Halloween at the Hospital

They're ba-aaaaaaaaaaaack...

The entries for this year's hospital pumpkin carving contest were on exhibit this past week. As much as I dislike Halloween, I can't help but smile over its festive aspect (the grim and gory I can do without).

I especially enjoyed the unit of packed red cells transfusing into Count Dracula. My favorite one, though, was the intubated pumpkin from the staff in the critical care unit.

Enjoy the gallery! (Click here to look at last year's entries.)

"Play the Bach, Dear"

My oboe and I are officially back together!

I had a long summer hiatus, in part due to a bad bout of DeQuervain tenosynovitis. Since then my practicing has been sporadic, especially as my work life has grown increasingly hectic. But today, after much wringing of hands and disclaiming, I had my first lesson of the season...

...And it wasn't so bad!

There is no substitute for practicing - the physical act of playing the instrument in a way that helps the mind and body learn and relearn what to do and how to do it better. But what Oliver Sacks writes about mental practicing is true: it can really help maintain learned skills. What it CANNOT do is keep up stamina. Kyoko found my actual fingering, embouchure, etc. passable but my endurance was PITIFUL. (She put smiley-face stickers on my score sheets anyway. My "child within" was totally into that.)

So after all the scales and etudes, when we finally picked up the Air from Bach's third Orchestral Suite, I couldn't blow any more. Which was a bummer, because last night when I practiced this it went FINE. High notes actually sounded oboe-like. But I had only done a few scales then, rather than a whole bunch of scales, plus some etudes, plus some duets, etc. Today low notes were doing better than high. Don'tcha love it when you practice and feel good about how things are going and then get to your lesson and BOMB? *Sigh*...I gotta get back into shape.

I have my assignments now. The scales of the week will be E major, A flat major, and F minor. Yes, I have to bite the bullet, finally, and deal with more than three accidentals at a time! Etudes will concentrate on that transition from B to C sharp that I STILL can't seem to do smoothly. I'm also supposed to work on first and second parts for the Bach Air AND try something I downloaded from IMSLP to hear Kyoko play - she turned the tables on me! It's one of the variations from Act III of Swan Lake. It's often assigned to the Black Swan in Russian productions of the ballet but not as commonly performed in American productions.

This video shows Russian ballerina Lyudmila Semenyaka performing the (60-second) Swan Lake variation Kyoko and I were working on toward the end of the lesson:



...But it's the Bach I dream of. There's an almost sacred feeling to playing Bach. From the first note of the Air - when it doesn't come out sounding like a lung full of crackles in a patient with pneumonia - whether I'm listening or playing, I get transported to what feels like a higher, more blissful plane of consciousness. I bet my brain waves on EEG would show a shift from beta to alpha or something like that. It's as if all the beauty and holiness in the world have been distilled into these mathetmatically perfect musical passages, and as I breathe life into them they breathe life right back into me.

The pieces I can still play on the piano today are mostly ones by Bach and Mozart. Even my beeper now plays Bach to me, and I believe I find myself a little less resentful when it jangles me out of a deep sleep. That's partly why I chose it - because it transformed even a trite little beeper tone into something less noxious. Bach's been a part of my life since childhood. Among my earliest musical memories is the image of my parents playing Sleepers Awake for four hands on our family piano. I remember the warmth and contentment of those moments - and how somehow through my parents' playing together I felt quite loved.

Later my own relationship with piano was somewhat more troubled, mostly due to stage fright. As a kid I identified with the heroine of the book Play the Bach, Dear by Judith Groch, in which an 11-year-old girl who hates piano recitals has a teacher who helps her enter into the music and let go of some of her fear. I think Kyoko's just that kind of teacher. I don't know if I could keep taking oboe without her. We all need teachers like that - ones that release us from our hindrances and bring out the best in us. Maybe that's a teacher's most important job - helping learners rise above their own misgivings and really discover the life and breath of a work. And when that work is Bach...the lessons almost teach themselves.

Postcard from Harvard Square (Warning: A Spilling of Strong Opinions Ensues)

Politics at the chocolate shop (shop window showing # of boxes Obama chocolates purchased v. McCain chocolates):

Additionally, the online tally of boxes ordered shows Obama 2,874, McCain 922 at the moment.

The Obama Box contains

• Hawaiian Pineapple - pineapple pate de fruit covered with dark chocolate
  
• Kenyan Coffee - coffee bonbon coated with milk chocolate and sprinkled with crushed Kenyan coffee


• Kansas Corn Crunch - dark chocolate crispy corn bottom with a ganache made from dark chocolate and Bourbon in the shape of a half moon


• Tennessee Sour Mash - small white mouse made with cinnamon and sour mash

The McCain Box contains

• Arizona Citrus - dark chocolate orange-lemon ganache coated in dark chocolate


• Hot Pepper Tequila - white chocolate ganache with pistachios and tequila, coated with white chocolate and sprinkled with red hot pepper


• Peanut Butter - peanut butter half moons coated in milk chocolate


• Kentucky Rye - dark chocolate ganache flavored with whisky, lemon, and pepper, covered in dark chocolate

Our family supports

• Character and family values - marriage to the same woman for 16 years (one who is educated, gracious, and not one to use her own charitable organization to obtain narcotics to support painkiller addiction); willingness to take a break from a busy campaign to visit a sick grandmother or celebrate a wedding anniversary; not abandoning a wife after a disfiguring accident; not marrying a filthy-rich woman and end up calling her a c--t in public; not assaulting reporters or women in wheelchairs in public fits of rage; supporting education and health care for all
  


• Intelligent, articulate, well-educated leaders - the kind that don't rank 4th or 5th from the bottom of their college class; the kind that don't choose uneducated, ignorant, ill-prepared, unqualified, undignified, corrupt running mates on IMPULSE; the kind that can speak well because they THINK well - sometimes in more than one language - rather than having trouble expressing coherent, unscripted ideas even in their native language; the kind smart enough to want a bipartisan cabinet and articulate why
  


• Policies that don't only recognize or benefit the wealthy - tax breaks for the middle class, not the rich or large businesses; support for rather than cutting of social programs; striving for fair health care access rather than supporting a plan that provides inadequate resources and penalizes Medicare; sound economic and foreign policies that don't replicate the same stupid, wasteful ones that have driven this country into the ground for the last 8 years, led thousands of young Americans into mutilation and death in an unjust war, and made us the laughingstock of the international stage
  


• Internationally respected leadership with sound judgment and stable temperament (and temper) - and with the qualities and skills to really unite Americans, rebuild relationships with foreign partners, and exert what Colin Powell called "transformational leadership."
  

