, Books, Books
Books That Made a Difference
Celsius 233
Brief Book Meme
Summer Reading Time (2008)
More summer reads, including a great blog - but first, HOMAGE
Happy Birthday, Little Sage

The Power of Books

Thoughts on Music
Oboe-lover's Guilt

Sounds in my Brain, Music in my Soul
Playlists
L'Insegnamento Medico Alla Moda
Discovering Dring
My Other Favorite Instrument
Snow! ...and, oboe news!
Oboe Name
Oboe Poem while on-call

Then there were those three posts where I accused a world-famous rock star of using someone else's work and failing to give proper credit: Hovern Engan, Hovern Engan II, and Hovern Engan III.

And finally, my own favorite post. No special reason.
Tales from Saint Boonie's: One of the Gang.

Thank you all for your support!

Looking Back

Before 9/11, like my little girl in this picture , we felt safe and free. We took that feeling for granted.



Three days before 9/11/01, my family and I were flying kites on a hillside overlooking the Hudson.



Days later, and for days afterward, we would see clouds of smoke rising over New York in the distance from a hillside like that one, after the planes hit and the Towers fell.


Today my husband and I took an afternoon stroll through our peaceful neighborhood. It's a gorgeous pre-autumn day - sunny, in the 70's.



Comfort. Safety. Freedom. Each other's presence. We're trying not to take those precious, precious gifts for granted.


Please visit Suture for a Living for great links and suggestions for remembering 9/11.

Cadaver Poem

In medical school I wrote a poem in honor of my cadaver, whom our anatomy professor introduced to us as our "first patient." I found the poem in a box in the basement during last week's excavations. It's strange to have this artifact now, after so much has happened - a window into what I was thinking at the very beginning of this journey in medicine.

I wrote it in voices, but that wasn't my idea; I was inspired by Paul Fleischman's book Joyful Noise: Poems for Two Voices, which won the Newbery Medal in 1989.

The voices in the poem alternate for the most part but occasionally speak simultaneously, indicated by lines occurring on the same line or in the center. It's hard to read, and it's not great poetry, but the thoughts are genuine. It had no title when I first wrote it. (P.S. The photo above is indeed of the anatomy lab at my alma mater, New York Medical College...but it was just getting built when I was a student there! I do envy the lucky folks that got to take their anatomy course in that beautiful lab instead of the old one...)


Learning Anatomy

(The Student)............................................(The Body)

Between you and me
my fears and my hopes

Between you and me

my heart in your hands

I am young

I am old

I am living

I have lived

The distance is wide

Between you and me.

How does one person

come to understand

another?

You have touched every scar,

traced the stories they tell

on my body, but my spirit

you have not read

A jumble of words.........................................I have become

a specimen, a chore....................................a jumble of words

an interesting case........................................a body, a case

A jumble of words

A mumbling of rituals

pacemaker.......................................................heart failure

mastectomy...................................................hysterectomy

hysterectomy.....................................................metastasis

metastasis......................................................nephrectomy

nephrectomy.....................................................pacemaker

heart failure.....................................................mastectomy

My hands have trembled

holding the silence of your heart

These hands

They have wiped

the tears I have wept

Want to heal so many hurts

Come together in prayer

These hands

They have clasped a dear one close

Been a part of good laughter

Been a part of much hurt

yet made wonderful things

Like music, and bread

They have cleansed and rebuilt

Made the ordinary extraordinary

I have nourished and created

I have suffered

I have hoped

How little we understand

How little you have probed

How wide is the distance

between you and me?

Only as wide

as your gentleness

I have never been as open as you

This is the most intimate time of my life

My death

To whom can I tell my stories?.......To whom will you tell my stories?

Your gaze is sharp

Sharper than a surgeon's blade

my imaginings about your life

Have you ever nursed a child?

Have you ever loved another?

Have you known loneliness and joy?

Have I really looked inside?.......Have you really looked inside me?

When you dance in a roomful of happy friends

Watch the first snow fall

Hold an infant

Kiss an elder

Think of me.

