Last Day At St. Boonie's

I'm sitting in my bedroom now with my husband and children watching the wind swirl snow off the rooftops. It's been snowing hard for hours. 

I can't believe it. It's finally here.

It was my last day at St. Boonie's.

I've said my goodbyes, and now I'm home.  But part of me lingers there for a moment.  For a couple of years I spent as many or more hours there than at home. Though our work load and situation got rough toward the end, the thoughts that echo through my mind are largely warm ones.

The O.R. community was like a village, or a second family. We joked familiarly with each other, teased each other, argued with each other, got into each other's business, supported each other. Leaving wasn't easy; but at the moment I truly feel it's the right step.

For now I rest with these memories, and many others - like the time one of the ENT surgeons did the merengue with me in the O.R.... and the time one of the OB/gyns was elbow-deep in a patient's abdomen trying to deliver a baby...and the time I did the polka with a colleague in front of the main O.R. desk...and the time we had to surgically extricate a rather large foreign object from you-don't-want-to-know-where...and...

The day they helped me change my flat tire...

The "Potty-Mouth Bucket" created for one of the surgeons...

One of the nurses expressing her affection for Johnny Depp...

Our turtle troubles, and our very own surgeon-cum-cheloniologist who was able to provide a curbside consult...

Bubba...

Caroline Walsh's highly appropriate T-shirt...

The "Fabio" effigy (face replaced) with which we'd decorate the lunch room in honor of a particular surgeon's birthday each year...

That surgeon's last Halloween appearance, when he showed up to work dressed as a certain well-known Plumber...

And this surgeon who was kind enough to stop for some Wheetabix for me on his way in to the hospital to do a weekend procedure...

And of course, the annual pumpkin carving exhibit:

Thank you, St. Boonies, for these past two and a half years. I won't forget them.

Ode to Vocal Cords

The ritual is the same every day:

parting tissues 

like a hunter parting reeds,

taking aim

and, if nature favors,

the surety and satisfaction of hitting one's mark.

Yet no two rituals are the same;

the mark can be elusive, 

or for all intents and purposes

 impossible.

I see it now: a frontier in time and space;

a narrow gate;

doorway between life and death,

between speech (or song) and silence;

the borders between human and other,

between "evolved" and "creature,"

incarnate in its vertical rims.

Every day I gaze upon

these Pillars of Hercules,

a cipher of our humanity,

evidence of our forward step:

the larynx low, fixed in descent

from its primal place 

in infancy and antiquity,

genetic words made flesh 

as flesh that - miracle of miracles -

makes words.

Words.  More than vowels,

howls, and primeval cries.

A voice - a voice is not enough,

nor a larynx far descended;

Cervus elaphus has that, and even

Phascolarctos cinereus.

Homo sapiens has found

that finely crafted, interwoven

movements, stops, and sounds

can place into our worldly roil

the measured contents of our thoughts.

A larynx powered by the mind:

portal to poetry, language, and song.

The hunt continues:

My daily ritual enacts 

an ancient yearning to understand

who we are, what gives us life,

and in what hidden places

our secrets can be found.

And so I snap my blade into place

and begin again.

_________________________________________________

This attempt at a poem was written in response to an invitation from Moneduloides to "step outside of the box" of what we usually write and submit a post for the December 30 edition of Grand Rounds, whose theme is "at the interface of evolution and medicine," in honor of the upcoming bicentenary of Darwin's birth and the 150th anniversary of the publication of On the Origin of Species.  Please check out this fascinating latest edition of Grand Rounds culled by brilliant blogger Moneduloides.

Silent Night

I am away from my family today.

I can't really complain. I just had the chance to be the CCU's "little Christmas elf" this evening, as the nurses started to call me: I happened to be "in the neighborhood" when they paged anesthesia stat, so there I went, blue jeans, jingle bell earrings, and all, to help the CCU attending with an intubation.

And I was with my husband and children earlier, thanks to my colleague Avram who offered to cover the morning hours of my call for me. I woke up to the sound of excited little feet thumping up the stairs and two adorable children jumping on the bed with cries of, "Merry Christmas!" and "Santa came!"

The reindeer had partaken of the oats we had left for them on the front steps, and the cookies and milk by the hearth had been (we presume) wolfed down with gusto. Delightful books, movies, and other dreamed-of gifts came out of their shiny wrappers under our tiny little Christmas tree. I sat in my almost-finished renovated kitchen - my husband's and father-in-law's mega-present for me - with the morning sun streaming in through a brand new window and sipped warm chocolate from my favorite mug. It was perfect.

I almost got teary-eyed hugging my children goodbye and leaving them today, but I know I'll be seeing them tomorrow morning. As we used to say during internship: "Morning always comes."

But for the moment, duty calls.

It's my last overnight call at St. Boonie's.

I finally did it. I finally made the decision to leave. My last day working here will be the 31st.

I have mixed feelings about leaving the St. Boonie's family. These empty halls I walk now are already haunted by ghosts this Christmas night - memories of moments with patients, of co-workers who have supported me. Like the time two nurses, an anesthesiologist, and a tech helped me change a flat tire in the parking lot so I could drive home. And the time people rallied around me when I felt threatened. And all the times we cracked up laughing over each other's antics, or inwardly cried for each other's sorrows.

So although I'm a little lonely this Christmas, I am warmed by these thoughts. I feel blessed to have come to know these friends. I look forward with hope to a new year and a new job. I rejoice in the Christmas morning that preceded this night. I am nourished by the ancient, hope-filled words from the Prophet Isaiah that have echoed in my mind and heart this season:

The people that walked in darkness have seen a great light:
they that dwell in the land of the shadow of death,
upon them hath the light shined...