In short, we think Barack Obama should be the next President of the United States, and in light of what's outlined above, we don't see how anyone could be "undecided" at this point - unconscious racism, maybe?

Some might ask, but how can you, a practicing Catholic who on moral grounds would avoid choosing abortion for herself, support a candidate who is pro-choice?

The answer is, I think single-issue voting is irresponsible. The good of an entire society rests on many more things than any single issue could possible encompass. And criminilazing abortion WILL NOT solve the abortion issue.

Moreover, I believe being "pro-life" means being ANTI-senseless-war, ANTI-cutting-programs-that-help-the-disadvantaged, pro-healthcare, pro-education, anti-poverty, anti-torture. It means MODELING HEALTHY FAMILY RELATIONSHIPS, and prioritizing stewarship of the world we live in.

With Jim Wallis of Sojourners magazine, "I will choose candidates who have the most consistent ethic of life, addressing all the threats to human life and dignity that we face — not just one. Thirty-thousand children dying globally each day of preventable hunger and disease is a life issue. The genocide in Darfur is a life issue. Health care is a life issue. War is a life issue. The death penalty is a life issue. And on abortion, I will choose candidates who have the best chance to pursue the practical and proven policies which could dramatically reduce the number of abortions in America and therefore save precious unborn lives, rather than those who simply repeat the polarized legal debates and 'pro-choice' and 'pro-life' mantras from either side."

Does my faith inform my political leanings? My personal view is simple. JESUS WAS NOT A REPUBLICAN. (He was a community organizer, though.) He spent his ENTIRE public life providing FREE health care and other services to the POOREST of the poor REGARDLESS of whether or not they "deserved it" or whether or not the intellectuals and elites of his society supported it (which, often, they didn't). I think it's pretty clear what he thought we all should be doing.

Finally, a well-written point by a physician, Sid Schwab, who has put his brilliant medical blog on hold to rant about politics:

"This idea that any change in Bush's incredibly unbalanced and ineffective tax structure is, by definition, socialism, is like saying improving your kids' education is brainwashing. Returning to some of the tax policies of Bill Clinton??? Why that'd be like, like, going back to times of, what did they call it back then, what was that concept, fading from memory?

Oh yeah.

Prosperity.

I believe John McCain is smart, at least enough to know what bullsh-- this is. And there's no doubt he thinks so little of his 'base' that he assumes they'll eat it. Unsurprisingly, lots of them are. From every angle, his campaign assumes the worst in us, treats us like we're stupid. If it works again, as it has in the past, our descent is unstoppable."

The highest moment of McCain's campaign was when he defended Obama as a decent family man.  It was also one of his lowest moments, as he held up those admirable character traits against the "Arab" label used by the ignorant, racist, bigoted woman who called Obama one, reflecting the disturbing tendency of so many conservatives in this country to demonize Middle Easterners.

Obama will clearly have a full plate if he is elected as he inherits mess after mess in the realms of economics, religion & politics, foreign policy, national security, and race relations.  Our family hopes that this forward-looking family man is given a chance to use his outstanding gifts in the service of this country.

The Beauty of Viruses

There's an episode of Star Trek: The Next Generation entitled "Silicon Avatar" that depicts an entity that can wipe out whole populations of people but is also, to many observers, exceedingly beautiful. To its victims it is an evil; in a universe that takes no sides, however, it is just a being that does what it does, according to the natural order of its structure and functions.

I think of viruses in much the same way. They are intriguing, even elegant; but to us, they are enemies, evil things to be destroyed. Yet all they do is function according to their intrinsic make-up, surviving or not presumably without sentience or intention. We as patients cry, "How could this happen to me?" To a virus, though, infection is not happening "to" anyone or being done to anyone; it simply is. Very often it's the defenses we mount that produce discomfort and suffering, though of course without those defenses that leave us feeling so ill, we would succumb to our microscopic but powerful little "enemies."

Mixed media artist and phlebotomist Laura Splan captures their terrible beauty in these gorgeous lace doilies, which I learned about through Martina Scholtens at FreshMD. Enjoy.

HIV

Herpes

SARS

Hepadna

Influenza

Chocolate Chip Cookies from the Island of Reil

When I'm on call, I get intense food cravings. They are especially intense when I'm up way past my bedtime.

I'm pretty sure I'm not alone in this. A lot of my friends say they graze a lot while on call. I try not to graze, and I try to keep guilt-free snacks around like fruit and yogurt, but when I don't graze and don't have a stash nearby, I daydream. And as the topics of conversation among fellow-employees might suggest, we all tend to daydream about food.

I should know better, because I always find food pictures on her blog enticing, but the other night at 3 in the morning after placing an epidural and while waiting for the next expected one (which I knew would be called for in a matter of minutes), I stopped by my friend Anali's blog, and BOOM - I got a sudden, enormous, overwhelming craving for chocolate chip cookies.

The next epidural happened to be one of those nightmare ones you wish you could just pass along to someone else. First I had to remind the patient to please remove a body piercing - which never makes patients happy, so already you're starting off on a negative note. After that, it took a few tries, but at last I had the epidural needle inserted a full 9 cm - its entire length - and only then did I have even a HOPE of being in the right space (average length to "the right space" is 3.5 - 5cm). That alone should have put a stop to my cookie craving, but alas, it didn't. In fact, it came back with a vengeance once the epidural was in and the patient was dozing off, comfortable at last. I went out to the front desk and remembered: COOKIES.

I wanted cookies. Not just any ordinary, store-bought, nothing-to-write-home-about cookies. I wanted artisan-quality, fresh-from the oven, soft-in-the-center but crisp-at-the-edges chocolate chunk cookies. Like the ones that used to be sold at David's Cookies stores in New York, where the head-spinning aroma would just waft down the street in tendrils that wrapped around you and lured you to the storefront. The online variety are no match for what the boutiques once baked and served.

According to neuroscience, the insula, a.k.a. the insular cortex / lobus insularis / Island of Reil, is to blame. It's a portion of the brain that lies tucked away in an area called the lateral sulcus on each side. It plays a role in body representation, pain experience, subjective emotional experience (especially of fear, anger, sadness, happiness, and disgust), empathy, and hunger. The right insula enlarges in people who meditate. There it is again: a physiologic locus that can be related to the overlap of spiritual, pleasure-oriented, and emotional experiences.