Has anyone given you such a gift?

Have I ever given a gift such as this?

I will not forget................................................Do not forget

This intimacy

This fractured life

full of possibility

You are so full of wonder

I wonder sometimes

Sometimes you laugh

when you'd rather weep

the folly of youth

I long to be healed

We are "wounded surgeons," all;

with bleeding hands we ply our arts

and try to tie the frazzled ends

Of mysteries and fragile lives.

We huddle close

You stretch far across

and now

your gaze is sharper

you see

Despite my wounds

Despite my many wounds

and the worlds I have lost

Despite all we have taken

away from you

we are yet not so powerful,

not so wise

I am still a woman

I am still one to be reckoned with

We think we have power

You think you know me

But you know the truth

We

are more helpless

and vulnerable

than you

Despite all we have taken

You could not take my soul

You have given so much

You have crossed the valley

of a shadow we don't know

But I fear no evil

for it is you there beside me

Though the distance is wide

Between you and me

a heaven, an eternity

You will stay with me always

I will remember .....................................You will remember

to speak softly

to touch gently

to walk in kindness

Never forget

You are precious, beyond price

Comfort me, then

for my dreams lie with you

my heart in your hands

My self in your hands

between you and me

The distance is wide

But we have held hands across it.

c. 1999

Discovering Dring

Last Friday's edition of the radio show On Point with Tom Ashbrook was an irresistible journey through twentieth century music guided by New Yorker music critic Alex Ross, whose best-selling book on the subject, The Rest is Noise: Listening to the Twentieth Century, comes out in paperback this October. (He authors a blog by the same title.)

This was a GREAT show. If you love modern music, or want to, listen here.

I really enjoy the stories associated with late-19th and 20th-century music (except the ones about Mahler's marital problems...those make me sad):

...The tension in the audience as people waited for the opening strains of Richard Strauss's Salome...

...Schoenberg deeply moved at a road-side food stand when he and his son heard his music playing on the radio...

...Messiaen and fellow POW's playing his haunting Quartet for the End of Time in the bitter cold prison camp, Stalag VIII-A, on January 15, 1941, for an audience of 400 prisoners and prison guards. "Never was I listened to with such rapt attention and comprehension," recalls Messiaen...

...And of course the riotous premier of Stravinsky's Rite of Spring, described so vividly in Michael Tilson Thomas's documentary for the series Keeping Score. (Though now I can never think of the opening bassoon solo without hearing in my mind the "bassoon's lament" musicians joke about: "I...am not an English hoooooorn.../I am not an English horn/I cannot play so high...")

I particularly like the story of Rite of Spring because I am always enthralled, though also deliciously irritated, when I learn of artists (or scientists, or leaders in other spheres) who are prophetic, ahead of their time, who go against the grain and shake people up, only to triumph in the end despite their detractors. Where would we be without Stravinsky?

I have my own favorites, too. I love Brian Easdale's score for the film (and ballet-within-the-film) The Red Shoes. I love Aaron Copland. I enjoy the very mechanical-sounding ballet In the Middle Somewhat Elevated by Thom Willems. And of course I love Ralph Vaughan Williams and Gordon Jacob.

But today I made a wonderful discovery: I also love the work of their student, Madeleine Winefride Isabelle Dring, whose Trio for Flute, Oboe, and Piano I heard for the first time on the radio today. What a beautiful oboe part!!! The second movement, especially, was lovely - almost-too-sweet-but-not-quite (like a perfect confection), lyrical, at times a little "biblical-sounding" (just my type!). I've heard parts of her Festival Scherzo for Piano and Strings and Peacock Pie Suite for String Orchestra, and her stuff is just YUMMY. And I love the fact that she wrote a lot for oboe, thanks to her oboist-husband Roger Lord. I'll have to check out her Dances for Oboe some time. The late Madeleine Dring would have been 85 this year, just a couple of days ago, on September 7.

