Saturday, May 31, 2008

Do You See What I See?

Today I went to a lovely baby shower during which we guests got to play some cute, enjoyable games, including "The Clothespin Game" and a scratch-and-sniff one called "Who Smells the Stinky Doo?" My favorite game (of course) was one called "Itty Bitty Baby Parts" (photo credit: http://www.babyshowerstuff.com/), which involved matching each of twelve numbered ultrasound images to an item on a list of anatomical parts we got at the beginning of the game. I didn't think I had an unfair advantage, because I skipped the radiology elective my senior year in medical school, and ultrasounds always look like unintelligible, fuzzy, gray stuff to me, but I ended up winning with a score of 10 correct out of 12 (uh...I kinda got the belly button mixed up with something else...)!

In medical school there was at least one anatomy exam during which we had to file silently past tagged body parts and answer questions about the part in question. Sometimes the task was simply to identify it (Wait - what is that arrow pointing to? Just looks like a wad of tissue to me...); other times we had to describe something more detailed, like the path it took from point A to point B in the body, or its physiologic role, or some key molecular mechanism involved in its function or in diseases that marred its function.

Radiology we learned during clinical rotations if we didn't take the formal class. It's amazing to me how much we can infer about people just from the ghostly markings of a chest x-ray - their disease process, their body type, sometimes particular stories about their lives. And yes, there are some astonishing x-rays - foreign objects in places you wouldn't expect them to be...

I like tasks that require me to look at something carefully and perhaps differently from the way I ordinarily see things. For this reason I enjoy "spot the object" illusions, and I've learned a little something about the way I see things. With the ones that require noticing a "big picture" or wide-angle image (take a look at the can-you-see-the-baby image on Dr. Deb's blog), I often find myself saying, "Oh, that's EASY, surely people can see THAT!" But when required to find a smaller object embedded or hidden in a larger picture (see the coffee bean one), I scour and scour and scour and mutter to myself, "Where IS that thing?"

I really liked this mother-and-child-praying one from a gallery of spot-the-object illusions at moilllusions.com:


But one of my favorite images is not so much an illusion as a startling fusion - "Fluffy Infiltrates" by Day, a Health Volunteers Overseas photo contest winner :


Whether it's a great photograph, an ultrasound, an x-ray, a painting, or a scene in daily life, something that makes us take a moment to look and see in a way that creates new understanding is not only valuable but also in many cases a source of intellectual pleasure. Something about moments of recognition must trigger satisfaction neurotransmitters in our brains. There's nothing like a great "Aha!" moment (especially in the middle of an exam!). Perhaps that pleasure in making sense of something, of things clicking into place, of solving a mystery or deepening comprehension, is more primal than we realize, with roots in our ancient histories. In people looking at the sky and making sense of the stars. In babies, brand new to the world, recognizing their parents' faces at last.


Friday, May 30, 2008

What is Music?

If you care about music...

If you care about composing and creativity...

If you care about people having access to music and to participation in music, regardless of background, "ability," "disability," etc....

If you know someone with cerebral palsy, or have it, or know someone who has a condition usually perceived as a severe limitation, or have one yourself...

THEN PLEASE WATCH THIS VIDEO CLIP. (You can also click on the screen below.)

It's twenty minutes of the most mind-blowing footage of the combined scientific and artistic work of Tod Machover, who also happens to be a friend.

PLEASE DO NOT MISS THE SECOND HALF (minute 11 onwards).


Thursday, May 29, 2008

Tales from St. Boonie's

Welcome to St. Boonie's!
St. Boonie's Hospital is a semi-fictionalized institution based on the three in which I practice. It is situated among a bunch of dairy farms in Elsewhere, New England. For the most part it takes good care of its patients and ships the really tough ones to The Big House, somewhere beyond all the pasture land.

I was going to call this post "Why I Can't Leave the Periphery of Excellence," in homage to a post at the blogofbleedingheart entitled "Why I Left the Centre of Excellence." I'm trying to figure out why, for all my behind-closed-doors moaning and complaining about work (which almost all of us do at one point or another, right?), after interviewing at several other possible work places all of which have made me attractive offers, I am still at St. Boonie's.

I think it's because I love village life. And St. Boonie's is just that - a village, a small town, with a sense of community and familiarity, but also with its share of the same frustrations and misunderstandings that might beset those who inhabit a small town or a family.

By way of introduction to some of those frustrations and a typical St. Boonie way of coping with it, let me introduce you to the Potty-Mouth Bucket.



We have a surgeon I will call Dr. Buddock who has a puerile habit of whining, speaking rudely, and/or expressing himself like a stubborn spoiled brat when things aren't quite the way he wants them to be. He was written up recently for his failure to refrain from frequent use of the "F" word in the O.R.

The incidents were addressed formally, of course. But after the smoke cleared, the nurses put together this contraption. He's supposed to put in a dollar for every expletive, $10 for each tantrum, and $20 for a meltdown. Yes, there is money in the bucket. We use it for chocolate.



Ah, St. Boonie's - where in the O.R. scheduling office instead of a portrait of Virginia Apgar or Rudolf Virchow, we have...Johnny Depp.



Look out for another installment of Tales from St. Boonie's, wherein I muse about the case of the disappearing hummus...or about the singing pig who makes rounds...or perhaps about why Fabio is standing in the lunchroom...

Tuesday, May 27, 2008

Reed-Making Tips, Time Capsules, and Trampoline Secrets

I laughed out loud over breakfast this morning when I read this excerpt from Elaine Fine's beloved copy of Incomplete Method fur die Holzblasinstrumente (if it won't enlarge when you click on it try this link):



Thank you, Professor Schmutzig - I'll remember to stomp all over the reeds I under-soak, over-scrape, and chip as I tie!

This made me think back to my own childhood. What books or other treasures did I carry around with me everywhere or have my calligraphic scrawl lovingly inscribed on them? What would I rejoice over if I were to find it again in some not-for-yard-sale box in my closet? What would I put in a "time capsule" today, and would it still be a treasure years from now, when I finally turn my house into an archaeological dig and unearth it?

The book I remember carrying around and poring over endlessly when I was in grade school was a volume entitled The Hodgepodge Book: An Almanac of American Folklore; containing all manner of curious, interesting, and out-of-the-way information drawn from American folklore, and not to be found anywhere else in the world; as well as jokes, conundrums, riddles, puzzles, and other matter designed to amuse and entertain - all of it most instructive and delightful by Duncan Emrich, illustrated by Ib Ohlsson. I must have checked it out of my school library a dozen times.

As for my time capsule...I'm realizing that the things I enjoy today, as much as I enjoy them, I could ultimately live without. I have tremendous fun when I dig up unintentional time capsules - a box of school day mementos, gifts from faraway loved ones, old letters and photos. And I do have pack-rat tendencies with the like. But I can't think of what I'd put in a capsule at this stage of my life. A laryngoscope? Too useful to store. An oboe? Need it beside me, and too expensive to hide. Missives? Pictures? Programs from shows? News articles? Maybe. But maybe it's a good sign that I don't have too many ideas or any real desire for creating a time capsule right now. I'm hoping it means I'm living in the moment as much as I can.

My daughter, on the other hand, has actually put together a time capsule with her dearest friend, a lovely boy I'll call Adam. That I can totally understand. They are in the waning years of what we're hoping has been a happy childhood, about to enter adolescence. Adam expects to be moving away. I think if I had a friendship as special as theirs I would certainly commemorate it with a time capsule to open in later adolescence or even adulthood. I don't know what they've included in it, but I don't want to pry about it, either. They really have a wonderful relationship that deserves its own space and time in the world.