Perhaps when we practice professions that require active empathy at all times, tend to leave us with rushed meal breaks if any, and arouse our limbic structures through stressful responsibilities, long hours on our feet, and lack of sleep, our insulae go into hyper-drive. "Give me cookies!" they cry. (Or, for some, cigarettes, or shish kabobs, or beers, or video games.) Luckily, that night it was late enough (or, by then, early enough?) that my desire for sleep won out.

I am currently on call almost every other night. Today I gave in. I took advantage of a rare afternoon at home and made chocolate chip cookies. Not as good as David's - but mm, mm good anyhow. The kids and the Hunk seemed happy. (And yes, I let them eat some of the cookie dough.)

Back to yogurt, berries, and tuna tomorrow...when I am on call AGAIN.

T.'s Chocolate Chunk Cookies

1 c (2 sticks) butter
1 c dark brown sugar, packed 
2/3 c white sugar

2 eggs
4 tsp. vanilla extract
1/2 tsp salt
1 tsp baking soda
2 1/2 c organic all-purpose flour
2 c semisweet chocolate chunks

Mix together the way you usually make your cookies, drop by spoonfuls onto an ungreased cookie sheet, and bake at 350 degrees for 10-15 minutes, depending on your oven, desired brown-ness, etc. Makes about 40 depending on how much cookie dough you end up eating... :)

Descartes' Bones

I heard an interesting conversation on NPR yesterday that's worth a listen: Tom Ashbrook of the radio show On Point interviewed author Russell Shorto about his latest book, Descartes' Bones. The book has received some criticism for giving Descartes too much credit for the role he played in philosophical movements in and around his time, but most readers seem to have found the work enjoyable and informative, and the questions it raises about faith and reason timely.

Upon his death from pneumonia at the age of 54 Descartes was buried in Stockholm but was later transferred home to France. At the exhumation, so the story goes, a captain of the Swedish guards removed his skull and replaced it with another. His original skull was sold several times before coming to its current resting place in the Palais de Chaillot, at the Musée de l'Homme, while his body lies in the church of Saint-Germain-des-Prés.

(This reminded me of the way the mummified head of St. Catherine reached its final resting place in the Basilica of San Domenico in Siena while the rest of her body stayed behind in Rome. I couldn't help but smile at the irony of rationalists keeping relics too.)

History and philosophy buffs will see in this tale of Descartes' bones the posthumous enactment of Cartesian dualism: the separation of mind and matter brought into symbolic relief by the very literal disembodiment of Descartes' head. His idea of mind and body as separate is probably among his most famous bequests to subsequent generations, along with his immortal (and, perhaps, often-misinterpreted or misappropriated) utterance Cogito ergo sum and his development of Cartesian coordinates and analytic geometry.

The question is, was he wrong? And if we are so sure he was, why are we still discussing the question today?

Neuroscience has increasingly shown, not mind over matter, or mind versus matter, but rather mind that IS matter. Memory, thought, experience, emotion, judgment and lack thereof, connection with "reality" or lack thereof, are all now thought to be the stuff of neurotransmitters being released (or not) in the brain, depending on the interplay of genetic and environmental influences on brain chemistry and development. Mind IS body, or so current science seems to tell us.

The pendulum has swung so far in this direction that commenters on the radio show's website have criticized Tom Ashbrook for even entertaining alternative points of view. In fact, there are Dawkins and Hitchens fundamentalists who seem to consider the very discussion of these matters a contemptible and even destructive waste of time and energy. And certainly in medicine, empiricism reigns supreme.

I'm not satisfied, though. I'm with Descartes, unlike the empiricists that followed him: I believed there are some truths that can be derived from outside the realm of mathematics and the observable. Granted, reason, logic and empirical thinking have their place, and a very important one at that, but they don't solve everything.

Descartes was interested in how we arrive at indubitable knowledge. Part of the answer lay in using simple, incontrovertible facts - not necessarily derived from frail, malleable sensory perceptions - as the basis and springboard for scientific inquiry and discovery. But even fairly reliable knowledge couldn't and can't give us answers to questions like, when does a human life count? When should it be saved? When should it be let go? When is a dead person dead? (More on this last question here and here.)

They all boil down to the same basic question Descartes and all those megaminds asked.

How do I know?

I think it would be arrogant for anyone to believe, and certainly dangerous to assume, that we have the answers for certain, or that we even can. But I also think we would be fools to stop trying for them.

_____________________________________________________

[Photo credit: "The skull of Descartes. Across the forehead, in Swedish, is an accusation of a theft in 1666 that began the skull’s peregrinations. Above it is a poem in Latin celebrating Descartes’ genius and mourning the scattering of his remains."]

Gotta Work On My NuVal Scores

OK, I'll bite (so to speak).

Thanks to an item earlier this month on Toni Brayer's blog I got curious about Yale's list of Top 100 Foods for nutritional value, and about their scoring system, the NuVal Score produced via an algorithm called the ONQI (Overall Nutritional Quality Index).

It seems we can expect the NuVal scores of most items on our grocery lists to be posted in stores this fall. I'm interested in this latest iteration of how to pass judgment on our food intake (I guess the "glycemic index" fell out of fashion?). Doctors' education in nutrition is notoriously sub-par, so hey, NuVal, show me what you got.

The highest score, indicating most nutritious, is 100. I checked on their website to see how our most-frequently-bought grocery items did:

Spinach 100

Red leaf lettuce 100

Green beans 100

Broccoli 100

Blueberries 100

Kiwi 100

Strawberries 100

Oranges 100

Carrots 99

Pineapple 99

Mango 93

Red onions 93

Bananas 91

Grapes 91

Corn 91

Salmon filet 87

Cod filet 82

Clams 71

Bay scallops 51

Boneless chicken breast 39

Lobster 36

Pork tenderloin 35

Flank steak 34

Ground Sirloin (90/10) 30

Ham 27

Beef spareribs/pork baby back ribs 24

Coconut 24

Hm. I thought corn was supposed to be pretty bad for you?  (Incidentally, the ONQI isn't the only nutrient assessment tool available out there.  Check out this Washington Post article for a different food guidance system developed by the Nutrient-Rich Foods Coalition.  Hat tip to registered dietitian Karen Kafer of the National Dairy Council for the links!)

The good news is that although we do eat and enjoy red meat and chicken on occasion, we are mostly fishetarians, so if we can just ratchet up the fruits and veggies we'll be in better nutritional shape.

