Code Indigo

The season's first snow is falling. It's raw and grey outside the hospital. Inside, Ella Fitzgerald croons a languid "White Christmas" from the internet radio station. We're wrapping up at the O.R. desk after an uneventful morning case.

"Attention all personnel. Attention all personnel. Code Indigo, third floor. Code Indigo, third floor."

I look at the nurses. "Indigo? Which one's that one again?"

Every hospital has coded security alerts for unusual events - emergency room on diversion, airway crisis or cardiac arrest, infant abduction, bomb threat, unruly patient or family member, etc. I don't recall having heard a Code Indigo* recently.

"Missing patient," says one of the nurses.

"Probably just went out for a smoke," says another.

I go to do post-op rounds. The all-clear sounds overhead for the Code Indigo. But when I get to the post-partum ward, a nurse there tells me as I leaf through a patient's chart, "Don't bother. You won't find that patient."

"Breast-feeding class?"

"No. Just gone. That was the Code Indigo."

"Oh! I thought I heard an all-clear a while back."

"Yeah, because the patient's definitively gone. Baby's still here, though. Wanna see?"

She lifts a swaddled bundle of warm, sleepy perfection out of a bassinette. The baby starts drinking formula from a small bottle the nurse is holding.

I start to think of another baby, a patient I had had to discharge to a foster parent during my internship. The baby had been hospitalized with bilateral spiral femur fractures. Yet every time I approached his crib to examine him, his face would light up with a bright smile that held nothing but joy. After I turned him over to foster care, I went into the call room, called my husband, and sobbed on the phone to him, utterly disconsolate.

My mind starts churning around my current situation, trying to figure out if there's some way we could take care of this baby ourselves. But of course we're not at all prepared for a decision like that right now; all I can do is call the social worker and make sure she's on top of what needs to be done to get this child into a suitable pre-adoptive home. It seems like such a small, ineffective measure to take.

The snow has turned into something a little wetter and clumpier. It's dark by midafternoon on days like this. I've turned on a mix of Christmas music - a little Nutcracker, some Kathleen Battle, a little Boston Pops and Leroy Anderson. I go back up to the nursery to hold the baby. The nurses welcome the break.

"Here, Dr. T - have a seat right here."

The baby sleeps in my arms. His cheeks bulge out like rosy little fruits. He is totally at peace. He has no idea that either nobody loves him at all, or someone loves him so much that she felt she had to set him free. He is blissfully unaware that he is alone in the world. Abandoned.

"At least she didn't try to flush him down the toilet, like the kid we got last week."

Thank heaven for small blessings.

Advent starts today: the liturgical prelude to the Christmas season, and the new beginning of the liturgical year. There's something in the baby's given name that conjures up images of light. Light, on this grey, darkening day.

"The people who walked in darkness have seen a great light." I wish, I wish, I wish.

I start humming the baby a lullaby. My favorite song of the season, half ancient chant, half carol for a newborn.

O Come, O Come Emmanuel

and ransom captive Israel

that mourns in lonely exile here

until the Son of God appear.

Rejoice! Rejoice -

Emmanuel shall come to thee,

O Israel.

I hope this baby gets his Christmas wish, the wish all babies are born with: a wish for love, for a life that matters, and for a world of hope to be cradled in.

*(Not the actual alert used.)

Cross-posted at Mothers in Medicine.

Status Post Gastric Distension

Do you have certain things you always do when you prepare the Thanksgiving meal?

My family prefers ham to turkey, so I've only done the turkey thing once, and had good results from squeezing an orange over it before roasting.

We eat green beans all the time. We like them with salt and pepper and a little dill and butter, or roasted shallots, or perhaps even some brandied chestnuts...

I always make apple pie - flaky, all-butter crust, Granny Smith apples seasoned with sugar and cinnamon...mmmmmmmmm.

What was your favorite Thanksgiving recipe this year?

My sister-in-law made this Better Homes and Gardens chorizo cornbread stuffing last year that was to-die-for, and her mom graced Thanksgiving dinner with it once again this year:

• Preheat oven to 350F.


• Grease twelve 8- to 10-ounce casseroles or a 13x9x2-inch baking pan or dish; set aside.


• In a large skillet cook 1 lb chorizo 10 to 15 minutes until cooked through, stirring to break up sausage; drain off fat.


• Transfer to bowl, set aside. Carefully wipe out skillet.


• Melt 1 stick (1/2 cup) butter in the skillet over medium heat.


• Add 2 large chopped onions, 2 fennel bulbs cored and sliced (if not using apple), 3/4 cup chopped celery, and 2 minced garlic cloves.


• Cook 10 to 15 minutes or until tender, stirring occasionally. Add 2 large apples cored and chopped (if using instead of fennel); cook and stir 2 minutes.


• Add vegetable mixture, 16 oz cornbread stuffing mix, 1 cup dry-roasted, salted pistachios, and 3/4 cup dried cranberries to sausage in a bowl; toss to combine.


• In medium bowl combine 14 oz reduced-sodium chicken broth and 2 lightly beaten eggs; add to sausage mixture. Toss to combine. (For moister stuffing, add 1/2 cup water.)


• Transfer to prepared dish or pan.