I spend this Christmas night striving to look outward beyond myself and my own little life. I think of being here, working here, as a prayer, an offering of faith that is well within my power to give. As for prayers made with words: my mind and heart recite tonight a favorite from the Book of Common Prayer:

Keep watch, dear Lord,
with those who work, or watch, or weep this night,
and give your angels charge over those who sleep.
Tend the sick, give rest to the weary,
bless the dying, soothe the suffering,
pity the afflicted, shield the joyous;
and all for your love’s sake. Amen

Bells in the Air

I have started work on the Corelli-Barbirolli concerto in earnest.

I first encountered this work on Youtube, where I saw this young girl holding her oboe practically parallel to the ground, as is often done in Europe. If I had tried that at the time I know I wouldn't have been able to produce so much as a sound!

Mahler wrote instructions for the wind sections to play with bells up or "bells in the air" - Schalltrichter auf or campane in aria or pavillons en l'air - in most of his symphonies, apparently. Not in the first, I believe, but definitely in the 4th and 5th. I have seen solo oboists play like this too, and I marvel at it. How on earth do they play that way? For fun yesterday Kyoko had me try to hold a note while moving my oboe from my usual position (bell down) to having bell diagonally up, just to see what kind of adjustments I had to make with my embouchure to keep the sound going. I didn't find it easy!

As a dancer I can understand why the bell-up position can feel so triumphant, almost glorious. Playing in this stance of celebration and victory, one can almost imagine oneself among the heavenly host announcing wondrous "tidings of great joy." The dancer in me believes in the meaning created by our bodies' movements, by the shapes we make in time and space, and how these can influence our daily experiences. This is why I don't consider admonitions such as "Don't slouch" old-fashioned. Slouching can sap energy as much as holding one's bell up can invigorate one's playing.

This is also why I believe in paying attention to body language as well as words when I talk to my patients, and why, after a painfully long day in the O.R. on this Christmas Eve, the one moment that made it all worth it and that gave me renewed energy for the long drive home was the moment my patient clasped my hand to her chest in the recovery room as she thanked me for seeing her through her surgery. That one generous gesture of trust and appreciation, and the conviction in her eyes as she spoke to me, put the tired feelings, and the aching head, and the beeper beeping as soon as I got home, all in perspective.

It helped me look out at her and at the rest of the world again on this Christmas Eve, rather than at my tiny little problems and at the delicious, selfish self-pity in which I was starting to wallow over being on-call for the holidays. It helped me remember to wish her well and squeeze her hand in return. It helped me enjoy a moment of plunking out carols at our out-of-tune piano with my kids without worrying that the beeper would interfere.

Schalltrichter auf, T. Keep your chin up and your bell in the air.

A Christmas Carol and Other Stories

"But you were always a good man of business, Jacob," faltered Scrooge, who now began to apply this to himself.

"Business!" cried the Ghost, wringing its hands again. "Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence, were all my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!"

Every year a different line from Dickens' classic hits home - which is probably why it is and should be a classic. This year it's this one. The dealings of my trade - laryngoscopes and stethoscopes, hospital life, group politics, patients easy and difficult both clinically and personally, exhausting calls, preoccupying stresses and responsibilities - these are the "drops" that need to be put in perspective in the "comprehensive ocean of my business."

This year work has grown increasingly problematic. I needed to be reminded: work is just work. My profession, my calling, is much more than what I've been dealing with at work. In any case, change is on the horizon...but of that, another time.

I took my children to see a local theater production of Dickens' A Christmas Carol tonight. It was quite a nice production. The performers not only acted out the classic tale but also took turns narrating the story using Dickens' own words. Woven into many scenes were lovely arrangements of some favorite carols sung or played by the actors themselves - Good Christian Men Rejoice, God Rest Ye Merry Gentlemen, Here We Come A-Wassailing, the Gloucestershire Wassail, and Let All Mortal Flesh Keep Silence, to name just a few.

Year after year this story makes me think Dickens was a total genius and knew all the elements of a near-perfect story: intriguing characters, appealing settings, mystery, conflict, secrets to be revealed, high-stakes trouble to be resolved, a ghost or two, moments that highlight little glimpses of humanity that make us think, "Yes! Exactly!" and of course, a final conversion that moves and brings joy, and can bring insight into ourselves in a transforming way. Dickens reminds us through his timeless character that hope and redemption lie at the heart of Christmas.

Here's another one of my Christmas Lists, then, for the eve of Christmas Eve:

My Favorite Holiday Stories and Books

7. The Littlest Angel by Charles Tazewell
6. Two from Galilee by Marjorie Holmes

5. The Best Christmas Pageant Ever by Barbara Robinson
4. The Gift of the Magi by O. Henry

3. A Christmas Carol by Charles Dickens, illustrated by P.J. Lynch

2. The Fourth Wise Man as told by Susan Summers, illustrated by Jackie Morris

1. The Christmas Miracle of Jonathan Toomey by Susan Wojciechowski, illusrated by P.J. Lynch

Christmas Lists

Happy Solstice!

I have a confession to make.

I love, love, love making lists. I think I may have to sign up for an account on Listography.com.

I've been list-making like crazy this season. List of gifts for family and friends. Christmas card list. Wish list. To-do lists for the day, the week, and the month. List of books I want to read on my next vacation. It's a form of self-soothing, I guess, during a hectic period.

Today's list was inspired by a quote I heard on a wonderful NPR interview of composer John Rutter. At the end of the interview Andrea Seabrook quoted Paul McCartney as having said,

"I love to hear a choir. I love the humanity... to see the faces of real people devoting themselves to a piece of music. I like the teamwork. It makes me feel optimistic about the human race when I see them cooperating like that."

I couldn't agree with him more. I've had the privilege of a music-filled holiday season so far - we were transported by The Christmas Revels at Sanders Theater yesterday, and we heard Kyoko play stunningly with the chamber orchestra at the Isabella Stewart Gardner Museum today. Every time I watch musicians or performers coming together to offer us their different talents and voices with love, energy, and real joy, I come away with a renewed sense of hope for the world beyond the concert hall.