The piano works of my daughter's piano teacher, Dianne Goolkasian Rahbee, are among my favorite modern pieces for piano. Alas, this fall, for various reasons, we've had to stop formal lessons and are home-schooling for both piano and catechism (we won't allow our kids to quit music entirely until they quit home). Even my oboe training is suffering; I won't be able to find lesson time for several weeks and am trying to go it alone till then, which is of course much harder. We need our teachers so much. I just hope I can give my daughter enough of what she needs to be nourished and educated as a musician (and as a person of faith). And I hope all the things that are tight right now - mostly time - open up soon!

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Image: Nicholas Roerich's 1913 set design for Part I of Rite of Spring

Excursions in Medical History: "Doctors Wanted - No Women Need Apply" - And Yet, We Did

For today's "Excursion" I created a post for Mothers in Medicine about a few admirable women physicians whose lives are described on the wonderful N.I.H/NLM website Changing the Face of Medicine. Click here to read the post. [Photo: Dr. Ruth Marguerite Easterling]

All the women I mention in that post died before 1922.

Let's see how far we got almost three decades later.

In her book Women in Medicine*, Hedda Garza writes, "In 1949 and 1957, hospital chiefs of staff and male physicians gave familiar answers to the questionnaires asking them their opinions of female doctors. Many of them commented that women doctors were 'emotionally unstable,' 'talk too much,' and 'get pregnant!' One dean actually declared that he preferred a third-rate man to a first-rate woman doctor."

Let's go another almost-thirty years.

As late as 1982, the Journal of the American Medical Association reported in an article* entitled "Attitudes toward women physicians in medical academia" that almost 50% of male medical students and physicians agreed with the statement: "Women physicians who spend long hours at work are neglecting their responsibilities to home and family."

And, finally, the present day. When I got into medical school I was criticized for considering day care for my baby. I was chided for expressing and storing breast milk (privately) during work hours when I was in physical pain from being engorged. Someone warned me against asking for a non-clinical day to deal with a school crisis. Another told me it was okay for the male residents in the O.B. lounge to watch the baseball game on T.V. between epidural placements but not for me to quietly address birthday party invitations. And, my favorite, a female attending physician at this same academic center was overheard by my pregnant friend saying "It's irresponsible for a woman to get pregnant during residency." Is the corollary, then, that it's also irresponsible for a woman to apply for and undertake med school and residency if she already has children?

Sometimes when I get disheartened or feel alone over being a doctor, wife, and mom all at once, I try to remember why I did it all in the first place - especially now that I have a couple of friends just starting that journey. I found a little window onto a T. from times past - an excerpt from my application essay to medical school, flaws and all, which I excavated out of my recent basement diggings through old folders and boxes. I hope somewhere deep down, it's all still true.

I think I will excel as a doctor not because I have done well in science but because I have done well in the arts. I like to think that Saint Luke, who is revered by some as the patron saint of painters as well as doctors, was a good physician for the same reason. We don't have examples of his painting, which may be the stuff of legend, but the writing attributed to him shows a keen awareness of others' feelings. A man who, as a writer, could describe unforgettably a father running halfway down the road to welcome his Prodigal Son into his arms, or a woman weeping tears of love at someone's feet, must, as a doctor, have been exceptionally perceptive, caring, and attentive. Because arts such as dance, acting, singing, and writing require a profound awareness of the body as well as of the mind and heart, they are wonderful teachers of sensitivity and compassion, and of how to be expressive through movement, through touch, or by describing what we see and hear...[When as a volunteer at Mass. General I] eased an Ecuadorian toddler's fear by talking him through a procedure in Spanish, I could not help but feel a deep reverence for the strong connections between medicine and art, between art and service, and between healing and trust.

...I have made a very strong commitment to medicine, not only because I want to help those in pain through word and touch and knowledge, but also for the same reason I dance or write stories: I dedicate myself to these arts to learn continually how to notice things, and to teach myself not to lose hope. Of all the gifts that medicine can give, this is probably the gift that means the most to me. It is like St. Luke's Prodigal Father running to embrace his son. It is that little Ecuadorian child, a candidate of a heart-and-lung transplant at MGH, asking me to pat him to sleep.