• Cover, bake 20 minutes for individual casseroles (35 minutes for large).


• Uncover, bake 10 to 15 minutes more or until heated through (165F) and top is lightly browned.


• Makes 12 servings.
  
  Better Homes and Gardens also suggests this blue cornbread and blue cornmeal chorizo stuffing, which is seasoned with sage and gets a little kick from some jalapeños.

***

Dr. Cris at The Scalpel's Edge tagged me with this Kreativ Blogger award. Thank you for thinking of me!

In response to this award I am invited to share six things I'm happy about right now. Not a ready task when one is on call Monday, Wednesday, Friday, Saturday, and Sunday all in one week!

But it's Thanksgiving weekend, after all, so here goes:

1. My family - adorable kids, supportive parents and in-laws, and a loving husband who sends me e-mails when I'm on call with sympathetic sentiments like, "How are you hon? I don't like not hearing from you. It means you are busy. Miss you. :( "

2. Writing. Especially here, on my blog, my little home away from home.  And books.  Books make me happy. Even just being around them is enough to inspire contentment.

3. Playing the oboe.

4. The opportunity to get R&R in a very special place.

5. Christmas

6. The Vietnamese take-out crispy eggplant I just had with some of the nurses on postpartum while listening to some Christmas music. It was so yummy. I truly lived in the moment...for a moment.

I am also supposed to tag other people, but as may have become apparent recently, I have gotten very shy / very bad about tagging folks, and many of the folks I thought of had already received this award! I'm honored to be counted among the Kreativ Bloggers out there.

Belated Happy Thanksgiving to all!

Engage with Grace

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.)

A Few of My Favorite Fabulous Things

One of my BBFF's - best-bloggy-friend-for-life - gave me this blog award yesterday. Thank you, Katy! I am honored to get this shout-out from one of the most courageous, talented, kind bloggers I know.

As a recipient of this award I am supposed to list five things that I think are fabulous. Katy, you already named one of my favorite things - Christmas in New York! But here are five more:

1. Old movies. To Kill a Mockingbird. Roman Fever. Casablanca. Anastasia. It's a Wonderful Life. Bringing Up Baby. They don't make 'em like this any more - engaging even without outrageous special effects and lots of action, captivating even without color, powerful enough to draw us in primarily through word, character, and story and hold our attention completely.

2. On a related note: the backstage scene just before the ballet, as well as the ballet itself, in the movie The Red Shoes. This is a truly FABULOUS sequence; no other piece of film captures so brilliantly the tension, anticipation, and sick-to-your-stomach excitement of the moments before the curtain rises on opening night. From the sound of violin bows thumping to welcome the conductor, through the chaos of missing props and broken scenery, we follow dancers practicing their lifts and turns, fretting about the choreography, counting down the seconds, and finally signalling their readiness for curtain rise. It's a wonderful scene, and the ballet after it, with Brian Easdale's incomparable score, is one of our favorites as a family.

3. A really great massage. My back and leg muscles tighten up so easily. I think massage therapists are truly FABULOUS.

4. Log homes. I could browse through log home decorating magazines and books for hours. There's something so comforting about the thought of curling up with a mug of something warm in front of a fire in a cozy (or, alternatively, luxurious) log cabin overlooking some lovely mountains, with nice music playing in the background. That's my idea of heaven right there.

5. Children's books. People who come to my house usually think our bookcases are lined with our children's favorites but I've had most of our inventory since I was their age. :)

I have so many fabulous fellow-bloggers out there - I can't pick just five! (Too much pressure!) But you know I think you guys are fabulous!

***

Had a wonderful visit and lesson with Kyoko this morning. My scales and fingerwork have improved. She's pleased with the improvements I've made despite the limits on my practice time. She has promoted me out of my "beginner" book and onto more "real" music today! Corelli and Cimarosa concertos glimmer ahead of me this year. As a special celebratory treat - which I much appreciated because it's been uncharacteristically hard for me to get in the Christmas spirit this year - we spent the last few minutes sight-reading Christmas carol duets. I was happy!

Yummy Words, Yucky Words, Happy Sounds, Sad Sounds

I think I might have a mild case of synesthesia. Ever since I was little I liked or disliked certain words because of the way they "tasted" in my mouth when I said them. I wouldn't get a physical taste sensation, exactly (hence the reason I call my case "mild"), but certain words evoked pretty specific taste experiences for me. The word "song" tasted like a buttery Filipino sponge cake called mamon. The word "hate" tasted like cheddar cheese.

When I looked up synesthesia on the web I learned there's actually even a name for this: "lexical-gustatory synesthesia," which is supposed to be a rare type. Figures!

It seems my brain likes the taste of words with the "r," "gr," or "cr" sound in them: Christmas, cryptography, graphite, garrison, gripe, grammar, figure. I recoil from "p" and "n" in close proximity, though: penis, panty, pons, nape, nope. Ugh.

This trait, or whatever it is, adds an interesting dimension to my day-to-day life in the hospital, wherein I spend my day speaking a different sub-language for hours on end.

Medical terminology has its treats that roll trippingly off the tongue. Chordae tendinae. Fulguration. Nissen fundoplication. Cardiac contusion. Urticaria. Hyperbilirubinemia. Gammaglobulin.