Christmas List of the Day: What the O.R. Team Can Learn from a Choir or an Orchestra

10. Show up on time.

9. Make sure you have all your papers in order.

8. Keep your instruments in tune.

7. Practice together.

6. If you're giving directions, know your notes really well and bring the best out in each of your players.

5. Be prepared for your own part.

4. Know and show that every voice counts / matters / deserves respect.

3. Pay attention and listen vigilantly to those around you.

2. Work together and help each other do your very best.

1. Never cut corners; put reverence and heart into what you do, not for your own sake, but for the work your team is doing and creating, which has the power to make lives better.

Christmas List II: An Anesthesioboist's Favorite Carols

O Come, O Come Emmanuel
O Come, All Ye Faithful (somehow always makes me cry when it starts; not sure why)
In Dulci Jubilo
Ding Dong Merrily on High
Rutter's Star Carol and Shepherd's Pipe Carol
Riu Riu Chiu
Personent Hodie
I Wonder As I Wander
Wild Wood
Wexford Carol
Un flambeau, Jeanette, Isabelle
Pat-a-Pan / Guillaume, Prends ton Tambourin
Do You Hear What I Hear
Most of the Wassail Songs - Somerset Wassail, Here We Come a-Wassailing, the Gloucestershire Wassail, etc.
The Sussex Carol
Most things on most Cambride Singers recordings...
Alfred Burt's stuff as sung by the Tanglewood Festival Chorus with the Boston Pops
Nick Bicat's "God Bless Us Everyone" from the 1984 film version of A Christmas Carol

Christmas List III: Boston Area Christmas Delights We'd Love To Try and Catch Every Year Even Though We Know We'll Only Make One or Two

Music:
-The Christmas Revels
-a production of Amahl and the Night Visitors
-the Messiah sing at Harvard's Dunster House
-Harvard University Choir's lessons and carols service at Mem Church
-the Gardner Museum concert series
-The Reagle Players' show It's Christmas Time

-the Pops
Dance:
-A Dancer's Christmas (sadly, in its final year)
-Boston Ballet's Nutcracker
-we still haven't made it to the Urban Nutcracker but really want to

Theater:
-A Christmas Carol at Arsenal Center for the Arts

Candy Cane Time

The one time I don't mind being on-call overnight at the hospital is during a blizzard. Everyone scurries around frantically trying to leave early, to avoid having to drive in the snow storm, but the person on-call isn't going anywhere. With any luck, the busy work dies down early and you can ensconce yourself in the doctor's lounge with a mug of something warm to drink (unless you're at a trauma center, in which case you might not sit down all night).

St. Boonie's is not a trauma center, but it does admit a lot of very sick patients, and the busy work did not die down so early on my last blizzard call. A PACU patient went into respiratory distress and was found to have a highly unexpected pneumothorax. The O.R. ran non-stop all day and into the night, though I did take a late afternoon break to have a yogurt and a couple of Lavender-scented Shortbread Nuggets. That night Bubba had to bring a patient back to the O.R. to control some bleeding. The ICU moonlighter called not once but twice to ask if I could perform a couple of after-midnight intubations for some really ailing, failing patients. There was a steady stream of work, but it was good work in a warm place.

The real gift of the day was the chance to help a colleague manage a really tough situation. While I was finishing my lavender-infused butter cookie in the break room, one of the nurses came in and said, "Do you think you could come and help Alex out? He's having trouble intubating this woman. He's been trying for almost half an hour."

"Half an hour?!" I got up and started walking back to the O.R. with her.

"It's a woman we've had a hard time with before. The last time this patient was here Jinny took four tries before she could get the tube in." Jinny's been practicing anesthesia for almost as long as I've been alive.

"Well, if Jinny had a tough time, and Alex is having a tough time, I don't imagine it's going to be any easier for me." Alex had done a fellowship in cardiac anesthesia at a prestigious heart center after his residency, so technically he had had even more anesthesia training than the rest of us.

When I walked in Alex had the situation under control with a temporary airway device, but we still had to find a way to get an actual breathing tube into the patient's trachea. "I had no view with a Miller blade," Alex said. "Tried twice. Then I tried a blind nasal - no luck. I thought I'd wake her up and do a fiberoptic next."

"Have you tried an intubating LMA?"

"No. We could do that first. Or you can have a look if you want."

We got the LMA and the fiberoptic scope ready and positioned our assistants. I got a tube and different laryngoscope blade ready, then I went to the head of the bed to take a look, expecting a very unpromising view.

I was right. No vocal cords to be seen. Not even arytenoids. But I did find the tip of the epiglottis, which Alex had had a hard time even visualizing. I asked Alex to apply some external pressure on the patient's cricoid cartilage, passed the tip of the breathing tube behind the epiglottis, and asked the nurse to remove the stylet from the breathing tube slowly while I advanced the tube. The patient coughed weakly. That was actually a good sign.

Alex's eyes lit up, almost not daring to hope. He hooked the breathing tube up to the ventilator. I squeezed the ventilator bag. The patient's chest rose. Our eyes swerved toward the carbon dioxide monitor to see if there was indeed a waveform indicating exhaled carbon dioxide. The electronic line appeared, drawing the exact curve we were looking for. Alex put his stethoscope on the patient's chest. "Good sounds on the right. Pull back a little...okay, good sounds on the left. We're in!"

Alex, the nurse, and I all breathed a sigh of relief. Then Alex turned to me and asked, "How did you DO that?"

"I think I got lucky," I said, "but I can show you what I was trying to do once we're all set here."

Alex set about securing the tube and positioning the patient while I cleaned up syringes and wrote a note in the chart. When he had gotten everything settled, I showed him how I had inserted a stylet into the breathing tube and curved the whole contraption into a letter J or, as I told him in the spirit of the season, an upside-down candy cane. Then I had him position his hand as a kind of epiglottis and showed him what happend to the tube as the stylet was being removed slowly. Because of the candy cane shape, the tube was propelled first vertically upwards before snaking horizontally into the glottic opening - a movement demonstrated to me during residency by an anesthesiologist I had had the chance to work with only a few times.