The bad news is, we do have guilty pleasures (bacon, apple pie, bread), and they are at the bottom of the list, of course. :(

*Sigh...* Why, all of a sudden, are visions of all-butter thumbprint cookies, red velvet cupcakes, opera gateaux, and chocolate squares dancing in my head...? :)

Still in Vacation Mode

Kathleen tagged me for a movie quote meme, so let me delay my reentry into the real world a little further...

Here are my rules based on the meme as it appeared on her blog, on Awkward Blogger, and on Moomin Light:

For the blogger (me):

• List 10 favorite movie quotes or quotes from favorite movies.
  
• Post them and ask readers to guess which movie each quote is from.
  
• Reveal the film title once it's been guessed.
  

For readers:

• NO googling or using IMDb search functions!
  
• Leave your answers in the comments.
  
• Hint: I won't be using quotes from any of the movies I already used for last week's Grand Rounds (and there's nothing from Lobster Man from Mars, either).

Here goes (hoping the ones I quoted from memory aren't too inaccurate...):

1. My dear chap, I never would have dreamt of depriving you of your moment of triumph. Alas, a moment was all I could spare. (The Scarlet Pimpernel, answered by Beach Bum)

2. George: I hope the damp hasn't killed him.

Innkeeper: The damp?

(Impromptu, answered by Anonymous from 10/20)

3. That boy is your company. And if he wants to eat up that tablecloth, you let him, you hear? (To Kill a Mockingbird, answered by Anonymous from 10/21)

4. Do you mean to tell me that my children have been roaming about Salzburg dressed up in nothing but some old drapes?! (The Sound of Music, answered by Kathleen and Beach Bum)

5. What you mean he don't eat no MEAT? ...It's ok. I make lamb. (My Big Fat Greek Wedding - Kathleen and Beach Bum, ya both got it again.)

6. Oh, he's just like any other man, only more so. (Casablanca, answered by Anonymous from 10/21)

7. Quite a glittering assemblage...Royalty. Nobility. The gentry. And...oh, how quaint. Even the rabble. (The Sleeping Beauty, answered by RAG and Zach's Mom)

8. By the word religion I have seen the lunacy of fanatics of every denomination be called the will of God. I have seen too much religion in the eyes of too many murderers. Holiness is in right action, and courage on behalf of those who cannot defend themselves, and goodness. What God desires is here [points to the head] and here [points to the heart]. (Kingdom of Heaven, answered by California PA)

9. No, we don't want any OATmeal! (Moonstruck, answered by Anonymous from 10/20)

10. That cannot be too difficult to understand for someone with the learning to read Plato in Greek. (Lady Jane, answered by Anonymous from 10/20)

Ether Day 2008

Happy Ether Day, everyone!

If you feel like celebrating, check out my Ether Day post from last year. Poor Horace Wells...

Off to Maine for a family wedding today. I'll be back soon! :)

Grand Rounds!

Welcome to Grand Rounds!

Today I've organized Rounds into six major sections (each preceded by a self-indulgent little nod to a movie from my personal list of favorites):

1. School Days - posts about our training experiences and their aftermath

2. Stories from the Trenches - one of the reasons I read medical blogs at all

3. Educational Materials - it's Grand Rounds, after all; but I'm optimistic that our audience won't have their heads nodding onto the back wall of the lecture hall as they helplessly snooze through some slides... :)

4. From the Patients' Side

5. Politics, Economics, "Systems" Errors, and Controversies

6. Medical Blogging: issues upon issues, now and forever


But first, a Prologue. Ramona Bates, M.D., author of the blog Suture for a Living, reprinted this essay on Why Michelangelo Studied Cadavers, and I think it's a great way to start. It's a reflection on the characteristics that allow people to attain success. Something to think about!

School Days

Mother Superior: The band will perform in their gym suits.

Rachel: Our GYM suits?! But they're AWFUL, Reverend Mother.

Mary: It's not as if we were like Sacred Heart. At Sacred Heart they wear short shorts for gym.

Mother Superior: They're French.

Ah, training. If only there were some other way.

First we turn to one of my favorite medical bloggers, Theresa Chan, who on her well-written blog Rural Doctoring looks back at her premedical days with two posts, "Premedical Education, the Long Way - Part 1" and "Part 2."

Next, the med school and residency years. DB offers some thoughts and quotations about medical educators. Medical student Jeff Leow muses on how our future responsibilities haunt us even as we prepare for them, for tasks as simple as obtaining I.V. access. During a tough month in the NICU for umbilical lines Beth doesn't take it for granted when hers goes in and learns why patience is a virtue. PathRes tells us what being on call during pathology residency is like. And just for fun, Check out the entertaining speculation on The Dragonfly Initiative on what it might be like if the characters from Heroes went to medical school.

Dr. Gurley takes us back to those professional patients who volunteered to let us learn how to do pelvic and rectal exams correctly. Remember that day? And how surreal it was to get actual feedback from these helpful patients who were willing to let us invade their privacy so we could do right by our future patients?

Finally, the years that follow. Jordan looks back at the layers of expectation that have been peeled away by the training experience to reveal a more nuanced primary care practice. And speaking of not having to practice according to the textbook, Dr. Zhang describes skipping over the usual rituals to deal with the hiccup boy. Bongi describes how despite their years and years of residency training, general surgeons still have to deal with people making the wrong assumptions about them. And Fat Doctor encourages students and residents who are still on that long road to take heart - you do come out better in the end.

Stories from the Trenches

Dr. Okun: The neatest suff has only happened in the last few days. See, we can't duplicate their type of power, so we've never been able to experiment. But since these guys started showing up, all the little gizmos inside turned on. (laughs) The last 24 hours have been really exciting.

President Whitmore: "Exciting?!" People are dying out there! I don't think "Exciting" is the word I'd choose to describe it!

Here's the latest by Pathmom from Mothers in Medicine. If you're a working mom and can't relate to this, you either haven't been working long enough or haven't been a mom long enough, or you're perfect, or your kids are perfect.

Bongi describes removing a "tumbler" -a bullet that wrought more havoc than its not-too-high-velocity might have suggested.

Just discovered a great blog, Mulberry Street, written by Jonathan, a senior anesthesia resident who wrote this post about a tough intubation for a dying patient. Not for the faint of heart (or stomach). No, Jonathan, you should NOT get a desk job - we need you.

Being with a patient at the moment of death can be a haunting experience. This one stayed with the author of Respiratory Therapy 101.

End-of-life issues have been on our minds lately; here's what Rag of The Chloroform Rag has to say about them. Some sobering realities in there.

Found this beautiful end-of-life story (written by an E.R. doc) thanks to KevinMD today and had to share it too.