Then there are those shudder-inducing words and phrases. Spermatogonia. Bile ducts. Mastocytosis. Morcellator. And my all-time un-favorite, a phrase I dislike intensely, probably more than any other: pulmonary toilet. Yuck.

I have no idea what this little phenomenon of mine says about the way I think or function. I don't think it means I am either cognitively impaired or unusually gifted, more creative or less creative than the next person. In fact, I don't think it's anything more than a personal curiosity. I think my brain just happened to connect a few wires differently while it was growing. Maybe there are indeed extra connections between my insula and my temporal lobe* (there goes that temporal lobe again!).

I was wondering while listening to a symphony in a minor key the other day how it is that certain sound frequencies in combination produce such dark emotional associations for us, and how other sounds and chords evoke lighter, brighter moods. What explains that? It must be something similar to this word-taste synesthesia. Why is it that a plaintive passage can conjure up the image of a weeping, suffering person, or such a person's words or feelings, even though the sounds themselves don't resemble actual weeping? Is it because certain harmonies set off different parts of the temporal lobe and limbic system? Rationally speaking a sound is a sound is a sound - vibrations hitting the eardrum and ossicles - but the brain interprets these physical phenomena in such complex ways. I wish I could ride a sound wave and follow it into the mind, see what electric impulses and neurotransmitters get fired, study from my unique vantage point why certain connections get bridged and not others. But even if that were possible, I have a feeling the mysteries of music and language, of sorrow and joy, wouldn't so easily be solved.

See here for an enjoyable old post by Aggravated Doc Surg which also highlights medical terms.

___________________________________________________

*Ward, J.; J. Simner & V. Auyeung (2005), "A comparison of lexical-gustatory and grapheme-colour synaesthesia", Cognitive Neuropsychology 22 (1): 28-41

Renovations

Renovation (′ren·ə′vā·shən): (1) the process of improving a structure (2) the process of restoring something to life, vigor, or activity. From Latin renovare, "make new again."

You'd think someone who restores people to consciousness and activity every day, who revives people for a living, would find renovation somewhat appealing, at least conceptually, right?

Wrong. I hate it. Hate it, hate it, hate it.

But doesn't everybody, though, until the endpoint appears, and all is well again?

This is why my blogging has been so sporadic lately. I am renovating.

We are re-doing our kitchen, which was poorly designed and aesthetically bereft of any redeeming qualities. It is gutted. A new window is in, but the electrical work, cabinets, counters, sink, flooring, tiles, paint job, and appliance hookups are like a dream out-of-reach.

My job is undergoing renovations. It's a very long story, but I got to the point of resigning. But there are some major "renovations" on the horizon. The hospital administration has been supportive beyond my wildest imaginings. The chief of surgery asked me to reconsider. Some other surgeons and nurses have approached me and asked me to stay. The president of the medical staff urged me not to go. New leadership and restructuring under a well-run group seem very promising. It's been as stressful as gutting the kitchen. The endpoint isn't in view yet, so for now I'm still dealing with exposed pipes and sledge-hammered walls.

Some of my relationships - friendships old and newer - have undergone changes that have rocked my world. Like ripping down your own house, it's painful while it's happening, but if you can get to the point of saying out with the old and hello new, it's ultimately a gift.

On the up side: we did make some progress on the roof work we needed to do. Our shingles are replaced - better stuff, nicer color. We have a new window in an upper room in which we hope to create a cozy library with a beautiful view. It isn't all bad.

But it's stressful. I'm exhausted. I'll be glad when it's all over, and we can have some peace.

A Word from My Little Sage

"Mommy - everyone can see molecules.  They just can't see them one at a time."

There's a nugget of wisdom in there somewhere... :)

The Play's the Thing

[The Adagio from the Serenade for thirteen wind instruments (K. 361) begins to sound. Quietly and quite slowly, seated in the wing chair, SALIERI speaks over the music.]

SALIERI: It started simply enough: just a pulse in the lowest registers — bassoons and basset horns — like a rusty squeezebox. It would have been comic except for the slowness, which gave it instead a sort of serenity. And then suddenly, high above it, sounded a single note from the oboe.

[We hear it.]

It hung there unwavering, piercing me through, till breath could hold it no longer, and a clarinet withdrew it out of me, and sweetened it into a phrase of such delight it had me trembling. The light flickered in the room. My eyes clouded! ...I called up to my sharp old God, “What is this? . . . What?!...Tell me, Signore! What is this pain? What is this need in the sound? Forever unfulfillable, yet fulfilling him who hears it, utterly. Is it Your need? Can it be Yours? . . .”

-from Amadeus, Act One, Scene 5

Last night I took my daughter to see a high school production of Peter Shaffer's play Amadeus. I was a little younger than she is now when my parents took me to see Ian McKellen as Salieri on Broadway. I can still remember the production. Taking me to the theater was one of the best things my parents did for my education during my childhood. I want my children to have the same opportunity.

It was a big first for us. My daughter had never seen a real play before - our theater outings have been to musicals, ballets, and opera, but so far no plays. And she had never really been allowed to watch anything R-rated, or any piece with real "adult content." We were both eager to see what this cast would do with this challenging work.