Had I not spent that particular day with that particular teacher and had a patient with a challenging, "anterior" airway, he might never have had occasion or taken the time to pass on this particular tip. It was a maneuver that had gotten me out of many, many sticky situations, when an airway threatened to be difficult and I didn't have much around in the way of extra hands or fancy technology. It's these seemingly simple, low-tech options that sometimes save lives in the field, during ICU intubations, or when you're the only attending anesthesiologist around for miles in a rural hospital in the middle of dairy farms. I thought of Dr. R, the man who gave me the courage and ability to try this little technique, and thought, "What an incredible gift you've given me. How many patients have I been able to help, because you taught me this one small thing? Thank you!" I wrote him to tell him so that night.

Teaching each other is truly one of those "gifts that keep on giving." It reminds me of something Will Smith said recently on TV, about the kind of work we should all be doing: "If you're not making someone else's life better in some way, then you're wasting your time." When I have been on the receiving end of an eye-opening, helpful lesson, I feel a small rush of excitement and happiness at having been given something truly constructive, valuable, and ultra-cool. When I've had the privilege of teaching others helpful things that my teachers have taught me, the feeling is doubled: I feel my own excitement and that of the person to whom I've passed on what I know, as well as a resurgence of gratitude to the teacher who gave me the initial knowledge or ability.

Alex and I felt like celebrating after we were able to secure his patient's airway, not only because we were relieved to have done so at last, but also because he was so excited to have acquired a new option for his store of airway-management techniques. So thanks, Dr. R, for showing me that candy cane maneuver, and giving me the chance to help not just patients and students but also fellow-physicians. I owe you one.

Truth Serum

Sometimes patients ask after they wake up from anesthesia, "Did I say anything embarrassing?"

The truth is, the answer is usually no, and our usual response to anyone who asks that question is an innocuous, general reassurance like, "You did fine! You're just waking up and everthing went well."

But I understand completely the questions that must lurk in the back of people's minds over "being put under" a general anesthetic. To require people to put their lives in another's hands and relinquish all control of their minds and bodies to a total stranger is almost too much to ask. Why should we have that kind of trust, often after only a few moments of conversation?

Often I try to spend some of those moments getting people to talk about their biggest concerns - in fact, their fears. The most common nervous question lurking in people's minds seems to be,

What if I don't wake up?

The second most common one is,

What if I wake up in the middle of surgery?

There are others:

• What if this anesthesiologist doesn't know what he or she is doing, and lets something bad happen to me?
  
• Will the anesthesiologist leave the room and leave me alone on the table? (The answer to that, by the way, is always NO - you will NOT be left alone without someone to guard you.)
  
• What if they do something bad to me while I'm under, or not quite under, then give me something so I don't remember it?
  
• What if something bad happens, and I DO remember it?
  
• What if I say something I'm not supposed to?
  
• What if I do something embarrassing - punch somebody, dance in the nude, pass waste, pass gas, urinate, touch my private parts, touch their private parts, belch?
  
• What if I act like a total jerk when they start giving me the drugs?
  
• What if I have a bad reaction to the drugs?
  
• What if the drugs damage my brain / impair my thinking forever / take away my creativity / change my identity / screw me up?
  
• What if something smells, or looks gross?
  
• What if they find out that secret habit I've been trying to hide from everybody?
  
• What else will they find out? Will they look down on me when they do?
  
• What if I die?
  
• Do they really even care about me, or am I just another slab of meat to them?

Here's the good news: there is no such thing as truth serum. You are highly unlikely to disclose top secret things under the influence of what we give you.

BUT...

What we give you can have disinhibiting effects. Are you a happy drunk or a sad drunk? I get giggly after just one glass of wine, so I seldom drink more than half a glass even with a nice dinner. I would probably be pretty giggly after getting a sedative or some laughing gas. But some people start weeping uncontrollably even though they don't really feel sad, and they can't explain why when we ask why they're crying. For those who hate to lose control of their faculties, this kind of disinhibition ranges from annoying to profoundly invasive.

Also: people may not necessarily be induced to tell the truth with sedative drugs, but sometimes they do talk more. They talk non-stop. Talk, talk, talk, chatter, chatter, chatter, as we wheel the gurney all the way to the operating room. Very rarely they talk about very personal things, like erotic fantasies - in fact, I've only seen that happen once.

As for disinhibited behavior: we have seen the occasional grope or right hook. Just recently a very charming young man started sliding his hand up a scrub tech's side, toward her breast, as he flirtatiously drifted off into a stupor. It's my personal belief - no scientific studies to back this up, that I know of - that people's true nature comes out under anesthesia; that the disinhibiting effects unmask people's natural tendencies or temperament. I've seen sour-faced women wake up from anesthesia flagrantly hostile. Sweet children come out whimpering for their mommies; hellions are...well, hellions. Adolescents do tend to swing at people whether or not their angry at baseline - they just have a lot of pent-up energy, I guess. But for the most part, the truth will out, or so it seems.

Finally: there isn't a drug that will reveal people's secrets better than their very own bodies, histories, and physiologies can. I've written this before: if you lie about how much alcohol you drink or how many pain-killers you take at home on a daily basis or whether you took any cocaine last night, your body will tell the truth under anesthesia (or your urine test or blood test will show it), and we'll all know that you lied. If you're bulimic and you think no one knows, we'll catch a glimpse of your teeth and realize it. If you cut yourself to soothe anxiety, we'll see your scars.

And you know what? We won't really think any worse of you - not for having problems. For disrespect, maybe; for problems, no. Nor will we want to take less good care of you, or do less than our very best for you. Why? Because if we've learned anything as health care workers, it's that EVERYBODY has scars. Everybody has SOMETHING about themselves that they wish were in better shape, that they wish people didn't know about them, and no one - absolutely no one - is perfect, including and perhaps especially ourselves.