But it's not all sorrow and loss. Here's a story of hope from FreshMd.


Educational Materials

Santa: I've been to New York thousands of times.

Buddy: Really?

Santa: Mm-hmm.

Buddy: What's it like?

Santa: Well, there are some things you should know. First off, you see gum on the street, leave it there. It isn't free candy.

Buddy: Oh.

Santa: Second, there are, like, thirty Ray's Pizzas. They all claim to be the original. But the real one's on 11th. And if you see a sign that says "Peep Show", that doesn't mean that they're letting you look at the new toys before Christmas.

The tradition of Grand Rounds evolved as a forum for educating physicians. Here are a few informative posts on a variety of topics:

First, a post on a subject near and dear to me: AIR. PalMD gives us "Breathing 101" on the Denialism blog.

Medical videographer Sterile Eye highlights the invention of the triangulation method for suturing of blood vessels in his fascinating look back at Nobel prize-winning surgeon Alexis Carrel.

Pallimed gives us a history of the concept of brain death. Lots to think about!

Dr. Auerbach continues to teach us about desert survival and warns us of the toxic metal content of certain ayurvedic products available on the web.

The Samurai Radiologist gives us some fascinating AED lessons from Japan.

Dr. Val introduces to MRgFUS. Who's he, you ask? Well, actually, it's the game-changing medical technology of MRI-guided ultrasound surgery - or as Dr. Val described it to me, a die-hard Voyager/DS9/Next Generation fan, "Star Trek medicine at it's best."

With his usual excellent writing, Dr. Campbell of Reflections in a Head Mirror tells us The Naked Truth About Tonsil Cancer.

Check out Harvard medical student Ishani Ganguli's column on the intersection between psychiatry and neurology, via Paul Levy's blog. It's all in your head, folks.

Docneuro discusses the optic nerves and how the world would be a different place without them.

Dr. Dimov teaches us about Spiriva treatment for COPD and warns on Allergy Notes that global warming may lead to more allergies.

Ramona Bates just re-posted a helpful, informative review of mammograms. Her blog Suture for a Living is always worth a visit; don't miss her recent hosting of the blog carnival SurgeXperiences, which includes a section on surgery in the news.

On a related note, Buckey Surgeon has a Mammosite post here.

In true Grand Rounds debating tradition, Sandy Szwarc gives us her scoop on Junkfood Science - food for thought, shall we say? - while on Respectful Insolence, Orac offers a scathing rebuttal to her latest post on obesity. Have fun!

From the Patient's Side

Humperdinck: To the death!

Wesley: NO! To the pain.

Humperdinck: I don't believe I'm quite familiar with that phrase...

Amy Tenderich of DiabetesMine reminds us of the very basic fact the patients are people (kinda like doctors...see above for those reminders).

Surgeon and best-selling author Pauline Chen reviews the book Sick Girl by Amy Silverstein and describes how it helped her understand the way patients make decisions. Check out her column too on The Dance Before the Diagnosis.

Duncan Cross tells the story of a visit to the dermatologist that will make anyone who cares about patient care and comfort cringe.

Laurie Edwards reflects on the impact of language on patients' experiences.

And speaking of language, Edwin Leap writes on his blog about the many tongues of the emergency room. His wonderful writing is always a treat.

Many patients face issues of chronic pain and its impact on day-to-day life. Jolie Bookspan provides valuable advice on how to minimize the strain of autumn yard work and keep fit despite problems such as rheumatoid arthritis.

Dean Moyer takes us through what it's like to get an epidural steroid injection.

Roger Federer, via the blog How to Cope with Pain, may (indirectly) have some secrets to share for patients who wrestle with chronic pain.

Jenni Prokopy has some suggestions for how we can teach ourselves to let go of our fears.

And Barbara Kivowitz offers an example of patients' lives behind-the-scenes through the description of one married couple who have stood by each other in sickness and in health.

Politics, Economics, "System" Errors, and the Quagmire of Controversy

Lermontov: Calm yourself, Sergei.

Sergei: But the door! The door! It won't shut!

Lermontov: Well, somebody will have to hold it.

Who wants to tackle the one about whether health care is a right or not? Shadowfax and Maggie Mahar did, then did again. I think we could all discuss that issue for hours.

Borrowed this Dilbert link from the latest post at The Ether Way. Hat tip to Mike O'Connor, who reflects on the whole "best practices" issue.

The Happy Hospitalist writes forcefully about doctors as professionals and what they might be associated with in people's minds. Makes for interesting discussion.

White Coat rants about the pediatric cough medicine brouhaha (sp.?).

Orac reviews Autism's False Prophets, writing, "Finally, science pushes back against antivaccine lunacy."

Dr. Rob on Musings of a Distractible Mind discusses the way prevention has become a buzz word.

An Australian doc tackles the issue of emergency department waiting room deaths. "The evidence is plain to see, easy to read, and possible to fix." Then why aren't we doing better? (See here and here for some attorneys' posts on waiting room deaths.)

Speaking of not doing better, Nancy Brown enjoins us to remember Native American victims of sexual abuse and to work on the gaps in care faced by these patients.

Kim over at her terrific site Emergiblog considers the current nursing shortage - which we really shouldn't take for granted, considering how a truly good nurse isn't "just" a nurse.

Jay Norris points out that a health insurance tax credit won't solve the problem of health care access.

The Happy Hospitalist is unhappy over the "goofy economics" of reimbursement for doctors.

JCAHO finally gets some competition, as David Harlow explains.

And what's happening in Canada? The Canadian Medicine blog, InsureBlog, and Ian Furst of Wait Time and Delayed Care weigh in.

What about Washington? Dr. Sinclair who authors Pallimed discusses the Physician Assisted Suicide Vote.

And it's high time we had some intelligent, in-depth, meaningful discussion, regardless of political or religious beliefs, on the fact that Pro-Life Can Mean Death for Women in the Third World, as Toni Brayer of EverythingHealth points out.

Medical Blogging: the Issues May Never Die

Sir Kay (after Arthur points to where he wants to set up camp for the night): It's too exposed, Sire. We could never possibly defend.

Arthur: (glares at Sir Kay)

Sir Kay: Sire. (rides away obediently)

I find I keep adding to my post "To Write or Not to Write: a question for doctors who blog." Why? Because every week, it seems, there's a new piece out or an additional issue described regarding the dangers of medical blogging. The latest link I added, from The Scalpel's Edge, suffers no fools and tells it like it is: "Medical blogging is risky because it is important." Kathleen Seidel of Neurodiversity found that out firsthand when she got harassed with an obnoxious subpoena.