We were not disappointed. In fact, our jaws were on the floor over the principals, Jacob Scharfman and Rob Knoll, the extraordinarily talented, impressive young actors who played Salieri and Mozart. I always love watching amazingly gifted young performers bring to life these complex, often difficult works; their energy is boundless, and they have none of the jaded arrogance that older professional performers can sometimes project. They throw themselves body and soul into these roles, generously, and the result, if they have some native skill and some strong guidance, can be breathtaking.

I realized after seeing it again that I liked the play even better than the film, despite my love of the movie's incomparable dictation scene. Salieri in the play struggles more, shows more complexity and passion, and when you watch this live - the flesh-and-blood character searching his soul even while he's giving in to his evils, just a few feet away from you - the effect is stunning.

My 11-year-old daughter had some wonderful insights from her enjoyment of the performance. She noticed the living, breathing, dynamic nature of live performance as opposed to performance on film; the energy added by the audience; the responsibility the actors bear, to carry the entire story with their own voices and faces and movements, without being able to rely on help from songs, scores, or special effects; the way physical acting can be just as important as vocal, a fact underscored by the outstanding portrayal of both the boorish, goofy Mozart and the tremulously ill yet feverishly driven Mozart by Rob Knoll in last night's production.

Children should go to the theater. They should absolutely go and see LIVE THEATER. Not just the fun stuff - though I love a good Christmas revue - but the challenging stuff, too. We should put our kids in touch with material that makes them ask questions, and think of more than one side of an issue; stories that draw them into a world that makes them see their own world anew; characters that open their eyes, through the specifics of a few, to insights about humanity, and perhaps to a more developed compassion for its members. The stories we learn, read, write, hear, and enter into ultimately recreate us. I'm looking forward to the next play!

My Favorite Plays

The Crucible by Arthur Miller

Proof by David Auburn

Amadeus by Peter Shaffer

You Can't Take It With You by George S. Kaufman and Moss Hart

The Arabian Nights by Mary Zimmerman

Copenhagen by Michael Frayn

Noises Off by Michael Frayn

Master Class by Terrence McNally

Trouble in the Operating Theatre

[Photo credit.]

I never thought much about workplace violence until the year after I graduated from med school. I was working in a community hospital in the Bronx - a place I actually still have tremendous affection for, probably because I had a wonderful mentor there. We admitted an adolescent patient who clearly had violent tendencies and a lot of anger at baseline. When I went to interview the patient, a tall, solidly built male medical student silently volunteered to accompany me into the room. Perhaps feminists would find this lame, but I was glad to have him standing beside me as I talked to this very hostile, erratic patient, and it made me stop and consider for the first time that there might be many other clinical situations in which I would feel personally threatened. Was I willing to face that?

Over the years there have been others in the hospital setting who have made me wonder about my own safety. Patients suffering from psychosis. Belligerent family members. My children were surprised, though, when I told them that as a group, federal prisoners have been among my most polite and deferential patients. What I never wanted to witness or experience was verbal, psychological, or physical violence among coworkers. But I have seen it, and I have experienced it. It's disappointing, unsettling, and deeply wounding.

Here's what I've learned as I've perused the internet for more information on this issue.

• According to the U.S. Department of Justice, the most dangerous place to be in America is the workplace.
  
• One in four to one in six workers is attacked, harassed, or threatened each year.
  
• Instances of verbal violence are triple those of physical violence.

What's the typical "profile" of a bully in the workplace? According to this source, over 80% of bullies are bosses. A bully is equally likely to be a man or a woman. Bullies tend to be profoundly insecure, with "poor social skills and little empathy" or with less ability than most to understand another's point of view. They get tremendous satisfaction out of cutting capable people down. A perpetrator of violence in the workplace may not fit this "profile," of course. He or she may have a pathologic rage problem without exhibiting any of these "expected" traits. It's a problem either way.

Whom do adult bullies / perpetrators of workplace violence frequently target? "The common stereotype of a bullied person is someone who is weak, an oddball or a loner. On the contrary, the target chosen by an adult bully will very often be a capable, dedicated staff member, well liked by co-workers. Bullies are most likely to pick on people with an ability to cooperate and a non-confrontational interpersonal style. The bully considers their capability a threat, and determines to cut them down." (same source as above) Over 2/3 of attacks are by strangers or customers, but women are more likely to be attacked by people they know (see here).

From this site: Who is at greatest risk of workplace violence?
"Anyone in a job that involves extensive contact with the public, especially if limited attention is paid to customer satisfaction. (Witness the increasing accounts of airline passenger rage.) Also, anyone working in markedly bureaucratic organizations where limited attention is paid to employee satisfaction."

What are some measures one can take in order to combat intra-worker workplace violence?

• zero-tolerance policies for abuse in the workplace


• staying calm and not giving into one's own anger at any time


• maintaining safe distances with perpetrators of abuse


• avoiding isolation


• allowing for a full airing-out of grievances without necessarily caving to unreasonable demands or reinforcing bullying behavior with compliance


• detailed documentation of and complaint about all incidences of verbal, psychological, and physical violence; no sweeping of stories under the rug


• removal of oneself from any situation that threatens to compromise personal safety

I think it's sad that any of us even has to think about such an issue. But we do have to reflect on this, and talk about it, and deal with it. The last thing any of us should do is stay quiet.