Do we sometimes recoil inwardly at what we see? Truthfully, yes. But do we also see the human need beneath it all? Do we care about you? Do we feel bad that not everything in your life is what you want it to be? Do we want to help, and make things better for you in whatever way we can? Yes. That's why we're here, day after day, doing work that's not always easy and not always pleasant. It's because ultimately we came to this work believing in our core that human lives are worth the effort.

I realize that I've seen a lot of "deep, dark secrets" in my line of work. People dying of cancer, teenagers who have lost pregnancies, the bruises of abuse, the tears of the undocumented, the marks of psychiatric disturbance both mild and severe. The truth of our lives, the stories we've lived through and are living through now, are written into our tissues and the workings of our bodies, into the very fabric of our being. The idea of truth serum is a tantalizing one, but it should stay in the movies; the real truth serum lies right in our own veins. I think having to deal with the face-to-face detective work involved in understanding human suffering, and having to sift through clues right before our eyes to discover what matters most to our patients, is a far richer approach than hoping a little sodium thiopental will unlock all the answers; the care-ful approach honors the truth and allows us to work with it fruitfully, whatever it may be.

Medical Weblog Award Nomination

I am stunned and humbled to learn that Notes of an Anesthesioboist has been nominated in the category of "Best Literary Medical Weblog" for the 2008 Medical Weblog Awards.

"These awards are designed to showcase the best blogs from the medical blogosphere, and to highlight the exciting and useful role medical blogs play in medicine and in society."

The categories for this year's awards are:
-Best Medical Weblog
-Best New Medical Weblog (for a blog established in 2008)
-Best Literary Medical Weblog
-Best Clinical Sciences Weblog
-Best Health Policies/Ethics Weblog
-Best Medical Technologies/Informatics Weblog
-Best Patient's Blog

And the nominees are...(so far)

Best Medical Weblog
The Best Evidence in Emergency Medicine Investigator Group
Edwin Leap, M.D.
Ivor Kovic, M.D.
other things amanzi
Running a hospital
Science-Based Medicine
ScienceRoll
Unprotected Text

Best New Medical Weblog (established in 2008)
Life in the Fast Lane
Mind, Soul, and Body
Mothers in Medicine
The Ozmosis Blog
Rural Doctoring

Best Literary Medical Weblog
Notes of an Anesthesioboist (I am amazed and deeply honored to be counted among these wonderful fellow-bloggers!)
other things amanzi
Reflections in a Head Mirror
Rural Doctoring
Science-Based Medicine

Best Clinical Sciences Weblog
Clinical Cases and Images
ER Stories

Best Health Policies/Ethics Weblog
Better Health
The Happy Hospitalist
InsureBlog
HIStalk
The Last Psychiatrist
Respectful Insolence
Running a hospital

Best Medical Technologies/Informatics Weblog
Clinical Cases and Images
Life as a Healthcare CIO

Best Patient's Blog
Alin's Site
Beating Social Anxiety
DiabetesMine
Duncan Cross
Every Patient's Advocate
Furious Seasons
Pregnant Stephanie
Soulful Sepulcher
Survive the Journey
Vicarious Therapy

Nominations will be accepted until Wednesday, December 31, 2008. Please second the nomination if you feel up to it, by leaving a comment here. Finalists will be announced on Monday, January 5th, 2009. Polls will be open from Tuesday, January 6th, 2009 and will close 12 midnight on Sunday, January 18, 2009 (EST). Winners will be announced on Friday, January 23, 2009.

Humblest thanks to BrainDoc over at Mind, Soul, and Body and Paul Levy at Running a Hospital for nominating me!

Don't Try This At Home (or, If You Thought Self-Experimentation Was Bad...)

Ok, I'll admit it.

I've done what might be considered minor medical procedures at home.

Minor. Very minor.

And only because I was concerned about someone's safety and didn't want to sit in Chairs (i.e., the E.R. waiting area) for hours before someone finally bothered to ask me a whole bunch of questions which would all have led to the very minor procedure I ended up doing.

But I don't think I'd be brave enough to cut off my own arm to save my life, and I certainly wouldn't be competent to take out my own appendix, even if I were stuck on Antarctica with no other physicians around (see photo, above).

Finally, here's the clincher: even with all the ferocious maternal courage and love I could muster, I think there's NO WAY on God's green EARTH that I could perform a "self-inflicted Cesarean section" even to save my own baby. Heck, I couldn't even get through normal labor without an epidural kit-wielding anesthesiologist.

Ines Ramírez Pérez did it, though, and she and her baby lived to tell the tale.

Cut her own belly open, down to the uterus, then sliced her uterus open and pulled her own baby out of it. OW. I mean, OWWWWWW.

I found these examples and a few more at ListUniverse, under "Top 10 Incredible Self-Surgeries." Have a look...it's weirdly fascinating.

Equus

"Tragedy, for me, is not a conflict between right and wrong, but between two different kinds of right." -Peter Shaffer


Yesterday I took a day trip to New York and saw Daniel Radcliffe in Equus.

WOW.

Move over, Harry Potter; make way for Alan Strang, the disturbed teenager Radcliffe plays in this play by Peter Shaffer. Radcliffe has ENORMOUS talent. How does he get up there and DO that eight shows a week? It's a physically and emotionally demanding role that requires some pretty mature artistry, and he totally ROCKS.

Equally compelling, in a quieter way, is his co-star, Richard Griffiths, who has worked with Radcliffe on the Harry Potter films, playing his mean Uncle Vernon, and who in Equus plays Alan Strang's psychiatrist, Dr. Martin Dysart. The play centers around a doctor-patient relationship and explores themes of trust and vulnerability, faith and doubt, domination and enslavement, the Apollonian versus the Dionysian, and being full of passion versus being emotionally dead, not only through Alan's psychosis but also through the evolving relationship between the two main characters.