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*References found via http://xnet.kp.org/permanentejournal/sum00pj/women.html:

Garza H. Women in medicine. New York: Franklin Watts; 1994. [Cites Walsh MR. Doctors wanted: no women need apply. New Haven (CT): Yale University Press, 1977. p. 245-6.]

Scadron A, Witte MH, Axelrod M, Greenberg EA, Arem C, Meitz JE. Attitudes toward women physicians in medical academia. JAMA 1982 May 28;247(20):2803-7.

The Gashlycrumb Tinies Come Haunting Again

When I saw the What-ifs post on Mothers in Medicine last week, I breathed a sigh of relief. I was not alone! There are other moms and docs out there whose thoughts churn around what-iffing!

Lately I've been doing a little home archaeology - excavating through boxes of old papers and mementos in an effort to decrease clutter, throw out useless, ancient stuff that should have gone out years ago, etc. Can I just say, that is SO MUCH FUN to do when you dig up interesting (though sometimes embarrassing) stuff from college or even high school - old pictures, essays, poems, letters, test scores, articles, notes to self...

One thing that turned up was my Worry List. When my daughter was born I discovered a whole new universe of what-ifs: parental worrying. My creative imagination went wild. Someone jokingly suggested to me that it might help prevent OBSESSIVE worrying if I wrote all my worries down - partly to see how unlikely they all were - and put the paper away, in effect "releasing" my worries so they wouldn't haunt me on a day-to-day basis.

So I did. Writing is therapeutic for me, after all. I wrote down all the things I could think of that struck terror into my brand-new-mom's heart. Looking over it was almost like reading Edward Gorey's Gashlycrumb Tinies. I put the list into a folder and, lo and behold, forgot about it. The plan worked. I worried a little less.

Well, I found the list, and though I acknowledge that it's all still true - I still worry every time my son goes on a beach excursion with another family that he'll get swept out to sea by undertow - I have to say, I could be much worse. Here are some of the items that were on my worry list for my kids (some of them very obviously from my med school days):

-entrapment in car trunks / closets

-falling through pond ice

-lost in a mall (been there, done that)

-poisoned Halloween candy

-Rohypnol

-rabies

-Naegleria fowleri (haven't thought about THAT one in years)

-carbon monoxide poisoning while they sleep over at someone else's house

-vertebral artery dissection while rough-housing

-eating the wrong kind of mushroom

-roller coasters (but I smile and wave anyway when they get on one)

There's something to be said for "releasing" one's anxieties to the winds, through writing or meditation or visualization techniques or what-have-you. It doesn't deny their existence or really change any hard realities but it allows the worrier the possibility of enjoyment and proper function.

The question is why I cope so differently in the O.R. My residency program director once described me on an evaluation or letter of recommendation as "calm" under pressure in the operating room. How is it possible for somone like me to be such an emotional basket case over her kids, or easily exasperated over tiny life stressors like lost car keys or tedious forms to fill out, to be "calm" in the high-stress environment of an urgent surgical procedure? And will I always be able to maintain this composure, and keep from cracking under the strain?

One night when the O.R. ran till the wee hours of the morning, we were preparing for a patient who, we had been told, was "crashing in the E.R." and had to be brought to the O.R. urgently. There was an immediate flurry of activity as we all set about making our individual preparations. At one point I was standing across from my circulating nurse, a young, highly competent nurse who was assembling IV infusions while I drew up various drugs into labeled syringes. She stopped what she was doing, looked up, and said, "I'm nervous."

I paused and met her gaze. She was someone I had always been able to count on to know what to do, when, and how. I had tremendous respect for and faith in her. My heart rate was up, too, in anticipation of the possible disaster we would have on our hands, but somehow I could feel myself tucking the fear into a little corner in my mind and erecting an imaginary force field around it. "Don't worry," I said to her. "We're in this together, all the way. You're an awesome nurse. I'm totally glad you're here."