Scourged

I would like to learn more about the Religion of Peace. I would like to hear from Muslims who can teach me about their faith so that I will not have erroneous ideas. I would like someone who knows more about Islam than I do to tell me, please, for the love of God, that a good Muslim would think this wrong (photo source here):

KevinMD alerted me today (I know - I'm, like, a week behind on the news) to the case of an Egyptian doctor convicted of malpractice for "driving" a female member of the Saudi Arabian royal family to narcotic addiction.

She had received painkillers as part of back pain treatment in the United States.

RED FLAG.

Her government appears unwilling or unable to acknowledge that addiction is a disease process that affects genetically vulnerable people despite their physicians' best efforts to provide relief of suffering correctly.

Any chance she pressured him to prescribe a certain narcotic for her? "Oh, Drug X doesn't work for me. I can only take Drug Y." Maybe. But maybe not. Maybe she just kept insisting on getting more. Maybe he suggested she needed more - sometimes the old dose just doesn't work for the pain any more. It's the nature of the beast. But is that his fault?

I don't know...maybe this is more than just about pain medicine...but WHAT is it about? What could justify the punishment he got, after serving the royal family for 20 years? Does anything warrant this kind of abominable cruelty? This kind of cruelty is personal, somehow. Vindictive, hateful, and personal. He offended them. How dare he.

He was sentenced to 7 years in prison and 750 lashes.

Then he appealed. Again, how dare he, I imagine them thinking.

So the judge increased his punishment (for what, someone tell me? For what?) to 14 years in prison and 1500 lashes.

It's not fair. This morning the nurses on labor and delivery rewarded me with cake and praise just for showing up to do a dawn epidural. We love it when you're on, Dr. T; you're so kind to the patients even when they're stressful patients, and you do such a good job. Here, have some maple walnut cake. I get pats on the back. He gets 70 lashes a week for months and months. We're both pain docs, trying to do our bit to relieve suffering.

What's WRONG with this picture?

Michelle Obama, President Elect Obama, Please Pick Stone Ridge As Your Daughters' School!

Stone Ridge totally ROCKS.

I went there from 3rd grade through 8th grade and it is still, to date, the BEST EDUCATIONAL EXPERIENCE of my life. Harvard was good too, but my years at Stone Ridge were the seminal experience that made the rest of my education as fruitful as it was.

If Stone Ridge is still anything like it was in the 80's, it is simply THE BEST PLACE for a young girl to get an education that will foster a rich intellectual life as well as strength of character and conviction in the face of a world full of challenges.

All due respect to Sidwell, Holton, Georgetown Day, and NCS, of course...but STONE RIDGE ROCKS!!!

Fallen

The Boston Globe article paints the picture all-too-clearly: "He was dead when they found him in the storage closet at the hospital...There was a half-filled vial of propofol...a syringe filled with midazolam...empty vials of morphine, hydromorphone, and Demerol...And then there was one nearly empty vial of vecuronium - an intravenous muscle relaxant that...would shut down the body's respiratory system in roughly three minutes, leading to certain death."

It's that last sentence that I found so chilling. He gave himself 100 milligrams of Propofol (half of the usual anesthetic induction dose, the effects of which would wear off in a few minutes), maybe, 10 or 20 milligrams of morphine, two to four milligrams of Dilaudid, and, say, 50 to 100 milligrams of Demerol, all of which would have depressed his respirations and affected his level of consciousness if he hadn't been accustomed to narcotics - but who knows what state of tolerance he was in when he took this final dose? - and then, perhaps, ten to twenty milligrams of vecuronium, guaranteed to paralyze him for at least half an hour, and to kill him in much less time. How horrifying and sad and awful.

Anesthesiologists are four times more likely than other physicians to be treated for drug addiction. Some theorize that second-hand exposure sentitizes our brains. Others blame easy access.

I'm with Christina Miller Reiter, M.D. (who wrote about a colleague who did not kill himself or perish accidentally): "I’m angry that it makes our specialty look bad and 'ruins' it for the rest of us more trustworthy individuals who aren’t injecting the drugs we administer to our patients...I’m sad that someone could be in so much unbelievably excruciating pain as to resort to a behavior that is so self-destructive. ..There is always that pressure. The pressure to take care of our patients, to get the cases started quickly, to wake up the patients quickly...to take on the most awesome responsibility of being the patient’s guardian during surgery...But our lives are also in our own hands. Do we take care of ourselves as well as we take care of our patients? Do we nurture ourselves so that these drugs we carry around to help our patients do not become poison to us?"

Doctors are notoriously bad at taking care of themselves. At first, because they're barely allowed to, during training - no time to eat, no time to sleep, no time to rest, expectations of total self-immolation for the sake of medicine. Later, though, why is it sometimes still so hard? Well, frankly, because sometimes there's no time to eat, no time to sleep, no time to rest, and no mercy for anything less than total perfection (excellence just isn't enough). And getting support from each other? It's nice when it happens, but in many circles it's considered weak to wish for it.