Last night Adam was over along with our niece and nephew, and the five kids played delightful games on the giant trampoline in our back yard. (As a former pediatrician-in-the-making I was at first reluctant to accept the apparatus, certain it was an unadvisable threat to our kids' safety, but I've slowly come around to the idea that it is, as my husband says, "the best 50 bucks we ever spent.") The four kids next door have a trampoline in their back yard as well, so sometimes there are double-trampoline neighborhood ball tosses in addition to the usual rounds of Sardines, Ghosts in the Graveyard, and our contribution, a game called Signal in French, till dusk.

As darkness set in and voices of parents called to their young to come in for baths and showers or pre-bedtime activities, Adam and my kids found themselves sitting or lying on the trampoline talking quietly together. My second story window overlooks the back yard, so I can see the kids down there, but I can only get snatches of their conversations, and I found myself smiling as I overheard bits and pieces like, "What's said on the trampoline STAYS on the trampoline!" And..."Trampoline secrets!" It's hard not to want to be a closer fly on the wall, and I have to laugh at my fantasies of hooking up a microphone to the underside of the giant disc just to monitor for sketchy content or misinformation. But I also believe kids need and should have this protected, private space and time for their own conversations...even if they sometimes stumble or misuse it, as we all have. Their expanding minds have bouncing of their own to do, off each other.

I was awed and delighted as these snatches wafted up from my daughter's lips (by this time, her brother had gone in for his shower, and she and Adam were looking up at the sky and talking quietly by themselves): "Seriously, why are humans here?...Why are we even alive...?...The world is tiny. It’s, like, one of the smallest planets...Our sun is one of the smallest stars...a little speck...So what are we?...Think about the poor molecule!” I wonder what their answers were. I would have loved to have been part of their conversation. But I also love that they were having this kind of conversation alone with each other, challenging and learning from one another, and having such a nice, peaceful time. Not long afterward I heard my husband's voice from a downstairs window calling them in out of the crisp evening air. I caught only timbre and rhythm then, a few last words, snatches of song and laughter, before they came into the house for the night.

Monday, May 26, 2008

An Anesthesiologist's Holiday Breakfast


This morning I woke up to sunlight spilling around the edges of the window shade, the distant sound of birds in the trees, and..."Anesthesia stat to ICU! Anesthesia stat to ICU!" on the overhead paging system.

I lifted my head with a start and looked at the clock. Six minutes past the end of my 24-hour shift. *Insert mental expletive here.* I still felt a little groggy from our midnight C-section hours ago, after a full day of O.R. cases and labor epidurals yesterday. I threw on my shoes and scrub jacket and ran to the ICU.

There was already a crowd of nurses and residents there. A cardiologist and two hospitalists were there as well but only one of them ended up staying. I got the story in bits and pieces from various people - the patient had been throwing up greenish-brownish, coffee-ground textured stuff and the oxygen saturation was (of course) low. After being brought to the ICU from a regular room the patient continued to throw up the stuff. The heart rhythm was abnormal, heart rate was high, and blood pressure was low. I got to my usual spot at the head of the bed, glanced down, and through all the wires, mask ventilator, and other paraphernalia recognized a patient I had just seen the previous night, to do a preoperative evaluation.

One of the memorable lessons that I took away from spending time in a medical simulator was this: one of the most common group errors at a code was to fail to designate a code leader, or "event manager." During the analysis of this tendency, we participants found that people were often hesitant to volunteer, either because of lack of experience or knowledge or because they were afraid to appear cocky, and people were also hesitant to nominate others. When we were prodded to express and explore these feelings, however, it became clear that we would all have felt relieved to have someone volunteer to take the helm; arrogance was the last thing we would have criticized a volunteer for at a moment like that. It was also clear that the person running the code, ideally, had to be someone who was not involved in performing a resuscitation task, like intubation or I.V. access - someone who could survey the whole scene, take in a lot of information, relay communication, and direct people's efforts efficiently.

I have a mental mnemonic for what I think a code leader needs to do. (Speaking of mental expletives, if you're easily offended, don't look at the mnemonic too carefully...)

-Own it. Step up to the plate, or agree to be volunteered to do so, or gracefully but quickly say, "I would prefer that you designate so-and-so to manage the event." The person who takes ownership of the manager's role has to do so unambiguously and expeditiously.

-See things. Stand in a position where all monitors and activity are visible, notice changes in vital signs or clinical status, pay FULL ATTENTION to all the action at hand, and communicate observations.

-Hear things. Listen, and HEAR. Information from participants, alarms from the monitors, and any other pertinent sounds.

-Integrate. All the input has to be processed quickly, judgments made, and action taken. Stat. Don't be afraid to use help or resources around you. Ask for differential diagnoses, suggestions, or reminders if you blank out. But however you do it, GET the info, put it together, then DO something.

-Talk. Tell people what you know, what you're thinking, what the next step should be, what's needed, where to go, what to do. Quickly. This is not the time for social niceties. They're called orders for a reason.


So when I got to my spot at the head of the bed, I said, "I want suction and a free-flowing I.V. I need a Mac 3 blade and a Mac 4 ready, an 8.0 ET tube with stylet, and drugs drawn up." I gave a short list of the drugs I wanted and how many cc's of each. "And I need one of you," I said, pointing my finger at a couple of individuals whose "rank" or "position" I won't specify, "you or you, to run this. It's better if it's someone who's not managing the airway or getting stuff. Who's it going to be?"

The people I pointed to and many others in the room could be assumed to have had training in advanced cardiac life support (ACLS). One of those people took the job.

I did a rapid-sequence intubation and got a large breathing tube in. The nurses and respiratory therapists who assisted me with the actual intubation were totally stellar. But as I kept watching the monitors, I noticed the heart rhythm was beginning to do sketchier things. My code leader wasn't saying anything. Did he even notice? The blood pressure was dropping again too. Hellooo?! What was my code leader doing?

"I want someone to go mix up a phenylephrine drip now and hang it," I said loudly. "Who's going to get that?" A nurse gave me a verbal affirmation and went to get the drug.

"Someone should get started on an arterial line and another I.V." I turned to the code leader, who was staring blankly at me. "Don't you agree?" I said to him.

We secured the airway, and once the vital signs had improved I went to write a note in the chart. One of my colleagues - the person on call for today - arrived, and we had to help the code leader read the x-ray confirming placement of the breathing tube and explain why we chose the drugs we did.

After all that I spent a little time venting to my colleague, a very experienced anesthesiologist whose skill and judgment I hold up for myself as a model. I was upset that even after designating an event manager, I still ended up essentially having to run the code (or near-code) myself, when I was already engaged doing a crucial task that demanded all my attention and energy. What are you supposed to do when other supposedly-qualified people around you are rusty, nervous, un-assertive, out-to-lunch, or unwilling to admit they're not so comfortable in the assigned role after all, and you're in a public crisis that's unraveling right then and there? I guess you're stuck trying to manage the event AND do the required resuscitation tasks. But having one clinician fulfill both or multiple roles is less efficient and potentially less effective than dividing the labor in an organized way. It's possible to do things the first way, and not necessarily harmful, and in fact it happens frequently, but it's really not ideal.

Needless to say, driving home to oboe-laden strains of Ravel's Tombeau de Couperin on the radio was like cool water on a hot day. And the clear, blue sky and sunny, breezy weather we had as we congregated at the neighborhood baseball field to enjoy our town's Memorial Day parade was truly healing.