I can already hear the naysaying from psychiatrists and other mental health professionals about how this relationship is portrayed: "A doctor would never say that or do that!" or "It's totally unrealistic!" But I think such criticism misses the point. The play is not about what's "realistic" in the therapy relationship but rather what is REAL: it's about making internal drama visible, building trust, opening up and being vulnerable to another and/or to oneself. While I like Shaffer's Amadeus better - hmm, drawn to music over medicine - I was completely riveted by Equus, dark as it is, and would totally see it again.

I have to gush a little bit about the production design, direction, lighting, and choreography here. The set was deceptively simple: a semicircle of horse stalls surrounding a central area in which oblong blocks were moved about to suggest the various scenes in the play. The use of music and lighting conveyed just enough spookiness to put the audience on edge, anticipating some mysterious and perhaps ghastly revelation. And the horses, played by men on platform "hooves" wearing sculpted wire horse heads, with their surreal, rhythmic movements and eerily well-timed hoof beats on the wooden floor, especially at the most dramatic portions of the play, were completely breath-taking and really "made" the world of the play in a way no other element of the production could have.

Much has been made of the nudity in the play, and being a fairly "PG" person I was a little nervous about seeing the actors "bare all" right in front of me, but as the story unfolded I saw Shaffer's wisdom in writing the action this way. The physical nudity is nothing compared to the emotional nakedness that Strang enters into, and by extension, that Radcliffe must enter into in order to portray Strang, which he does with a magnetic vulnerability I didn't see in Peter Firth's interpretation in the film version.

The pain of Strang's character is so raw and so tragic. I'll never forget the pity I felt as Strang's mother described how Strang cried and cried when his father threw his picture of the suffering Christ in the trash, and how ominous it was that he recovered beautifully when the picture was replaced with the photograph of a horse. As the characters reveal clues about the mystery of that pain, in layers, Strang's psychological wound appears with greater and greater clarity, as if seeping through a dressing that's slowly being removed, until the wound is finally exposed in all its horror.

In the end one comes away realizing that deep compassion has replaced the initial inclination to abhor and judge the deranged teen as nothing more than a violent monster. Dr. Dysart goes through this journey himself and finds that there is an element of tragedy, too, in the healing of such a wound, in restoring what is "normal": by excising the offending portion of Strang's psyche, he is also "cutting out his heart," a life of worship and passion that Dysart wishes he could know for himself. Medicine becomes a constraint, a way of "reigning" in and being reigned in - as Dysart says, "all reigned up in old language and old assumptions;" it is also a way to take an individual's most precious and primal self from him, resulting in a deeply personal kind of loss that I've heard described by some patients who take antidepressants or antipsychotic medications.

Dr. Dysart, in the end - and here I cannot help noting the sound of his name, "dies-art" - burdened by the suffering he has witnessed or by the treatment he is contemplating, or both, identifies not only with his troubled patient but also with his patient's victims, the horses: "There is now in my mouth this sharp chain. And it never comes out."

It was an unforgettable theater experience.

I've embedded a Youtube video below of the last portion of Daniel Radcliffe's appearance on Inside the Actor's Studio, which I caught last week on T.V. I was so impressed with the intelligence, maturity, humor, humility, and professionalism he projected during this interview that it was ultimately what made me decide to take the day trip into Manhattan to see the play. See him articulately quote Keats at minute 3:09 and explain to an acting student at minute 8:08 what he tells himself to keep his performance fresh every time. What an impressive and self-possessed young artist.

Equus Cast, Broadway 2008

Martin Dysart...........................................Richard Griffiths
Alan Strang..............................................Daniel Radcliffe
Nurse.......................................................Sandra Shipley
Hesther Saloman..........................................Kate Mulgrew
Frank Strang..............................................T. Ryder Smith
Dora Strang...........................................Carolyn McCormick
The Young Horseman and Nugget.......................Lorenzo Pisoni
Harry Dalton............................................Graeme Malcolm
Horses..................................Collin Baja, Tyrone A. Jackson,
......................Spencer Liff, Adesola Osakalumi, Marc Spaulding
Jill Mason.....................................................Anna Camp

Grand Rounds is Up

Check out this week's edition of Grand Rounds over at Sharp Brains.  Alvaro Fernandez creatively uses an interview format to present topics ranging from the training experience to treating patients to technology.  Check it out!

Flatus

Medical student (rounding at a nauseatingly early hour some time before sunrise): Mrs. McGillicuddy? Hi, sorry to wake you-

Patient (opening her eyes with a start): Huh? What?

Medical student: Sorry - I just wanted to check and see -

Patient: Speak up, dear, I can't hear you.

Medical student: How are you doing after your surgery, Mrs. McGillicuddy?

Patient: Oh, fine I guess -

Medical student: Are you having any pain? Nausea? Are you passing gas?

Patient: I beg your pardon?

Medical student: Gas. GAS. Are you passing gas?

Patient: Why? Do you smell something?

Medical student: No, no, we just have to ask-

Patient: What's that?

Medical student: We have to ask-

Patient: Ass? They did surgery on my belly, kid. Are you trying to be impertinent?

Medical student: Not at all, Mrs. McGillicuddy, we ask everybody...about...

Patient: About farting? You go around at the crack of dawn to ask about people's farts?

Medical student: Do you mind if I check your surgical site?

Patient: My what?

Disclaimer: I debated and debated with myself about whether to post about this rather sensitive subject. I decided to go ahead because there's so much in medicine that people are reluctant to discuss but do have thoughts on, and sometimes if we share those thoughts, we can learn something from one another. Or, we can totally embarrass ourselves...but I'm willing to risk it. Maybe I'll start a series of posts on "Sensitive Subjects" - death, sex, moral quandaries, competency measures, and the like. For now, though, inspired by a recent interaction at St. Boonie's, my topic isn't quite so lofty; what's on my mind is...gas.