How timely it is, then, that Bob Coffield should write about Dr. Wes's legal blogging woes. I was just thinking about those as I reviewed Dr. Wes's own response to the situation, as well as reactions by KevinMD (on "Physicians and blogging") and TBTAM ("Every blog needs a bouncer" - definitely!)

Coffield's post on the Health e-Information Technology Act of 2008 might be helpful as we bloggers continue to participate in the information age and have to navigate a world in which technology like this, highlighted by Laika Spoetnik of the MedLibBlog, makes information accessible to all, ready or not.

Finally, Buckeye Surgeon offers this thought-provoking post on why he "came out" in the blogosphere. If it hadn't been for my kids, I might have considered doing the same...might still do it...although I find Buckeye's own travails dealing with people invading his family's privacy discouraging, so for now, I'll stick to the blog persona.

It's a Wrap!

That's it, folks! Time to go back to clinic / the O.R. / the lab!

For those who, like me, enjoy rounding further in the medical blogosphere, White Coat Rants's blog links might be helpful.

Thank you to everyone who submitted posts for this edition of Grand Rounds, and to all who didn't submit but got volunteered to be in it anyway, by me! Please tune in next time when it will be hosted by Christian Sinclair, M.D. at Pallimed.

"C'mon, Dear" (or, How Many Buttons II/Revenge of the Buttons/Buttons Redux/Son of Buttons)

I try to be a nice person, but the truth is, I am not always a nice person.

I'd rather not admit or draw attention to that on my blog, my beloved refuge for sorting out my thoughts and stories. But it's the truth.

Being honest about myself and my experiences has in the past invited lots of judgment from those superior folks out there who ALWAYS make the right decisions and NEVER make any mistakes or commit any sins, but what can I do - I DO stumble, I'm not always perfect, I'm just learning, and I'd be lying to myself if I only described rosy, feel-good moments during which I was brimming over with compassion and behaved like a veritable paragon of sweetness.

Not long ago I got irritated with an elderly male patient who kept addressing me as "dear." And I told him so - not explicitly, but unambiguously nevertheless.

The irony is, I've been guilty of the same myself.

In his post "Don't Call Me Sweetie," KevinMD highlighted a recent New York Times article about how the affectionately-intended habit some doctors and nurses have of calling elderly patients by terms of endearment, such as "Sweetie" and "Dear," comes across to many elderly patients as condescending, belittling, and offensive. I have been guilty of using such terms of affection, usually because I feel protective, and genuinely HAVE affection and a feeling of nurturing for many of my patients, and it spills out into the language I use.

But I've tried to avoid it recently, even before this article came out, because I realize, too, that many patients, understandably, feel as Elvira Nagle, an 83-year-old woman from California, feels: "When I hear it," she says, "it raises my hackles." I have never meant to be insulting - only kind - but perhaps I have expressed that intention in a way that causes patients to feel insulted and patronized.

So the patient I'm referring to probably never meant to be insulting either. In fact, like me with my patients, perhaps he felt protective and nurturing, in this case because I was so much younger than he. That's a kind attitude, really, not a degrading one. But like Elvira, it "raised my hackles."

Part of the problem was the baggage I brought to the table. People make comments about my young appearance ALL THE TIME. I've had patients ask me on more than one occasion, "Are you old enough to be doing this?" and when I look at their chart, I happen to be older than THEY are. I just don't look it, I guess. I'd be happy under other circumstances, but when people start forming opinions about you professionally based on how you LOOK, and calling you "Miss" or "Young lady" or any other moniker that fails to recognize your hard-earned PROFESSIONAL ROLE, and it happens almost daily, it's ANNOYING.

Another piece of luggage I carry is that I never see my male colleagues treated with this same skepticism. And most patients will NEVER call a male clinician in scrubs "Mister" instead of "Doctor," or assume they can just address him by his first name without so much as a by-your-leave. It's almost amusing to see the confusion on people's faces when I show up with a male nurse. Almost.

Part of the problem with my particular situation, too, was the clinical interaction that was supposed to be going on. I was seeing the elderly gentleman as part of a preoperative evaluation. I was looking at his various test results and trying to form a judgment on whether one of them should be repeated, and as I thought out loud about the possibility, the patient said, "Aw, c'mon, dear, I've been through that so many times. You don't have to make me do it again." Would he have said "C'mon, dear" to a physician who did not appear so young or who was male? Would he have tried to direct an older physician's decisions like that, repetitively and argumentatively - as he continued to do, for a minute or so? ("It's just a [insert name of minor procedure] dear." Have I mentioned how much I hate it when people describe any surgery as "just" a little surgery?)

I curtly but politely (I hoped) asked him a few more questions, and after a couple more "dears," I stopped, looked at him, smiled as sweetly as I could, and said, "Please don't call me dear."

"Why not?"

"I prefer not to be called 'dear.' "

"Well, what should I call you, then?" he asked, almost-but-not-quite disrespectfully.

"Um, doctor?" I replied, almost incredulously, and resumed my perusal of his chart.

We went back to exchanging medical information about elements in his history. Then it was his turn to shift the conversation. "Can I ask you why you don't want me to call you 'dear?' I meant nothing by it. Do you find it demeaning, or something?"

"Yes, actually." You said it. Not I. Somewhere in there, you know you wouldn't be talking this way to an older person, a male person. But it wasn't just that he called me that; I've had other patients call me "dear" before and not minded. It was the TONE he used that I found grating.

He seemed taken aback by my candor, then must have sensed my implication that he was being sexist or age-ist or both, because he then made the mistake of bringing up (as if to justify his over-familiar language with me) the example of a woman he and I both knew of - let's say, for example, a City Council member in that town - who appeared youthful but had achieved a great deal professionally. I was too ticked off to refrain from commenting on the example because I thought the example itself just magnified the sexism I was hearing.

"To be honest, in my opinion, that woman is ignorant, uneducated, unintelligent, and self-aggrandizing, and not an example I wish to emulate," I said, in as gentle a tone as such an opinion can be uttered.

"Oh. Wow. Oh well," he said. We stuck to medical points from then on.

I learned something from the intensity of my own irritation. That I am imperfect and fallible I knew already, all too well. But I also learned, or re-learned, that I may very well be unwittingly causing the same offense to people whose safety, well-being, and comfort I genuinely care about. For all my attempts to show outward kindness, I might actually be making my patients very upset, or at least creating some bad feelings.