I always well up a little during military rituals of remembrance. Our baseball field is right across the street from our town cemetery, so when those marching in the parade arrived - little flocks of Brownies and adolescents in school bands side by side with veterans who had seen a lot of years, lived through a lot of stories - they stopped in at the cemetery for a brief memorial ceremony. Thanks to Dr. Wes for this link to moving tributes to individuals who have served this country in the name of peace and freedom.

I'm still on call, but today it's beeper call from home. Hope I can just spend the day enjoying this weather and a barbecue and the comforting company of my family. I'm tired. I just wanna go back to sleep.

Saturday, May 24, 2008

My Favorite Things: A Light, Mindless "Fluff" Post for the Weekend



"Brown paper packages tied up with strings /
These are a few of my favorite things..." -The Sound of Music

The thesis of the song "My Favorite Things," of course, is that thinking of life's little blessings, things that make one happy, might take the edge of any unpleasantness at hand and actually remind us to be grateful.

Let's see if it works.

This week has been a bit of a roller coaster.

Earlier this week I walked in to help a couple of colleagues with a patient who was hypotensive with septic shock on the table and subsequently got a lot of appreciation from the people involved with the case.

Then a surgeon at one of my hospitals complained I had insulted her after I told her in a pretty determined way that her patient was not an appropriate candidate for surgery at that particular hospital in the current state the patient was in.

Then at another hospital a patient's family told me I was their favorite doctor during their whole ordeal at the place and that I had really made a difference in a way that reduced their anxiety about their loved one's care.

Then I got into a disagreement with someone in my anesthesia group (now smoothed-over).

At some point I had some good news, about an essay I wrote getting included in an anthology due to be published this fall.

Then yesterday a CRNA I was working with had trouble intubating her patient and I stepped in to try, certain that if she, who had been practicing anesthesia for as long as I'd been alive and had actually helped train some of my colleagues, couldn't get the airway, then I certainly didn't have a better chance. Relief replaced alarm when the tube went into the right place. But after that the O.R. kept running till midnight. Again.

Now I'm a little tired. But I'm also on call. As luck would have it the weather's supposed to be glorious this whole holiday weekend.

Thus I'm trying to think of my favorite things, so that

"when the call bites /
when O.B. stings /
when I'm feeling sad /
I simply remember my favorite things /
and then I don't feel so bad..."

Here they are, then, like a giant meme. I've grouped my "things" into four sections: general, books, movies/music/performing arts, and food. Thanks to Katy who writes the blog Funny Girl for getting me thinking about the book section!

My Favorite Things

Accent:  Scottish, Australian
Animal: Alpaca
Artist:  Norman Rockwell
Bird: Snowy owl
Building: The National Shrine of the Immaculate Conception in Washington, D.C.; Chartres Cathedral
Cities: Florence; Paris; Boston; London
Color: Blue
Country: France; the U.S.
Experience: hearing a brass concert at Gore Place, or Dixieland at Cate Park, on a picnic blanket w/ husband and kids; a great, relaxing massage
Flower: rose (red or white)
"Foreign" accent: Scottish
Historical person: hmm...gotta come back to that one
Hobby: blogging! and of course, oboe
Holiday: Christmas
Invention: writing; indoor plumbing; warm showers
Language: to hear – French, Russian; to express ideas – English
Make-up: MAC
Outfit: comfortable blue jeans, tank top, and button-down work shirt
Painting: Hilltop Farm in Winter by Maxfield Parrish
Pen: Sanford Uniball Grip Fine (micro tip)
Place: our cabin in New Hampshire
Saint: René Goupil
School: Stone Ridge School of the Sacred Heart; Harvard College
School subject: English, French, social studies
Scripture passage: Romans 8: 38-39
Sport to do: if dance could be considered a sport, I’d say that
Sport to watch: Men’s gymnastics
State: Vermont
Store: Borders
Time period: 19th century
Thing-to-do from a to-do list: Wrap Christmas presents

Books / Literary Favorites

Fictional characters: Atticus Finch, Sherlock Holmes, Elizabeth Proctor
Magazine/periodical: Image Journal; O
Nonfiction book: On Writing Well by William Zinsser
Novels for adultsTo Kill a Mockingbird by Harper Lee; The Help by Kathryn Stockett; Prodigal Summer by Barbara Kingsolver; The Curious Incident of the Dog in the Night-time by Mark Haddon; Gilead by Marilynne Robinson; Lying Awake by Mark Salzman
Novel for children: Tuck Everlasting by Natalie Babbitt
Novel for young adults: A Ring of Endless Light by Madeleine L’Engle; Two from Galilee by Marjorie Holmes
Picture book for children: The Christmas Miracle of Jonathan Toomey by Susan Wojciekowski and The Fourth Wise Man by Summers; Hooway for Wodney Wat by Helen Lester
Poem: Barter by Sara Teasdale, Stammerer on Scree by Owen Sheers
Poet(s): Herbert, Hopkins, Donne
Short story: The Expert on God by John L’Heureux and Roman Fever by Edith Wharton

Movies, Music, & Performing Arts Faves

Action movie: Independence Day; King Arthur; Troy; Kingdom of Heaven
Actor: Edward Norton, Hugh Jackman
Actress: Scarlett Johansson, Reese Witherspoon, Anna Popplewell
Black-and-white movie: To Kill a Mockingbird; also, Roman Holiday & Casablanca
Cartoon: Pinky & the Brain
Comedy (movie): By the Light of the Silvery Moon; While You Were Sleeping; Elf; The Trouble with Angels; Little Miss Sunshine
Drama (movie): The Mission; The Illusionist
Movie moment: dictation scene in Amadeus
Musicals:  The Secret Garden, Jesus Christ Superstar, Annie, Chess, Les Miz, Miss Saigon, Wicked, The Sound of Music, Legally Blonde
Period flick: A Christmas Carol starring George C. Scott; A Room with a View
Scary movie: The Exorcism of Emily Rose
Sci Fi movie: Independence Day
Screen kiss: Jeremy Irons' in And Now Ladies and Gentlemen
T.V. Show: Bones; The West Wing; Star Trek: the Next Generation; Star Trek: Voyager; Boomtown

Cellist: Rufus Cappadocia
Choral piece: Os justi by Bruckner; There is No Rose by Stroope
Christmas carol: In Dulci Jubilo; Ding Dong Merrily on High; O Come, O Come Emmanuel; O Come All Ye Faithful
Concerto: Concierto de Aranjuez by Rodrigo; Piano Concerto #17 in D by Mozart
Oboe piece: Concerto for Oboe and Strings by Ralph Vaughan Williams
Oboist: Celia Nicklin
Orchestral work(s): Appalachian Spring, Fanfare for the Common Man, and Rodeo by Copland; millennium parade music from Epcot Center; 4th Movement of Tchaikovsky's Suite #4
Piano piece: Prelude in G minor by Rachmaninoff; Sonata in B minor by Liszt
Pop Song: Who Knew
Violinist:  Gil Shaham
Religious song: By the Rivers of Babylon by Marty Haugen