With that we finished our preparations, the patient arrived, the operation took place, and everyone - patient, doctors, nurse, and tech - did just fine.

Now, where does that composure go when I'm at home? I feel like if I didn't have my husband's unwavering support, patience, and kindness, I'd be lost. I can look at an injured or very ill patient without flinching, but when my kids are sick or hurt it's all I can do to keep from openly wringing my hands and getting weepy.

I guess it's just different when things are that personal. There's no force field to quarantine immeasurable love.

Appalled

As a working mother I am exasperated by those who, without knowing Sarah Palin at all, question just on principle whether she can be effective both in her work outside home and in her role as a mother.

I mean, come on. Are people still so ignorant as to believe that it's impossible for a woman with a career to be a good mother? Or that a woman with children can't be as capable at her work as a woman without? Or that a woman who works only in the home and not outside of it contributes less (or more) to society than a career woman? Come on.

But that's not what I'm most appalled about.

I am appalled that anyone who calls herself a true, loyal American, or feels prepared to assume leadership in the United States of America, should criticize her opponent with the statement,

"Al-Qaeda terrorists still plot to inflict catastrophic harm on America, and he's worried that someone won't read them their rights."

I was already appalled by the way she insulted community organizers by implying they don't have "actual responsibilities," but I was even more appalled at what followed that jab and the one above: applause.

Applause by people who consider themselves true, loyal Americans, living in a country founded on principles of respect for human and civil rights (and by de facto community organizers, no less, who rallied people together for the common cause of independence).

Now, I know what the Constitution says. I know Article I, Section 9, states, “The Privilege of the Writ of Habeas Corpus shall not be suspended, unless when in Cases of Rebellion or Invasion the public Safety may require it.”

But I think this article needs to be interpreted very narrowly. I think the leader of the so-called free world SHOULD be worried about reading people their rights. Even a state of war doesn't entitle this country to abrogate the very principles of jurisprudence that have been established to ensure that decisions are predicated upon facts rather than feelings.

It's bad enough that the current administration has pretty much killed habeas corpus. But to take pride in that, and sneer at those who would uphold it? It's that kind of disdain for The Other that betrays an underlying sense of entitlement, arrogance, and complacency in a society, as well as that society's ignorance. It's only by consistently respecting human rights that we avoid becoming like the very Enemy we consider so hideous and against whom we hope to prevail.

Mothers in Medicine

I was honored to be invited recently to be a regular contributor to the blog Mothers in Medicine, and I'm happy to announce my first post there, which went up today! (Sorry - it ended up being a little long...)

It turned out to be even more personal, in many ways, than some of the ones I write here, if you can believe that. But I guess I shouldn't have been surprised. Being a mom is a big choice; being a doctor is a big choice; and being a mom and a doctor at the same time is the kind of choice that brings a lot of complicated, interconnected feelings and thoughts to the fore...

And of course everyone has an opinion on all of that. Including us. :)

Here are just a few of my many favorite posts from the site:

Mothership - on the similarities between motherhood and internship

Cry - on the tears we shed as physicians

Mothering a Med Student and Babymaking in Residency - on how low the glass ceiling still is in medicine; these reminded me of why I wrote my posts "Medicine Hates Moms" and "Sweetie, Please Don't Go to Med School..."

Seriously, I Wanna Know - alternative career fantasies, which reminded me of my own career-fantasies post

Normal Incompetence - on how we can be humbled by mothering if the doctoring somehow doesn't already do that...

The Orchidometer - on puberty and its little lessons

Taking My Kids to Work - a post which made me wish, for a moment, that I had gone into pathology...!

A Comment from a Daughter - a very moving word of encouragement from the daughter of a physician to all of us who worry about the hurt our careers cause our families

(And for anyone who's wondering...yes, I enjoy the show Dr. Quinn Medicine Woman, even though it can be a little corny at times! I'm a sucker for corny (but wholesome) family fare (I watch 7th Heaven too), and I can't resist escapist "period" films/shows...like The Scarlet Pimpernel with Anthony Andrews...hmm, Jane Seymour's in that one too...)