Here's a sobering tidbit from Newsweek: "No other profession has a higher suicide rate."

There's something very wrong with that, I think, if it's accurate. There's something very broken about this system. Something that's going to take complete overhauls of subsystems to improve.

I am thankful that I've never even had an INKLING of a desire to try any of the drugs I use every day as I practice anesthesia. Not once. Zero interest. But maybe I'm just lucky. There but for the grace of my genetics and brain chemistry go I. I hope I stay lucky; that's all I can say. And for our the loved ones of fallen colleagues who were not so fortunate, who have suffered or are suffering unimaginably right now, I pray that peace and hope come back within reach in the not too distant future.

How Much is Too Much?

I attended a conference recently in which a talk was given entitled, "Partnering with Patients to Improve Patient Safety." In principle I applauded the thesis of this talk: that we should strive to foster enough of a sense of empowerment in patients such that they feel they have a strong voice in their care, can question treatment decisions and reasons behind them, and can advocate for themselves. I agree. The more a patient talks to me, and the more attentively I listen, the better care I can provide for him or her. I strongly believe that.

The talk did not, however, address situations in which there need to be clear limits to partnering with patients. And I do think such situations exist.

For example: I always invite parents of young children into the operation for the induction of anesthesia, so they can provide comfort for their children and enjoy some degree of participation in their care, with the understanding that they will be shown to the waiting room immediately after induction. One time - not in my O.R., but in someone else's - a parent grew belligerent and insisted on remaining for the entire operation. This was seen as potentially compromising to the delivery of good care and distracting to those providing it, and security had to be called to escort the parent out. The other option would have been to wake the child up and cancel surgery.

I have declined a patient's request for her (physician) husband to be summoned into the operating room if there were "any problems" during surgery. I considered it a breach of boundary lines and a potential hindrance to the delivery of good care. While I know in some centers family members are allowed to be present during code situations, I think this should only be permitted if a liaison person is available whose sole job is to explain what is happening to the family member and to answer that family member's questions.

Finally, patients occasionally try to insist that I not intubate them for certain surgical procedures. I'm sorry, but if I feel the intubation is absolutely essential, then they have no choice. I ordinarily cannot allow much in the way of "partnering" for such a life-and-death decision. If a patient is admitted to the hospital with a DNR/DNI order and suffers an arrest, that's a different story; but if they need and agree to major surgery and I feel they need a breathing tube, in it goes.

For many, the prospect of "having no choice" in a matter is odious. But just as partnering with patients can increase patient safety, there are circumstances in which the partnership can be inimical to safe medicine. Perhaps some will think, reading this, "She's not being fair;" "She wants to be paternalistic;" "She's a control freak." I submit that these would be mistaken conclusions. A good anesthesiologist cares about his or her patient's concerns and, while being firm about the standard of care, can be flexible and adaptable over its delivery. When a woman was so anxious about getting spinal anesthesia for her C-section that she was sobbing as she walked into the operating room and asked if her partner could come and be with her during the placement of the spinal, of course I agreed. After it was placed, I asked him to step back out of the room for a moment while we prepared the surgical field, then invited him back in at the "usual" time once surgery was under way.

In general, I am in favor of a collaborative approach to treatment decisions, as I have written before. I am more than happy to abide by my patients' wishes in most matters, and usually they find me more than willing to listen to their concerns, answer questions, explain things, and change my plans according to their preferences. But of all the medical specialties, anesthesiology is one in which collaboration is occasionally not advisable or possible, for the simple reason that SAFETY IS NOT NEGOTIABLE.

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Shadowfax has this great example, via Orac of Respectul Insolence, of what I mean when I say that sometimes we just CANNOT afford to "partner with" patients to make a decision:

"...This patient, despite having an acute abdomen and a CT scan showing air where it should not be (i.e., outside of the intestines, meaning that there is a perforation somewhere), refused surgery, even though surgery was the only thing that could save his life. This is about as close to a no-brainer of a situation as there is in surgery and medicine. Patient with perforated intestine and acute abdomen = operating room. If no operating room, patient with perforated intestine = dead patient. In any case, it was pretty clear that this patient was in denial. At that point, Shadowfax deployed a most interesting technique of persuasion:

'Okay sir, before you go up I've just got some paperwork to complete. Do you have a next of kin?'

'Um, yeah, my sister.'

'Great. What's her phone number? We'll be needing to call her later. Do you have a mortuary or funeral home selected, or should we just have your sister pick one?'

'Um, I don't think -'

'No problem, we'll just have her pick one. Now, in a few hours, you're not going to be able to breathe any more, and if we're going to keep you alive, we'll have to put you on life support. Do you want us to do that, or should we let you suffocate?'

'That sounds bad -- I don't want to suffocate.'

'Right, then, the ventilator it is. But a few hours after that, your blood pressure is going to go really low and your heart will stop. Do you want us to pound on your chest and shock your heart to try to bring you back? It won't work, of course, but I just need to let the ICU doctor plan how to handle it when the time comes. So should we do CPR or not?'