You know what part of the trouble is? The English language. There's no deferential word, as there is in Tagalog (the word po), to address people and convey, regardless of age or sex or profession or role, respect and attentiveness with some of the warm sentiments contained in English terms of endearment but without any of the condescension (po is never used to talk down to children as terms of endearment can be, hence, I think, some of the sense of insult when endearments are used with adults). I miss that word/particle/concept in English. It would totally get rid of this entire conundrum.

The truth is, when I hear my colleagues use terms of endearment with patients, I hear only warmth, sincerity, and genuine compassion, and I hope that's what my patients have heard in the past coming from me. But I can see how such terms, if used in a dismissive, insincere, or almost snide or sarcastic way, can transmit all the destructive negativity described in the New York Times article.

Such a small moment in the middle of a stressful day. Yet it was an island of lessons at which I felt I had to drop anchor for a while in the midst of trying to navigate these sometimes choppy seas.

______________________________________________________
Addendum:

Let's pretend for a moment that my name is Dr. Smith.

TWO WEEKS after the above incident I had this conversation with a patient and her son:

Me: "Good morning, I'm Dr. Smith."

Son: "Oh. Hi Smith." Hi Smith? SMITH?!

Me (to patient): "I'm going to be your anesthesiologist this morning."

Patient: "Oh. Really? Wow."

Me: "What is it?"

Patient: "Nothing, I'm just suprised."

Me: "Oh? How come?" As if I didn't know. Wait for it...wait for it...

Patient: "Well, you're a GIRL. I was expecting to get a man." Bingo! There it is, ladies and gentlemen. "And I didn't expect the anesthesiologist to call herself a doctor. We were just expecting..."

Son: "The bone doctor." C'mon, you know you wanna say it. The "real" doctor?

Surgeon (walking in): "Good morning, everybody."

Son: "Dr. Brown! Hi! How are you?"

Patient and Son proceed to ignore me despite the fact that our conversation has been interrupted and is not over and I was just beginning to ask about important medical information.

Just another day at the office...

Grand Rounds is Coming: Call for Submissions

The current edition of Grand Rounds: Best of the Medical Blogosphere is up at M.D.O.D. Check it out!

I will be hosting next Tuesday, October 14, so please get those submissions in (by midnight on Sunday, October 12, if possible) by emailing a URL for your blog post to anesthesioboist@gmail.com.

Thanks!

Before Dying, Leave Word

To cure sometimes, to relieve often, to comfort always.
-attributed to Hippocrates (460-370 B.C.E.)

There are families who accept death with peace, dignity, and an unselfish regard for their loved one's wishes.

There are other families who cling to the one they love, and want "everything done" for the person, not because that's what their loved one wants, or would benefit from, but because they, the family, aren't ready to say goodbye.

And there are a whole lot of families who struggle in between these two responses in a morass of confusing emotions and data, with a situation that is nowhere near black-and-white. Many, many cases probably fall into this category.

The second response to the dying process is a challenge for clinicians who are caught in the middle. We sometimes feel trapped into doing things against our own wishes, against what we sense to be our patient's wishes, and against what we feel is medically (and in other ways) right, only because the family has legal say.

I was called in the middle of the night to intubate a man with dementia who was almost a hundred years old. He had been admitted to the hospital with respiratory distress and intubated several days prior. He yanked his own breathing tube out, and for a couple of days he tolerated life without it. But the night I was called he had taken a turn for the worse. His carbon dioxide level was in the triple digits, appallingly high. The family could not be reached for discussion and had previously indicated they wanted invasive interventions (such as the initial intubation).

Normally, getting asked to do an intubation in the ICU is one of the most satisfying parts of my job. I feel like I'm being asked for help because I can do something no one else on the medical team can (comfortably, at that particular moment, in that particular hospital), at least not with the same expertise, and the task is potentially life-saving. It's also my favorite anesthesia task in general. I enjoy intubating.

But this one made me terribly sad. The nurses told me that between the last intubation and this one he had said plaintively, through the cloud of dementia that was robbing him of his rights to make decisions for himself, "I'm tired. Please let Jesus take me." So why were we doing this? We felt our hands were tied.

The author of The Choloroform Rag said it well: "Watching someone posture and contort, be maintained on machines, and receive multiple medications through large bore IVs and central lines is an awesome spectacle and testimony to the advancement of medicine; but it's wrong. We know when Death has arrived. Wanting 'everything' to be done to keep grandma, mom, dad, brother or whomever alive simply because we can't accept the fact that Death lurks in the room is destructive."

Please don't do this to your loved ones at the end of their lives when aggressive medical intervention cannot improve their quality of life. Please let them go, peacefully, if that's what they want. Have a plan for the end, as RuralDoc suggests. And trust that even when treatment and cure lie beyond reach, the clinicians involved still want to provide "comfort always."

Don't Say the Q Word: Doctors' Superstitions

I was asking some very run-of-the-mill, routine preop questions for what would be considered a fairly small surgical procedure. The patient closed her eyes. The corners of her mouth began to turn downward. She started to cry. I put my hand on her arm.

"I'm going to be right by your side the whole time," I said. "I won't leave you."

"I don't want to die," she said through her sobs, her voice sick with anxiety.

Whenever a patient says that my wariness increases a bit. It's doctor-superstition, I suppose, but it's been said that when patients have a feeling they're going to die, it's because...they're going to die. But I was hoping this was just her extreme nervousness talking rather than an actual sense of impending doom.

"I'll be there to protect you," I said, looking into her eyes with every ounce of my confidence. "I'll protect you," I repeated.

The woman nodded. A tear slid down her cheek. "Promise you won't leave?" she asked.

"Absolutely. I promise. I'll be with you until you wake up, and afterward too."

The actual surgery went fine, but she had medical issues that made her management a little tricky. I visited her later that night to see how she was doing. She was watching House. She was in much brighter spirits and had a warm smile for me as we spoke.

"I want to hug you. Is that ok?"

"Of course," I said, leaning over to hug her back. She thanked me.

But it was I who was thankful. I was thankful that she didn't in fact code and die on the table. I never tell people, "You're going to be fine," or "Everything's going to be all right," because the truth is the most routine procedure can turn deadly without warning. I guard my words with almost superstitious care. I tell people, "I'll be by your side," or, "I'll do everything in my power to keep you safe."

But that morning, for this woman, I had said, "I'll protect you." I had violated my own ritual observance of meticulous attention to language. What if I hadn't been able to protect her? What if some problem or other among all her medical issues had taken a turn toward disaster, and what if I hadn't been able to keep her safe? I never take those possibilities for granted.