Ballet, classical: Sleeping Beauty
Ballet, contemporary: In the Middle Somewhat Elevated by William Forsythe
Ballet, overall: Revelations by Alvin Ailey
Dance company: Alvin Ailey Dance Company
Sung play, not exactly a musical: Missionaries by Elizabeth Swados
Opera: Amahl and the Night Visitors by Giancarlo Menotti; Der RosenkavalierLa Boheme; Tosca
Operetta: Die Fledermaus
Play, comic: Noises Off by Michael Frayn and You Can't Take It With You by George S. Kaufman and Moss Hart (esp. the Jason Robards production that aired on TV in the'80's)
Play, dramatic: The Crucible by Arthur Miller; The Arabian Nights by Mary Zimmerman; Proof; Copenhagen; Amadeus; Equus

Food Favorites

Appetizer: baked brie en croute with a bit of a fruit-&-nut layer
Beverage, cold: water
Beverage, hot: Viennese Chocolate Café coffee by International Foods
Breakfast: coffee & croissant, just like Dr. Crusher on Star Trek:  the Next Generation; cereal & berries with a little fromage blanc or Greek-style yogurt; tartines; Tita M’s ensaymadas
Cake: opera gateau; the Philippine cake known as sans rival; sachertorte; one at Whole Foods that has little pink flowers on it and beige buttercream icing
Cheese: Bailey Hazen Blue; Stichelton; Reypenaer; Comte; Boursin
Chocolate: Godiva; Toblerone (milk > dark > white)
Cookie: chocolate chip cookies from the now-closed “David’s Cookies” chain in New York (the online version’s not the same, somehow, and you miss out on the amazing aroma of fresh-out-of-the-oven, warm, chocolate chunk cookies at the bakeshop…); also, Taiwanese "ChocoRoll: pudding flavor" cylindral cookies covered with milk chocolate
Dessert: crème brûlée
Dip: Whole Foods' Smoky Harissa Hummus; fresh guacamole
Fruit: Philippine mango; blackberry
Hors d’oeuvres: bacon-wrapped scallops; crab rangoon
Ice cream: Oreo ice cream by J.P. Licks, slathered with hot fudge of course; Ginger Snap & Molasses ice cream at Rancatore's; Tres Leches by Haagen-Dasz
Main Course: really good Thai food
Meat/Fish: teriyaki beef skewers; great prime rib; grilled trout
Merienda: Philippine mangoes with bagoong; croissants; churros con chocolate
Pasta: butternut squash ravioli with a light sage-infused or maple-cream sauce
Rice dish: wild mushroom/porcini/morel risotto; Philippine garlic fried rice
Salad: my cousin Gaita’s Insalata Pacifica at her restaurant, Cibo; Thai Crunch Salad or Field Greens Salad at CPK; Cobb salad with sherry vinaigrette at Not Your Average Joe’s
Side order: the now-defunct Tony Roma’s onion ring loaf; sauteed onions and potatoes seasoned with a little salt and pepper; brown or white rice
Sidewalk snack: French crêpes
Soup: lobster bisque with lemon grass and coconut milk at Top of the Hub in Boston
Really, really, really bad, eat-it-only-once-a-year-in-small-servings type of junk food: Barbecue-flavored Doritos (I think they stopped making these…thank goodness…)
Really, really, really bad, eat-it-only-once-a-year-in-small-servings type of sweet food: chocolate-frosted Krispy Kreme doughnuts; cupcakes
Vegetable: green bean, I guess

I do feel a little better. I think I'll go have a cupcake...

Wednesday, May 21, 2008

The "F" Word


Doctors won't talk about it. Patients don't want to know about it. Try doing an internet search on the topic and you come up dry.

It's a subject so taboo in medicine that there may be readers out there who'll want to question the validity or veracity of what I write here. It's the ultimate four-letter-word for physicians: FEAR.

A few days ago a premed student named Jack wrote this comment for me:

"During your work as an anesthesiologist, when was the time where you felt most afraid, if there has been one which sticks out? I ask because im soon to be entering medical school and I feel that fear is a topic which has not been touched on by those advising me."

I'm not surprised about that last part. No one talks about fear in medicine because no want wants to admit a) that it exists b) that it's NORMAL and c) that physicians experience it. People don't want their physicians to be normal, human. Humane, yes, but human - with normal aspects of humanity such as fallibility, frailty, fatigue, and, yes, fear? Not really. I've often felt we're expected to be as faultless as God but without god complexes. I agree with the latter: the best doctors I know have the wisdom and self-possession to have true humility. But strive though we might, how can any of us expect perfection of ourselves, or criticize others for failing to attain it?
True humility accepts imperfection, refrains from passing harsh judgment on it, and instead recognizes where successes come from, where the limits are within a given situation, and, without lapsing into contempt, where there might be room for improvement.

The question is, why this reluctance to admit to fallibility, to error, to fear? It's not simply because human lives are at stake, though naturally the high stakes create high standards. I think there is a deeper problem within medicine, and that is the pervasiveness of hubris and disdain in the culture of medicine, a culture which has deep roots in the DE-humanizing training process, the very system which forms physicians from their embryonic, idealistic beginnings into the clinicians that must go out and meet suffering face-to-face, touch the very margins of some very dramatic and important stories, and sometimes get pulled into the fray without warning. I've seen this culture destroy the very best in people, rip out their still-beating hearts - the ones that contain all their hope and compassion - chew them up, and spit out the bloody mess as if it were worthless trash. It's a culture where the highest compliment a doctor or doctor-in-training can be given is the phrase "Strong work." Strong. Not weak. Finding something difficult is weak. Having needs, physical or emotional, is weak. And being scared, even just a little, is very, very weak. Or so the unspoken message goes.

But the truth is, what we do can be scary. Really scary. I remember thinking on my very first day of anesthesia residency that any of the drugs I was drawing up into syringes that day and administering into people's IV's could KILL SOMEBODY. That is still true today - there is still the potential for any action I take to cause great harm instead of doing good - but at least today I have some training and experience under my belt to allow me to use these drugs as part of a design thought out carefully ahead of time or quickly adapted to a given situation.

The answer to the first part of Jack's question is that several moments stand out in my mind as ones during which I felt "most afraid." Even in the midst of a bustling room crowded with lots of people helping, it's easy to feel incredibly ALONE at the head of the bed, watching a blood pressure go from 80 to 70 to 60 to 50 even though you're pushing pressors and inotropes into the IV as fast as you can, then having to make split-second judgments and life-and-death decisions. There's nothing like watching someone's vital signs tank, circling an ever-widening imaginary drain, the cardiac rhythm waveform shifting and getting ominously squigglier before your eyes, as you ask out loud if the code cart is in the room.

Interestingly, during moments like these I don't find myself asking other fear-based questions like what will I tell the family, what will my colleagues think, what if I lose this person, what if nothing I try works. So far the fear has acted as a spur to action - let's try this; get help, get an arterial line in, try another approach, do, do, do. It's only later, when the crisis is over and there's time to think, that the emotional after-shocks come. The what-if questions. The I-should-have ruminations.

The scariest moments, though, aren't even ones like these in the operating room. For me, despite my background in pediatrics, nothing is scarier than a newborn needing to be resuscitated. (Well...maybe a pregnant woman with a difficult airway is scarier,or at least as scary...but that's about it.) I am very comfortable with children. I doctored children for a while before I started doctoring all ages. But when a voice on the overhead system at the hospital says, "Attention all personnel. Attention all personnel. Respiratory stat to labor and delivery," I still go into fight or flight mode. I run up to the floor to offer help. I know what I need to do. I have lots of help around me, and I know they know what to do too. But I see a lifeless-looking, tiny little infant as grey as ash, whose limbs flop back down to the bed when lifted and released, whose chest shows no sign of respiratory effort - all very, very abnormal signs - and my heart races. Still. Even though I've seen this before. Meanwhile the parents are behind us, mother perhaps still receiving sutures after the delivery, father nervous or in tears, and lots of people crowd a tiny little space where we're supposed to bring this baby out of trouble in its first few minutes of life on earth. We all do what needs to be done, outwardly composed, business-like in the urgency, but inwardly, speaking for myself at least, SCARED the whole time.