Here's the truth of the matter: everyone passes gas, sometimes in the hospital, and not only do clinicians sometimes hear it and smell it, but also, very often, doctors, nurses, and students have to ask about it.

I haven't been a patient many times, but from my few experiences as a patient I can completely understand anxiety over the lack of privacy one has in the hospital when it comes to bodily functions. I certainly didn't want anyone to know, by sight, sound, or, heaven forbid, smell, if and when I had expelled waste of any kind.

Here's another truth, though: health care workers deal with body fluids and gases for a living, and very little comes as a surprise or as an unusual event. And, deep down, we feel, or should feel, that if people need help dealing with private bodily functions, it's part of our calling to provide that help with sympathy and respect, even if it's not our favorite part of the job.

As an anesthesiologist I have opened mouths that didn't seem to have known the presence of a toothbrush for years. I have suctioned copious amounts of mucus from the throats of smokers or people with colds. I have had a sedated patient pass gas directly into my face while I was placing a spinal. I have been in a room full of people in which an expectant mother in whom I had just placed an epidural let out a particularly loud gas cloud. I finally broke the momentary stunned silence by turning to her husband and saying, "Gordon, my word! I told you the three-bean salad in the cafeteria was a killer." Thankfully everyone took it in the spirit in which it was intended and had a good chuckle.

"A fart can sometimes be musical." -Graham Greene, in the novel Monsignor Quixote.

I guess the point is, it's not so bad. If a patient pees or poops or passes gas or burps or barfs, we offer help if needed, without so much as batting an eyelash, then move on, business as usual. It's okay. Really. Next time I'm the one on the hospital bed, I'll try to remember that. But it's not easy. It takes trust, some real faith in the good intentions of others.

There's a good chance we'll all need help at one time or another with private bodily things. I hope when my turn comes around again that there will be an understanding word and a gentle touch from the person offering that help - that I see in my caregivers the same kindness my colleagues and I, for the most part, try to extend to our patients.

***

I found out some interesting things about flatus when I looked it up online. Here's a little CME quiz I concocted just for fun (answers below):

1. Flatus is composed mainly of

a) carbon dioxide

b) methane

c) nitrogen

d) hydrogen sulphide

2. The ability to "break wind" at will is mentioned in the Catholic classic

a) City of God by St. Augustine

b) Canticle of the Sun by St. Francis of Assisi

c) Summa Theologica by St. Thomas Aquinas

d) The Story of a Soul by St. Therese of Lisieux

3. The particular characteristics of a sample of flatus are influenced by

a) the velocity of the gas being expelled

b) the types of microorganisms living in the digestive tract

c) the tightness of the anal embouchure

d) all the above

4. Which of the following statements is false?

a) Dairy products, legumes, cashews, cabbages, sweet potatoes, leeks, and Jerusalem artichokes can produce flatus.

b) Odor from flatulence isn't treatable.

c) Cumin, coriander, and caraway may reduce intestinal gas production

d) Rice is the only starch that does not cause gas.

5. High-altitude flatus is attributable to this gas law:

a) Charles's Law

b) Boyle's Law

c) Poiseuille's Law

d) Gay-Lussac's Law

(If you're wondering if this is what anesthesiologists do on their vacations to relax, I think the answer's definitely NO - I just had to...get it out, so to speak...)

I leave you with the following august quotations:

"It is universally well-known, That in digesting our common Food, there is created or produced in the Bowels of human Creatures, a great Quantity of Wind. That the permitting this Air to escape and mix with the Atmosphere, is usually offensive to the Company, from the fetid Smell that accompanies it. That all well-bred People therefore, to avoid giving such Offence, forcibly restrain the Efforts of Nature to discharge that Wind."

-Benjamin Franklin, "A Letter to the Academy," collected in Fart Proudly: Writings of Benjamin Franklin You Never Read in School (1990)

"Never was bestowed such an art

Upon the tuning of a fart...

Thanke God quoth Sir Edward Hungerford

That this Fart proved not a Turdd."

-from The Censure of the Parliament Fart, 1607

Thus endeth my reflections on "the gas we pass."

________________________________________________

Addendum 12/16/08: just catching up on my blog rounds and saw this delightful recipe from Elaine Fine featuring the musical fruit ("Beans, beans, the musical fruit: the more you eat, the more you toot.")

________________________________________________

Answers to flatus quiz:

1)c 2)a 3)d 4)b 5)b

A Little Medicine for Sunday Night Syndrome

Well, the good news is that I don't have even a bit of the Sunday-night blues tonight, because I am on vacation.

The bad news is that my son, though he is very young, does.

"I don't want to be sleepy," he said to me tonight as I tucked him in. "Because if I'm sleepy, then I'll fall asleep, then it'll be MONDAY, and I have school and karate."

"But you do so well in school and karate," I reminded him. "And you'll enjoy seeing your friends.  Then Monday will pass, and it'll be Tuesday, and you can go to your grandmother's house, which you enjoy too."

He was only slightly placated.

I totally understood.

***

Today at Mass our pastor spun off from the Scripture passage that begins, "Comfort my people," and asked us all to reflect on what brings us comfort.

I've been thinking about those comforts a lot lately, actually, because as much as I cherish the true meaning of Christmas - the presence of love alive in the world, and the hope of spiritual light in the midst of darkness - I really, really enjoy its more superficial, material comforts too.

My absolute favorite thing to do - something I look forward to all year and try to do as much as possible for as long as possible - is wrapping Christmas presents and putting together Christmas cards while Christmas music is playing in the background, or a holiday movie. The other day I finally had my chance to put my pager away and immerse myself completely in holiday spirit. I wrapped to my heart's content.

My husband knows me well. When I caught him glancing in my direction with a little smile on his face I only pretended not to know what he was smiling about. He was happy for me. I sat on the floor like a little kid to cut paper and make gift labels. I was happy for myself.