He gave me a long look. 'You really mean it, don't you?' I said nothing, but let the long silence linger. 'You really think I need the surgery?' I nodded. He sighed, and slumped back, resigned,'Well, all right, if you really think I need it...'

The question is: Did Shadowfax go too far?

I would argue that, in this case at least, he did not. Sometimes the only way to overcome a severe case of denial is through extreme bluntness. This case, however, was fairly obvious. Without surgery, this patient was definitely going to die a very unpleasant death within a matter of hours, or at most, a couple of days."

Amen.

YES. WE. DID!

"Thank you, Barack Obama...Thank you for blowing away the ether of complacency." Jamie Lee Curtis. (A quote an anesthesiologist can appreciate!)

McCain supporter calling C-Span from Ohio: "Something very special happened tonight."

From tonight's speech:

"The true strength of our nation comes not from the might of our arms or the scale of our wealth, but from the enduring power of our ideals: democracy, liberty, opportunity, and unyielding hope."

-BARACK OBAMA, November 4, 2008

Where were you when you first heard?

I was on the phone with my husband, who had spent the day volunteering his lawyer-ly talents as a poll watcher in New Hampshire.

What are some of the memories that rushed through your mind?

I remember the first time I heard him speak, which was on a radio interview, and thinking, "Wow, he's REALLY smart."

I remember him accepting the nomination.

I remember specific moments, like the time he reminded people, "I have READ the Constitution. I have TAUGHT the Constitution." I remember thinking, "At last! Some intelligence!" when he talked to Charlie Gibson about why a bipartisan cabinet would make sense, and just now, too, when he said, "I will listen to you. ESPECIALLY when we disagree."

I remember his electrifying speech at the convention, and his wife's, and his running mate's, and the Clintons'. And the debates - including the VP candidates'. I remember how proud I was to hear my daughter saying Michelle Obama was her new hero after hearing her speak - previously her role model had been African-American opera singer Marian Anderson - and I recall thinking that maybe, just maybe, we have hope of a truly color-blind generation in-the-making.

I remember worrying about voter suppression, and racism, and his grandmother. And about the way his aura of greatness makes me think of Kennedy, Lincoln, Gandhi, and King.

I remember the teeming crowds of supporters. His deep affection for his wife and children. His tears.

I remember a stellar campaign that itself made history, with its grassroots resources, mobilization of the internet and communications technology, and its impressive organization and scope. I remember faces of young people energized, inspired, fired up with "a new spirit of patriotism, of responsibility, where each of us resolves to pitch in, and work harder, and look after not only ourselves but each other," and thus be a vibrant part of American history and democracy.

I remember my amazement as endorsements from people like Powell and McLellan rolled in, and as New Hamsphire, New Mexico, Pennsylvania, Ohio, Florida, and Virginia came in "blue" on the electoral map.

I will not forget this speech I'm listening to now, which he is giving in front of half a million people in Grant Park, in which he enumerates what 106-year-old African American voter Anne Nixon Cooper has witnessed in her lifetime: the aftermath of slavery; the rise of woman suffrage; the Depression; wars; the Civil Rights Movement; the election of a the first African-American president. I will not forget McCain's gracious and moving concession speech.

I treasure most of all remembering the faces and voices of my own children as they learned about the electoral process and participated in the campaign, and the exhilaration of seeing, at last, someone who strikes me as a loving family man with brilliance, character, discipline, thoughtfulness, and vision elected to the White House.

Something very special did happen tonight. We made history. It's a shot being heard around the world: David Cameron in British Parliament said something like this (I don't have the exact quote): "To go from the horror of segregation to the election of a black president in just four decades is a remarkable transformation...[showing that the] United States is a becacon of hope and opportunity and change." He has inspired around the world "a renewed love for the United States after years of dwindling goodwill." At last we can look at our international colleagues with pride in our president and in our nation again. At last. Our "first truly global president," elected joyously by a populace ready not only for change but also for transfiguration.

Barack Obama recognized that we, America, are NOT just Joe Sixpack and Joe the Plumber; we are ALSO Maria of Guatemalan descent, Abdul serving in the army overseas, Jen whose parents immigrated from Asia, Jessica whose great-great-grandparents were slaves, Mike in college voting for the first time. I hope we can do as McCain has called us all to do: cherish our being Americans, together, far more than we cling to being Democrats or Republicans, so that we can all help this new president do his absolute best to serve this country. It's time to replace fear with hope - not optimism, HOPE: an active spirit that strives for the best, in the fundamental conviction that we CAN move toward it.

"It's the answer that led those who've been told for so long by so many to be cynical and fearful and doubtful about what we can achieve: to put their hands on the arc of history and bend it once more toward the hope of a better day."

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Election stats as of 2:30 p.m. 11/5/08:

Popular vote: Obama 63, 378, 910 (52%), McCain 56, 035, 630 (46%)

Electoral vote: Obama 349, McCain 162

Thursday, 11/6/08, as of 1:30 pm:

North Carolina called as BLUE! Electoral votes so far: 364

An Open Letter to the Integrity-Bereft Republican Who Stole My Obama Sign

To the person or persons who took my Obama/Biden yard sign not even 24 hours after I put it up:

Do you really feel so threatened that we might finally succeed in electing a strong leader with vision, intelligence, outstanding communication skills, and policies that will ultimately restore our prosperity and credibility as a society, that you felt you had to commit a federal offense, trespass onto my private property, and violate my freedom of expression?