There are those who say admitting to fear weakens one's performance at these events. I say it's weak to deny a very normal emotional reaction, and perhaps even dangerous. I say we can control our responses to fear without having to suppress it, because it can be an ally, maintaining in us a healthy respect for the importance of the task at hand. I say the day my heart rate stops going up when an airway is difficult, when a patient is in septic shock on the table, or when a child's oxygen saturation drops like a stone, put me out to pasture, please. Because that's the day I've spiritually stopped doing my job as a physician.


***

Years ago when I was exploring my own moral formation I made a list for myself of qualities I see in spiritually highly evolved individuals and qualities I would expect to see in spiritually stagnant, unevolved, or stunted individuals. I came up with the first list by thinking of exemplary people, like my in-laws, and friends I admire, then flipped all the qualities around to come up with the second list. One list was essentially the mirror image of the other, and I found a lot of me fitting into the spiritually unevolved side, unfortunately. This is what I jotted down:

The Spiritually Evolved Person…
-Tends to be forgiving, see the best in others, and be accepting of what others can offer.
-Responds to people’s comments / needs / objections with the desire to be better and to serve
-Sees every person as one of great worth and believes all have equal rights
-Works hard
-Has a deep sense of gratitude
-Knows “it’s not about him/her”
-Knows happiness and misery are chosen
-Rolls with the punches – often with a sense of humor
-Takes nothing personally
-Is not reactive and is slow to anger if at all
-Does not pass judgment or need to blame
-Considers others' needs as valid and at least as important as his/her own
-Makes others feel welcome
-Forgives

The Spiritually Unevolved Person...
-Tends to be critical and to look for things to criticize, to feel irritation or anger at others' imperfections, and to look down on those who might have faults or failings to forgive
-Cannot bear to have his/her imperfections or mistakes pointed out or discussed and may in fact feel he/she is beyond reproach
-Feels superior
-Is lazy
-Has a deep sense of entitlement and/or complains a lot
-Feels everything is “about” him/her
-Feels that others / external circumstances make him/her miserable
-Whines, throws a tantrum, or acts like a martyr when things don’t go his/her way
-Takes everything personally
-Is reactive and is often easily angered
-Judges harshly & blames readily
-Thinks his/her own wants take priority over others’ needs and may be incapable of being considerate of others’ needs or see them as important; lords it over others
-Makes others feel alienated or rejected
-Punishes

If the culture of medicine could be personified, the resulting incarnation, I think, would have a lot of the characteristics on the second list - scorn, arrogance, judgmental attitudes, unsupportive perfectionism. By contrast, a lot of the people who pursue careers in medicine aspire to behaviors and ideals such as kindness, cooperativity, compassion, and forgiveness. I think if we could talk about fear and fallibility without being judged, criticized, or blamed, the world would truly be a better place - not only for doctors but also for patients. There are already efforts to bring discussions of medical errors in this direction...but change comes gradually and incrementally.

One individual who has begun to work for change in "the system" is an extraordinary physician who was involved in a devastating medical error but had the courage to face the experience, in all its loneliness and pain, and use it as a springboard from which to start transforming the way the world of medicine responds to adverse events. I admire this man's heroism. Please read his story here.

"I wanted you to see what real courage is...It's when you know you're licked before you begin but you begin anyway and you see it through no matter what." Harper Lee, To Kill a Mockingbird
_______________________________________________________
Addendum, June 12 2008:

Quietus Leo over at The Sandman has written an incredible post in response to this one with some insights of his own regarding physicians and their fears. I want to highlight an excerpt from his closing paragraph because it really hits the nail on the head:

"The only thing that disgusts me more than incompetence in a physician is vanity. Hubris is born of fear. Fear of exposure, fear of failure and fear of showing weakness. When you see a vain person, scratch the surface (one may need an ice pick) and you will discover a coward. Not a coward in the sense of external bravery, but one who won't face his/her own failings. Such a person has stopped growing, learning and improving."

Amen, amen, amen. May I never lose heart or the ability to see myself honestly and learn to become better.

Monday, May 19, 2008

Commotion of the Heart


What does an anesthesiologist baseball-mom think about at her son's first baseball game?

After the hit, after screaming "Go, go, go!" as his little legs carry him by to first base; or when he's waiting to run to the next base; or when the other team's up and he's the little angel in the outfield, waiting for a ball to come his way?

This anesthesiologist baseball-mom, despite the rare occurrence of such disasters, could not help thinking of commotio cordis. Don't get me wrong - I had a blast cheering my little guy on - but that lurking thought did creep around the back of my mind once or twice: what if he takes a ball to the chest at just the wrong moment?

I can usually maintain my composure during acute situations at work, but when it comes to my kids, I can be as much of a worry-wart as any other mom out there. I try not to be too irrational, of course. I try to keep passing thoughts of possible doom from taking away our enjoyment of life's normal little milestones and adventures. My daughter enjoys roller coasters? Have a good time, I tell her as she boards the scariest one in the park. My son enjoys rough-housing with the neighborhood guys (with my husband watching over them)? I cringe inwardly, but I smile and carry on. I even survived my daughter's first trip away from home without us, to go to an ecological campus on a school trip with the rest of her class. And I had a great time at today's baseball game, despite the ice-cold wind. But I'll admit it: the worry-thought crossed my mind. A couple of times.

Commotio cordis is rare - sudden death from cardiac arrest due to blunt force trauma to the chest. Most cases from the United States commotio cordis registry several years ago occurred in Little League baseball, softball, or lacrosse, though soccer, ice hockey, martial arts, polo, boxing, fencing, cricket, and rugby carry the risk as well. The scary part is that the impact doesn't have to be that forceful; it just has to happen at just the right millisecond during the cardiac cycle, "at an electrically vulnerable phase of ventricular excitability," to cause a fatal rhythm abnormality. Timing and rhythm - musicians take note! - are far more important than the strength of the blow. The mechanical properties of children's thoracic cages render them particularly vulnerable, but chest protectors are basically useless, as far as I understand, because the issue is in fact timing rather than force. Finally, there is a dismally low "rate of rescue" for commotio cordis.




I've heard the wisdom of the ages already, countless times: no amount of worry about something can prevent its occurrence, so we might as well let the worry go, appreciate each moment fully, and hope all will be well. I agree. That's all true. But I also think a parent's worry is a pretty natural, normal emotion, and instead of denying that it sometimes occurs, or criticizing those who express it, we should find ways to transform that commotion, that swirling of loving concern in the heart, into something fruitful - perhaps by rejoicing in each little victory, like crossing over home plate, or being fully present to the moment as we hug our little ones in our arms.



Sunday, May 18, 2008

Music and Medicine Meet at...Forensic Art?!

Who's this?




Think sheep safely grazing. Sleepers awake. Mass in B minor. It's Bach!