Most often I do this to CDs featuring the Cambridge Singers or the Boston Pops, though lately thanks to Pandora.com I've also become enamored of Ella Fitzgerald's album Ella Wishes You a Swingin' Christmas. I've done most of my shopping online this year. My son the budding astronomer is getting a book of Hubble space telescope images. My daughter's growing up fast; she wants a pair of black pearl earrings similar to a simple pair I have. As for me - I've ordered myself Zipoli's adagio for oboe, cello, and strings.

The actual stuff doesn't really matter. What I enjoy is the choosing, procuring, and preparing. I love the protracted enactment of one's affections for others, and the chance to reconnect with people near and far.

And I do love the sensory delights of the season.

Snow flurries. Peppermint-flavored cocoa. The smell of butter cookies in the oven. The sound of sleigh bells and festive music. Colorful cards and ornaments and lights. Gifts, food, movies that transport us, stories that inspire, and great company. I know a lot of people find these little details too frivolous, or shallow, or often too commercial, but I really appreciate them. I think they make people stop to look, listen, and feel, to be truly present for a moment, and consider allowing themselves a little childlike wonder, a little faith in the possibility of peace and joy.

The Quincke and the Pain

Pinky: "Gee Brain, what do you want to do tonight?"
The Brain: "The same thing we do every night, Pinky—try to take over the world."

When I was in college a few of my classmates and I would gather in the lounge of the Catholic Student Association on many afternoons to watch one of our favorite shows: Steven Spielberg's satirical Animaniacs (our other favorite was Star Trek: the Next Generation). Animaniacs had a recurrent feature entitled Pinky and the Brain, a cartoon about two genetically-enhanced lab mice who, each episode, try (and fail) to "take over the world" by some circuitous, outlandish scheme concocted by The Brain. The Brain is a misanthropic, grumpy, muttering cynic, while his faithful friend, Pinky, is a guileless, clueless, goofy sidekick - a fitting foil. (See videos below for their intro song, which includes the above exchange, and for a song in which The Brain reviews the anatomy of...the brain.)

I was thinking about them recently because I was missing their Christmas special, A Pinky and the Brain Christmas, which is one of my favorite Christmas specials, right up there with the Grinch, Elf, and A Christmas Carol starring George C. Scott as Scrooge.

I was also thinking about them because I've done an unusually high number of spinals this week, for obstetric and orthopedic patients, and that made me think of August Bier and August Hildebrandt, who experimented on each other 110 years ago after trying cocaine spinals on a handful of surgical patients. I can just picture them in their lab saying, Pinky-and-the-Brain like, "Gee, Bier, what do you want to do tonight?" "The same thing we do every night, Hildebrandt - try to take over the spinal cord."

Well, of course it didn't go exactly like that. Here's what really happened.

Bier wanted Hildebrandt to inject a small dose of cocaine into his spinal canal so he could study some of the side effects he had observed in his surgical patients. Hildebrandt couldn't get the syringe holding the cocaine to hook up well to the spinal needle, and a lot of cerebrospinal fluid and medication leaked out. When Hildebrandt tested Bier's sensation, Bier said ow. He had no spinal anesthetic effect.

Hildebrandt volunteered to be guinea pig (now, honestly - would you have done that?). Bier, who was more experienced at administering spinals to begin with, managed to inject the medication into Hildebrandt's spinal canal and kept a meticulous record of his subsequent actions, their timing, and their effects.

The Brain: Pinky, are you pondering what I'm pondering?
Pinky: I think so, Brain, but scratching just makes it worse. -from the episode "Bah Wilderness"

Bier pricked Hildebrandt's thigh with a needle. Then he passed a blunt, curved needle into the soft tissue of the thigh. No pain.

He pushed a long needle down to the thigh bone a few minutes later. No pain.

A few minutes after that, he applied the burning end of a cigar to Hildebrandt's legs. (A cigar in the lab...how quaint...)

He pinched a leg (no pain). He pinched the upper chest (lots o' pain).

He yanked body hairs down below, if you catch my drift (painless - eew). He yanked hairs up high ("very painful").

At 23 minutes he hit Hildebrandt's shins with an iron hammer (not painful; but again, honestly, would you let someone do this experiment on you?! sublimated hostility, anyone?).

At 25 minutes he applied "strong pressure and traction on the testicles" (not painful - ditto above).

At 40 minutes he hit him on the shins again.

At 45 minutes pain sensation was gradually beginning to return.

Bier then writes, "After performing these experiments on our own bodies we proceeded without feeling any symptoms to dine and drink wine and smoke cigars." Both of them subsequently developed debilitating post-dural-puncture headaches that lasted for days (much less common with the finer needles used today). In addition Hildebrandt had shin pain and bruising (ya think?!). Again, I submit: I don't know that I'd have been willing to self-experiment like this, and endure such potential risk and discomfort, in the name of science. I am not one of those who would have exhumed bodies for illicit dissection in the Renaissance period, either. I guess I am not pioneer material...but I'm entirely at peace with that!

The Brain: Pinky, are you pondering what I'm pondering?
Pinky: I think so, Brain, but wouldn't his movies be more suitable for children if he was named Jean-Claude Van Darn? -"Inherit the Wheeze"

One hundred and ten years later I suppose I'm glad they had the audacity to try this. The technique has transformed the specialty of anesthesia and probably made delivery by C-section much safer. But their story does make me wonder if today's ethical standards for experimentation mean that change will have to come more slowly in medicine, and that bold moves, like trying innovative and potentially transformative surgical techniques - think of past leaps in cardiapulmonary bypass, aortic repair, plastic surgery, and transplantation! - will be fewer and farther-between?

The Brain: Pinky, art thou pondering that which I am pondering?

Pinky: Me thinks so, Brain, verily, but dost thou think Pete Rose by any other name would still smell as sweaty? -"The Melancholy Brain"

__________________________________________________________

"Are You Pondering What I'm Pondering" quotes compiled here at Tom and Matthew's Pinky and the Brain Page.

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!