Are you filled with so much hate, small-mindedness, and fear that you cannot tolerate the display of an opinion that differs markedly from yours?

Do you really believe your larcenous actions and efforts to suppress our freedom of speech offer the kind of example your party wishes to propagate about itself, when so many people are already fed up with its penchant for lies, dirty tricks, contempt of habeas corpus, xenophobia, poor judgment, and voter suppression?

Don't think I didn't consider scouring the area for an enormous replacement banner to drape over my front balcony, then reconsider, because I don't underestimate your capacity for resorting to immature, ignorant, base behavior, like vandalizing such a banner and destroying the property to which it is attached. We've seen it before, and I wouldn't put it past you to descend to that level.

But do you actually think that invading my space, stealing from my home,and trying to shut me up is going to discourage me, suppress the energy Senator Obama has ignited across the country, and squelch his message and spirit of hope?

No, Sir or Madam, I think NOT. Take as many signs as you WANT. Go ahead. Make yourself look like a sleazy, cheating, low-class crook. Let that speak for your grand old party. Go. Take the signs away. It won't matter. You can try and take away our voice, if you fear it that much; but you'll never take away our spirit: the transformational power of a people united in concern and hope for every member of society, especially the voiceless; a people that truly does put country - not corporate pockets and special interests - first.

(In case you hadn't noticed, I'm MAAAAAAAD. Just had to vent. But the galaktoboureko I had for dessert tonight should be kicking in right...about...now, so I'll be calmer in a minute....)

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Thanks to Michael Leddy for this:

And to the Huffington Post for this:

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Addendum, November 3, 2008: A Follow-Up Letter to the Sign Thief

Dear Integrity-Bereft Republican Who Stole My Obama Yard Sign,

Just wanted to fill you-in on what an inspiration you've been since you trespassed on my property and tried to violate my rights and freedoms. I want to tell you about the amazing night we had tonight.

I replaced the sign you stole, of course, so yes, that's more money for the Obama campaign. Oh, and I bought three t-shirts, 4 buttons, and another bumper sticker, while I was at it.

Your behavior only served to remind us of how strong our admiration for Barack Obama really is. We don't just support him. We love him, the way we imagine the supporters of people like Kennedy, Lincoln, Gandhi, and King must have loved them. Our family has supported other democratic candidates in the past, but this one's different. His power to inspire is so great that my 11-year-old begged me to take her to the Obama headquarters in our area so she could volunteer to make calls. And you know what, tonight I did, and she did, encouraged by her little brother (her "trusty sidekick"), who stood by her side. I am immensely proud of both of them and the way they participated in their country's democracy (not to mention warmed to my core to hear her cute, sweet little voice cheerfully calling voters to encourage them to participate in the election tomorrow).

Obama's office was a-buzz with volunteers filled with spirit (as one commenter put it on 538, "This is what happens when a community organizer uses his much-ridiculed experience."). There was a kind of joy in the air that stoked the fire in our hearts. We were proud to be there, to be part of this historic "ground game." Charisma comes from the Greek word for grace - the spirit-filled kind, the kind that moves mountains. This candidate's charisma not only draws people to him but also flows outward from him and bestows on all of us an energy that produces willing, heart-filled action.

I am glad we didn't let your childish actions discourage us. I am glad we left ourselves open to adventure tonight, on a school night, found our way to campaign headquarters, and in our own small way, participated in this inestimably important political process.

Because I want what's best for this country and its relationship with the rest of the world, I hope to see Barack Obama as our new president. I hope the people who constructed the polling machines had more integrity than you, and will not have rigged those machines to default at a Republican position just so they can steal the election by cheating. I hope this country has the courage and honesty to let the people's true choice be recognized. And whatever the outcome tomorrow, I do wish you well, and I hope this country moves in the right direction for both of us in terms of human rights and freedoms, natural and financial resources, and care for every member of society. Despite people who behave as you do, I believe this country deserves that.

Could Not Resist

Someone found my blog today searching for the phrase "oboists for Obama."

WHY DIDN'T I THINK OF THAT?!

Du-uh!

There is a group (on http://www.barackobama.com/), and they have this cute logo (notice oboe bell at bottom of logo) and even cuter description:

"This group is for oboists, baroque oboists, broke oboists, Barack oboists, English hornists, oboe d'amore-ists, and yes, Heckelphone-ists, who support Barack Obama for a better future!"

:)

(There's a Facebook group too - thanks, Dragonfly, for the suggestion! - where I got the above photo. Someone sent me a video of some members of the Facebook group playing "Hail to the Chief" but I can't figure out how to embed it...)

I have to admit, though, that I honestly still can't think of myself as an actual oboist, considering my still-a-beginner-now-and-perhaps-forever status. But to be a Barack Oboist I'd consider allowing myself the promotion!

I felt the energy today as I shared a thumbs-up from my car with a total stranger who was planting campaign signs along the road in New Hampshire.

I think this man has the potential to be one of the greatest leaders in American history.