This is totally old news, from last February, but I just found out about it and think it's totally cooooooool. Janice Aitken and Dr. Caroline Wilkinson of the Centre for Forensic and Medical Art at Scotland's Dundee University recreated the face of Bach using a bronze cast of his skull and historical documents describing features such as swollen eyelids from an eye condition. Dr. Wilkinson taught Joerg Hansen, director of the Bachhaus Eisenach, something that dispelled a common myth to which I've often subscribed: the furrow over the nose bridge, and facial furrows in general, have nothing to do with personality or character or temperament but rather are determined by skull anatomy. ""If you have that type of skull you have to furrow over the nose," Hansen explained. "But I also think he looks interesting."

Who hasn't daydreamed about traveling back in time? I think it's natural to be fascinated by the possibility of knowing what someone from the distant past looked like. In the 90's National Geographic put a reconstruction of King Tut's face on its magazine cover. Although it's true that skillfully painted portraits can be almost photographic, their accuracy depends on a contemporary witness, whereas a forensic artist can create an eerily compelling likeness across time by taking actual anatomic structures to recreate a face in three dimensions, layer by layer. It's simultaneously more distant and more intimate as a technique, requiring the artist to reach across sometimes vast chasms of time but also to touch a subject's innermost structures to and make visible "flesh" out of what has been ghostly memory of muscles and skin creases for centuries.

I couldn't resist including one more example here, though of course most people wouldn't consider it valid. An information systems consultant named Sebastian Ferreyra used the mysterious image on the Shroud of Turin, believed by some (but not by most) to be the burial cloth of Jesus Christ, to reconstruct a "face of Jesus." He hasn't finished the computer painting yet; it depicts Christ in death, resting in peace.

Whether it's a bust of Julius Caesar or a bronze mask of Agamemnon, artistic renderings of long-lost individuals captivate us, I think, because we enjoy imagining these almost mythic human beings as real people, flesh and blood just like our next door neighbor, our teacher, our political leaders, our friends, with the same vulnerability, potential for greatness, and mortality as any others. By imagining we can see them, almost touch them, they become less remote, their stories and deeds more accessible and, perhaps, even more thought-provoking and inspiring.

Friday, May 16, 2008

T. Unmasked (just a bit): the Interview


It's my one year blog anniversary!!!

I cannot believe this blog has been part of my life for a year. Thank you so much to all of you who stop by, read, and support it!

Happy one-year anniversary, too, to Dr. Ramona Bates, who writes the extraordinary blog Suture for a Living.

As part of the blogiversary celebration I invited readers to send me "interview" questions for today's post. Some of your questions overlapped, so if you see yours worded a little differently, that's probably why.

Enjoy!


***

What crummy (or not so crummy) jobs did you do before becoming an anesthesiologist?

I worked behind the pastry counter at Sutton Place Gourmet once. Lots of yummy crumbs, so not so crummy.

What’s your favorite food?

Chocolate! And, really good Thai.

What is the healthiest food you love and the most unhealthy food you love?

Healthy: ripe, plump, sweet blackberries. Unhealthy: unfortuately I really enjoy sweets (really great cakes, chocolate-chunk cookies, creme brulee, and ice cream), and deep-fried stuff – hush puppies, onion rings, yucca, plantains, dough…

Do you do crossword puzzles?

Love ‘em. Also love sudoku and logic problems.

Do you speak any foreign languages (badly or fluently)?

I can speak some Spanish, French, and Tagalog, and a little Italian. I’m in the beginning stages of Arabic, Russian, and ASL (and may be in these stages indefinitely!). I learned some ancient Greek in high school but all I can do now is read some words. Ditto with Syriac, except it was college, not high school. I don’t consider myself fluent in anything except English.

Why did you choose anesthesiology? Did other specialties cross your mind?

I was going to be a pediatrician! I even did a year of training in pediatrics at a tertiary care center that had a large number of kids with cancer. Then I was going to do a fellowship in medical genetics or neonatology…

But I fell in love with anesthesiology after an anesthesiologist at this same tertiary care center taught me how to mask-ventilate a 12-year-old boy. It was so direct, so visibly effective, and it felt so great to be able to make a difference in a particular moment, to help a child breathe when he was unable to breathe for himself. It seems incredible that one’s life should change so drastically because of the inspiration (so to speak) of a moment, but after exploring the field a little further, I was hooked.

That episode explains in part what I love about anesthesiology. You can see the help you provide coming to life right in front of you. Every act, whether it’s running a code or drawing medication up into a syringe, is meaningful and requires complete mindfulness. Anatomy and physiology, which so many doctors feel they don’t get to use much once they leave med school, are integral to our daily work. And being present to people when they’re at their most stressed-out – even after I’ve rendered them unaware of my presence – can be rewarding in and of itself.

Anesthesia Oral boards sound frightening and beyond stress...

They were!

How did you make it through all the stress and the pressure to prepare for those 70 minutes of your life?

Well, for one thing, I had my friends C. and O. going through the process with me. If we hadn’t spent all those months calling each other once or twice a week to do mock orals, there’s NO WAY I would have passed. Practice and prayer. These seem to be my main coping strategies.

After you found out that you had passed, what was the first thing that came to your mind? Just curious about life after Oral Boards...

To be honest it took me days to accept the fact that I had passed. The results were posted online earlier than expected, and I kept having irrational feelings that it was all a mistake. Because people had said the pass rate was 2 out of 3, I was sure that it would be C. and O. moving on and me left to bite the dust. I even asked my husband to look at the page to see if I was hallucinating or something. “Um, I think the word PASSED in big letters means you passed,” was his sardonic rejoinder.

Once I got over the shock I spent time celebrating repeatedly with my family, then I thought to myself, oh my goodness, I can read whatever I want, spend free time NOT studying, have vacations and weekends not marred by the burden of anesthesia books…I’m free at last! So I looked up oboe teachers online and the rest, as they say, is history…

How did you select the oboe as the instrument you wanted to learn how to play?

I’d never considered being able to choose an instrument - till now. My son’s violin teacher once said it’s always better when students actually ENJOY the sound of the instrument they’re studying. I’m grateful I studied piano as a child, and I think it’s key (no pun intended) if you really want to learn theory, but I have to admit it’s not my favorite instrument. I didn’t realize how deep my oboe-longing was until I was actually FREE to spend my time and energy as I chose. Many of my favorite passages of classical music are oboe parts, and I’ve always loved the sound of the instrument.

How do you feel about the concept of making your own reeds? I bet, with all of your other areas of expertise, you would be rather good at it. Have you tried?

I feel…INTIMIDATED! I haven’t tried yet because my teacher wants me to focus on playing right now, and I think her instincts are right on – perhaps she senses that the perfectionist in me would get trapped in a cycle of obsession & frustration if I tried reed-making right now. I don’t know that I’d be good at it at all – so much fine motor, such an art to judging how much to scrape off the end - athough I guess, as with arterial lines and sutures, it just takes practice…

When do you have time to write, read, and play your instrument?

Before dinner (while I’m cooking), or after dinner, while the kids are practicing their instruments or showering. Or after the kids go to bed, which is getting later and later with each passing year. Weekends. Vacations. Post-call days, which I usually have off.

Where do you get the energy to do everything you do?

Love o’the game, as they say, and also from the affectionate support of a loving husband. That really keeps me going.

Do you and your hubby share domestic chores?

Often he’s better about those chores than I am. He has always been a hard worker, at home and away from home, and he’ll do almost anything – laundry, dishes, taking out the trash & recycling, diaper changes when our kids were babies, maintenance stuff. No cooking, though.

What is the one thing you have to do nearly every day that you really dislike doing?

Interact with unpleasant people.

If it were easy to pick up and move where would you like to live?