Doctors pride themselves on being rational creatures. We act based on empirical evidence. We scoff at non-Cartesian thinking. And yet...

There's so much stress and chaos in the hospital, and lack of control in medicine, that sometimes little rituals and superstitions can be very comforting. I know one surgeon who never books his cases in a particular O.R. that he considers the Room of Doom. Some folks arrange their instruments a particular way without fail. I knew another doc who had a lucky brassiere that she would make sure she wore on her calls so they would be qui - er, not too busy. That's another thing - never admit that a call is quiet, or say the word quiet at all, ever! Then the cases will start pouring in and the beeper will be beeping non-stop! As for me, my superstitions are language-oriented. I try to avoid phrases like "Everything's going to be fine," or "You're gonna do great," and it makes me uncomfortable when the nurses say things like that. I'd rather say things I know will be true no matter what - like, I'll be right by your side, and I'll do everything I can to keep you safe.

In addition to little superstitions, we have little irrational beliefs. Take, for example, the quiet call versus the painfully busy call. There are those among us who would swear there's such a thing as a Black Cloud - the doc who's always horrendously busy on call - and a White Cloud - the doc that's consistently favored with tranquility and sleep while on call. There's another belief, practically urban legend, which I alluded to above - that patients who feel they're about to die are, in fact, about to die. Or that if someone has a bad, bad disease, and he or she is a really, really nice person, the prognosis is probably dismal.

Then there's the one about patients with red hair. There's an idea floating around that patients with red hair are more prone to complications. I personally haven't observed that or seen any evidence to support even a single anecdote. That said, there's actually been a study* done and presented to the American Society of Anesthesiologists that shows that red-haired patients need more anesthesia to get anesthetized or to experience relief of pain than non-redheads - but the study sample was minuscule, so who knows? There may indeed be a relationship between genes for pigmentation and genes for drug receptors but I certainly haven't read that it's proven.

Many docs, whether they'll admit or not, have these little customs and rituals, some of which have no basis in rational thinking at all. But I think this is humanizing, this "lapse" of our hard, scientific practices. It forces us to acknowledge that no matter how hard we try, in this world of ours that exalts total self-reliance, we're never going to be totally in control, and though we try to anchor ourselves with these consoling things, in the end we're going to have to accept some degree of uncertainty and lack of absolute power as we go about our work.

*Liem, E.B., Chun-Ming, L., Suleman, M.I., Doufas, A.G. and Sessler, D.I. Increased Anesthetic Requirement in Subjects with Naturally Red Hair, American Society of Anesthesiologists Meeting Abstracts, 2002.

Why I Love Elaine Fine; and then, some ramblings...

[Photo: shofar photographed by Olve Utne]

Just check out this beautiful passage by Elaine Fine from a recent post on Musical Assumptions:

"Blowing the shofar this Rosh Hashana somehow allowed me to think about the potential sacredness of every single note that I play. And it also helped me to realize the deep difference between a note that is sounded and a note that is sung, and it helped me to have a glimpse at the infinite musical possibilities available to me on the instrument(s) that I love to play. It also helped me to understand how much responsibility I have as a musician, and, in a population that otherwise does not seem to think of the music that I play as something beyond background sound, pleasant entertainment, or a way to get all the bridesmaids in for a wedding, how what I do can actually be, note-by-note, important and meaningful simply for its own sake."

Wonderful.

Most of what I do in my daily work is "important and meaningful" only for the sake of another, but most of what I really love to do has this blessing of being meaningful in and of itself. And maybe that's what makes any act sacred: the fact that it is "important and meaningful simply for its own sake." Thanks, Elaine, for that thought.

***

Sacred music has always had a special place in my life and is a living, breathing part of our family's spiritual experience. I think this must be true for many who enjoy an active practice of their faith. Psalms, chants, Shaker hymns, Negro spirituals...there's something about music, more than any other form of expression, that makes it particularly well-suited to our sense of the sacred.

Perhaps the reason is neurobiological: the temporal lobe is where we process musical and religious experience. But I think it's more than that. I think part of the reason is that music demands a response, full engagement, in the moment. Sculptures and paintings can continue to exist without their creators, as can written passages. But music...the actual experience of music calls the player and listener both to enter in, fully, right then and there, then it's gone. Even recordings can't recapture all of that precious moment, that transient bond between player and listener. Yet of all the senses, sound is the one which, if recorded and replayed, can almost conjure up the speaker or player's presence right beside the listener. Photos, and even videos, can't do that.

There's something about that call to enter fully into a moment, and the way sound almost mimics presence, that makes music the perfect way to invite people to attend to the sacred - be it with the sacred sound of the shofar, the opening chant of a cantor in a cathedral, or an imam calling the faithful to prayer. Ryan Fennerty in his evocative essay for the American Foreign Service Association writes, "Whether a practicing Muslim or a foreigner, the Imam's call to prayer stirs something universal in people. It is a calling to pause and reflect - and in this way awaken to a new level of understanding." Sacred music can grant us fruitful silence and mindfulness, making us more aware and thus able to perceive meaning - and sacredness - in a given moment.

***

One of the things that's sacred to me is writing. There's something so fascinating and mysterious about being able to lay down your thoughts so that they exist in time and space for other people, in an accessible way they can return to if they want to. I look at pictures of cuneiform tablets sometimes and think to myself, Boy, am I glad you guys invented this - look, I can still see your thoughts 5000 years later! Where music connects human beings in a moment, writing can connect people across vast stretches of time and space. I think there's definitely something sacred about that. Our smallest acts might still be reverberating ages from now.

I've been thinking about the traces of ourselves we leave behind - especially today, when I read about the survival of an astronaut's diary from the conflagration that took the lives of the astronauts on space shuttle Columbia. (Ever since I started reading Orange Crate Art, the blog of Michael Leddy, Elaine's husband, I've had my eye out for notebook sightings.) Then I start to wonder if the little traces we leave in our wake are the ones we expect. Sometimes my kids will bring up things I've said that I never thought about again, and I think, "It's all in there somewhere, the good with the bad...and some stuff I've forgotten, they'll remember forever!" Sometimes I get discouraged thinking that I'm not making the difference for others that I believe we're all supposed to be trying to make...but then I think of It's a Wonderful Life and hope that in my own small way the traces add up to a net of "better" for this corner of the world rather than "worse." If my profession and my non-professional interests have taught me anything, it's that small moments matter, more than we usually think.