Mushroom Love

I am a budding mycophile (so to speak)!


My oboe teacher's husband enjoys mushrooming. I must admit that before I learned this I had never before given the art of mushrooming a second thought.





Then recently we hiked the Oak Ridge Trail at Castle in the Clouds in New Hampshire and came across some lovely, colorful mushrooms. Hmm.




Then last weekend we hiked a trail at the Shaker Village, and there were fungi galore! Big ones, small ones, flat ones, curly ones, even coral-reef-looking ones.



Somebody please tell me what this one with the purple lamellae (gills) is!!! Could it be Laccaria ochropurpurea? [I arrived at that guess via the enjoyable flowchart at the bottom of this page at mushroomexpert.com.]



And what's this pure white one with the scalloped edge? I need a chart!

All in all I think I took pictures of 18 or 19 different species. I kept falling farther and farther behind the rest of my family. Bugs attacked me from all sides every time I crouched down to take a picture. At first my companions would call across the woods from the trail ahead to see if I was still following, but after a while they gave up. And at first I'd cry out with excitement to them every time I saw a new one, describing color or some distinctive characteristic, but I never got more than a tolerant, "uh-huh," and the distance between them and me got wider and wider, so though my enthusiasm never waned, I just kept it to my happy, mushroom-loving self after a while. My son later chided with good-natured grumpiness, "You could have hurried up a little bit, Mommy!" after I caught up with the rest of the hiking party. My husband just smiled knowingly to himself and said nothing.

Later that night as my husband and I were pillow-talking I began babbling enthusiastically about my mushroom finds. "I need a book!" I exclaimed. "A picture atlas or a field guide or something."

"Did you see that last big one on the trail with the pinkish ring on the cap?"

"Yeah! Wasn't that cool? You saw it too?"

"Actually there were a lot of old leaves and stuff all over it. I picked off the leaves so you wouldn't miss it."

That's my husband for you. He'll tell me he loves me with words every day, but he'll show me, without words, with quiet, often-unnoticed actions, much more often than that. It's probably the one time getting fungus was even better than getting flowers as a token of affection.

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Addendum, 9:30 p.m.: John Halamka's my hero (along with Chris who put me in touch with him)!

John D. Halamka, MD, is Chief Information Officer and Dean for Technology at Harvard Medical School and a practicing Emergency Physician. He authors the blog Life as a Health Care CIO at http://geekdoctor.blogspot.com/ and happens to know a lot about mushrooms! He very kindly sent me the following reply when I e-mailed him asking for help identifying my mushrooms (stuff in brackets and hyperlinks to mushroomexpert.com/wikipedia added by me):

"Happy to help. Here are the identifications in order of your pictures.

[The orange one]: Omphalotus olearius - the Jack o Lantern mushroom, sometimes confused with Chanterelles - it's filled with cholinergic toxins such that folks who eat it exhibit the signs of organophosphate poisoning.

[The red ones]: Amanita caesaria - an edible Amanita favored by Claudius. However, its appearance is similar to Amanita phalloides, the death cap, so I recommend avoiding all Amanita species.

[The yellow sea-anemone-like ones]: A mushroom without gills that's part of the family Ascomycetes. The genus is Clavaria and the common name is Fairy Club.

[My favorite, the purple-gilled one]: Could be a Laccaria, but more likely it's a toxic Cortinarius.

[White with the scalloped edge]: A toxic Amanita - likely pantherina.

[The one with the pink-tinged cap - my husband's love note]: Russula emetica. [Hmm...too bad about that emetica part...]

[Big snuggly ones]: A bolete of some type such as Boletus luridus.

Buy David Arora's Mushrooms Demystified - it's the only good field guide on the market.

Here's my blog entry about mushroom poisoning: http://geekdoctor.blogspot.com/2008/06/mushroom-season.html."

Thank you, Dr. Halamka!