Some place with lakes and mountains. I haven’t actually been (yet), but I dream of British Columbia. Nelson, or Kaslo, or the Vancouver area…

You seem to really love dance, so why didn't you pursue it? Ever wish you had?

Professionally? I’m actually glad I didn’t pursue it. I would probably have missed out on so much of the life I have now if I had stuck to it and made a successful career out of it. Moreover I wasn’t genetically endowed with the requisite body type and would have had to center my life around a strictly limited diet in order to maintain the expected weight. I do miss it, though, and I still dabble sometimes.

Pants, skirts or dresses?

Pants, usually - I’ve gotten used to them. But I love finding dresses that work!

Have you ever had acupuncture?

I’ve never had a full treatment but did have auricular needles inserted once during a workshop. My father-in-law had acupuncture for migraines with wonderful results.

Hey T! I know this is a long shot, but I was wondering if you've ever met Oprah?

I have! I got to be one of the discuss-ers for her book club. They flew me to Chicago along with some other readers, wined and dined us, and taped the book discussion. After that we had lunch with the author and with Oprah, and I got to sit right next to her. It’s been ages since I’ve had a chance to check in on her show but from what I recall she’s exactly the same off-screen as she is on the show - gracious and exceedingly smart.

If you could invite a few special guests to dinner (other than family), real or fictional, from the past or the present, who would be your chosen guests?

René Goupil, Jean Donovan, Pierre Teilhard de Chardin, Mary Catherine Bateson, Madeleine L'Engle, and Avicenna.

What books would you want with you if you were stranded somewhere indefinitely?

Prodigal Summer by Barbara Kingsolver, the New Testament, the Norton anthologies of poetry and short story, and a blank journal with pen.

Is there any way you can adjust your schedule so you can attend more orchestra rehearsals?

I’ll have to ask the scheduling person at work!

Picture yourself at 90. Which message would you like to send back to yourself in 2008?

Don’t wish; be. And trust in the process.

What does T. stand for?

The truth? My childhood nickname, which only my family’s allowed to use.

When I first started this blog I didn’t have much patience for the sign-up process and didn’t think anyone was going to read it anyway, so I put the T. down in haste. Then people started using it…I'll take votes for a lengthier pseudonym, though!

What makes you happy?

My children's affection and delighted laughter. My husband's kindness. My family enjoying a meal I've prepared, and eating well. Life's simple pleasures - quiet evenings in the park with my husband and kids, browsing through a book store, beautiful music, good company.


***

That's it for now! Thanks again, everyone, for celebrating with me!

Wednesday, May 14, 2008

Last Chance to Send Me Your Questions


Blogiversary's almost here!

If you have any last-minute "interview questions" for me,
please e-mail them before midnight tomorrow (Thursday) EST
to anesthesioboist@gmail.com, and I'll try to put together
a blogiversary post by Friday evening.

Tuesday, May 13, 2008

My Looooooong Day


In the space of one call (yesterday) I

-anesthetized a woman for a brief gynecologic procedure (7:30 a.m.)

-did post-op rounds, pre-op interviews, and gave breaks to colleagues

-performed a spinal right after a nurse was inexcusably rude to me; then helped an expectant mother through her urgent C-section (mid-morning)

-anesthetized another woman for another gynecologic procedure (mid-day)

-in the afternoon, took over for a colleague in the vascular surgery room...and found myself still there, 5 hours later, in the same procedure to de-clog the femoral arteries of a (relatively young) woman who had smoked SOOOOOOO much that her blood vessels were practically destroyed and the circulation to her legs was compromised

-got paged by the obstetric floor to do an epidural which I could not do because I was stuck in the 5-hour vascular case

-wrangled with my colleague who was supposed to be the back-up call person but did not want to come in and do the epidural while I was stuck in the O.R.

-wolfed down a ham sandwich - my first real food that day - that the nurses had set aside in the fridge from an untouched patient tray

-brought an elderly man to the operating room (by now 8:30 at night) to have his gangrene-afflicted extremity amputated above the knee

-got paged stat to the cardiac intensive care unit to intubate a woman in respiratory failure just as I was placing monitors on the amputation patient

-ran up to the CCU, where the nursing supervisor tracked me down by phone and insisted on speaking to me as I was talking to the covering physician (and the nurses were getting medications ready) because she wanted to know why it was taking "anesthesia" so long to show up for the epidural on the labor floor

-intubated the now-truly-distressed woman

-ran back down to anesthetize the guy for the ampuation

-wheeled him in stable, comfortable condition to the recovery room (close to 10 p.m.)

-dealt with e-mail problems

-talked to my husband on the phone

-heard an overhead page for respiratory therapy to go stat to labor and delivery (midnight)

-ran up to find a greyish-looking newborn with no respiratory effort; could not see the vocal cords because of copious fluid in the oral cavity; suctioned, then got the oxygen saturation up with positive-pressure ventilation; father, in tears, invited to bedside to be with his newborn when his condition had stabilized

-collapsed into the call room bed wishing I were in my own and dreading the next beeper sound...

Tomorrow: gotta do it all again...maybe it'll be quieter?

_______________________________________________________
P.S. Thanks to Anali for clue-ing me in to this cute little piece of comic relief.

Friday, May 9, 2008

Oboe Risks


On the eve of my one-year anniversary playing the oboe I'm thinking about where music and medicine intersect. There's one obvious interface: injury. This past week I was at Johnson Strings to pick up violin books for my son - Adventures in Violinland, Books 2A and 2B - and found a very interesting book by Janet Horvath, associate principal cello of the Minnesota Orchestra: Playing (less) Hurt: An Injury Prevention Guide for Musicians. I was pleased to see that she includes information and suggestions for players of all kinds of instruments. Who ever thought playing such a sweet little instrument could be risky? It's true, the oboe is lovely, but it's also a tough task-master - sometime hard on body, mind, and spirit all at once. I made a list for myself of things I'd have to watch out for if I actually played the oboe with the ability, frequency, and intensity of a professional.

Headaches, eye strain, and eye damage. The oboe is a high-resistance instrument. Other instruments in this category include the bassoon, the trumpet, and the French horn. Playing these instruments a lot, especially when increased blowing force is required (high pitch), can put eyes at risk due to increased pressure. According to an article from the journal Ophthalmology, "The cumulative effect of long-term intermittent ocular pressure elevations during high-resistance instrument playing may be sufficient to create long-term damage to the eye."

Teeth. Horvath informs us, "Playing reed instruments, brass instruments, and violin and viola can affect a young person's occlusion...It is essential to monitor the duration and intensity of playing...Overbite can occur in oboe, bassoon and violin and viola players even after only one or two years." She quotes the Journal of the American Dentistry Association which states, "Because less than 100 grams of pressure is required to orthodontically move a tooth, the forces of a musical instrument (up tp 500g) can harm the occlusion and teeth."

Hearing loss. Chronic exposure to the decibel levels of a music ensemble such as an orchestra at close range can place musicians at risk for hearing loss, which is irreparable and which, in a musician, can be devastating even if subtle.

Thumb issues. Most of the oboe's weight exerts its force against the right thumb, so pain syndromes can occur as a result of thumb tension, tendonitis of the extensor tendons at the joint, and De Quervain tenosyovitis, a condition in which there is inflammation at the base of the thumb. Loading stress on the thumb is exacerbated by holding the thumb straight (rather than flexed) while load-bearing for long periods of time - a tendency I definitely have when I hold my instrument, which of course as luck would have it is the heaviest oboe out there.

Finger, wrist, and neck pain. Keys in an odd position for one's hands can cause strain and lead to pain. The stresses of reed-making can increase the risk of developing carpal tunnel syndrome. Poor position or neck straps (which benefit the thumbs) can strain the neck. An endpin or commercial oboe support like the FHRED might be a viable alternative to take the weight of both neck and hands.

Respiratory issues. Oboists can be vulnerable to upper respiratory tract infections, but playing a wind instrument, which at times can mimic exercises such as incentive spirometry used in hospitals, can also confer some respiratory benefit by conditioning respiratory muscles.

Focal dystonia. This is a rare neurologic condition that is thought to be caused by a "blurring" of the "map" of the human body contained within the cells of the cerebral cortex, where normally specific cells are "assigned to" or "responsible for" specific areas of the body. In focal dystonia, these "assignments" can get jumbled such that the brain sends nerve impulses to the wrong muscles, causing them to contract - a phenomenon which is experienced by the individual as painless "cramping," abnormal positioning, or an inability to rely on intentional movements for certain tasks. It is task-specific, often affects those who engage in large amounts of fine motor activity, and affects men more often than it affects women. Frequent intense repetition is thought to be contributory. Sensorimotor retraining activities, sometimes using mirror boxes, can be helpful, but medical treatments and acupuncture are not. Notable people with this condition include oboist Alex Klein, pianists Gary Graffman and Leon Fleisher, and writer Scott Adams of Dilbert fame.


Some of Janet Horvath's suggestions for musicians, to reduce the risk of injury:

Warm up.
Maintain good posture.
Vary your movements.
Wear hearing protection.
Take breaks / get enough rest.
Keep instruments well-adjusted.

_______________________________________________________
Addendum 5/16/06: Patty at Oboeinsight.com reminded me,

"But T., you didn’t write about mental health. About how crazy we go over reeds. Over the fear of failure. The humiliation we sometime face. Nerves that can eat us alive. All that fun stuff!

"And I continue to wonder, too, about the cane we use. I’ve known of so many reed players (single as well as double) who have had cancer. Far too many. Could it be something that’s in our cane? Does our cane get sprayed with something? Insecticides? Anything? Where does it grow and how clean is the area? (One oboe maker told me I’d really rather not see where cane is grown! He said I might not want to play any more.) Maybe it’s just coincidence that so many reed players have had cancer, but I do wonder. (All the ones I’ve known are non-smokers.)

"And then there are the joys too. Those great job rewards! I’m guessing lots of jobs bring people joy, but I sure do read a lot of complaining from people in other professions. While I ramble on a lot about rotten reeds and other negative issues, I wouldn’t want to give this job up. There are too many wonderful things about it!"

Thanks, Patty!

Monday, May 5, 2008

May Invitation for Anyone Who Reads This Blog


Happy Cinco de Mayo! And speaking of May celebrations...

I have a lot of little celebrations ahead in the month of May this year:

-my birthday (THIS WEEK!);

-MY ONE-YEAR OBOE ANNIVERSARY(May 10), which coincides with

-my son's First Communion;

-Mother's Day;

and, believe it or not,


-MY ONE-YEAR BLOG ANNIVERSARY, COMING UP ON MAY 16!

To mark this last happy occasion, I'm asking readers to e-mail me some questions they'd like to ask me, and I'm hoping to put together an "Interview of T. by her readers" type of post for my blogiversary.

So don't be shy! Now's your chance to put me in the hot seat! (Can't guarantee I'll be able to answer everything, but I'll try.)

Please send your "interview" questions to anesthesioboist@gmail.com. Thanks to all who have already sent me questions so far! I have my homework cut out for me!

Sunday, May 4, 2008

Arts First


Arts First, an arts festival held at Harvard every spring, is the Boston area's best cultural event. Period.


Hundreds of talented students involved in the visual and performing arts share their (sometimes world-class) gifts with the public during this amazing festival, during which most events are FREE. There is no better deal than that in this city.

I had the pleasure of sharing Arts First 2008 with my children and one of my daughter's friends yesterday, and it was with a bittersweet sense of love and pride that I strolled through campus, visited a number of performance venues, and reminisced about performing in the very first Arts First ever, established by actor John Lithgow in 1994, my senior year. Some of the groups that performed yesterday - like the Harvard Ballet Company and the Harvard Pops Orchestra, which started us off with a rousing selection from the soundtrack to The Lord of the Rings - were founded by students who were my contemporaries and friends.



Very often productions by gifted college students have something the flashier professional productions in New York, L.A., and London can't capture. A fearless energy, passion, and raw exhilaration in the midst of costumes put together at home and soundtracks scraped together on laptops. The best production I've ever seen of the Gilbert and Sullivan operettas and of Arthur Miller's The Crucible have been ones put together by Harvard undergrads, and the best Amahl and the Night Visitors I ever saw took place in a tiny little church in Arlington with simple props but a great deal of musicality and heart. Bigger, more prestigious, and more expensive aren't always better! Then there are the affectionate shouts of support from roommates and buddies in the audience - where else can you get that?



I was thrilled to see that the dance portion of the festival, which still takes place in Lowell Hall as it did when I was a student, was one of the most packed events. The line waiting to get into Lowell Hall stretched halfway down the block. It consisted of various campus dance groups performing ALL AFTERNOON in 20-minute blocs; we stayed for three different segments which included Irish step dance, stunning hip-hop by EXP, energetic numbers by my former company (Mainly Jazz Dance Co.), absolutely gorgeous ballroom dance numbers by the Harvard Ballroom Dance Team, break dancing, Philippine folk dancing (woo hoo!), and modern dance (we missed the ballet, tap, and capoeira segments, unfortunately). As I watched from our seats on the upper balcony I could almost see ghosts of myself and my classmates superimposed on the performers below, diaphanous visitors from our past, moving with the music under the colored lights, reminding me of a life and energy I often forget I had.



One of the most memorable offerings was an outdoor interactive exhibit in Harvard Yard which consisted of lantern-like sculptures made of upside-down tissue boxes containing messages as well as extra-large apples strewn about under the campus's stately trees. There was a sign there that said "Take One," so of course my son scooped up an apple, encouraged by one of the artists of the exhibit, Peter Hedman, class of 2010 (internet research is a wonderful thing!). He's a thoughtful, creative, talented man who will no doubt go far. The other artists who helped create the exhibit were Tom Lee (from the Office for the Arts) and Yichen Feng ('10). I wish I could describe how captivated passersby were with this work, peering into the "lanterns" from below and delightedly taking pictures of the apples under the trees, enthralled just as passersby had been during last year's festival, when Hedman and his colleagues, under the tutelage of local artist and instructor Gary Duehr, put together an interactive exhibit entitled "Ten Red Phones," consisting of red telephones around a central sculpture. What is art but creative work that elicits a strong response from people? In this regard the work by Duehr's students has definitely met with great success.



The great thing was that the art work extended its presence throughout campus and had a life outside its original home in the Yard. ALL AFTERNOON people responded to the giant apple under my son's arm with, "Whoa! Is that REAL?!! It's HUGE!" and asked us questions as we found spots for it at our feet at the concerts, juggling event, and dance performances that we attended. I was happy for the artists, excited that their work had such an extended reach.

We finished up our afternoon listening to my favorite Harvard a cappella group, the Harvard Opportunes. As was true when I was an undergrad, the group today still has some of the strongest voices on campus. I was glad my daughter had a chance to see young adults enjoying their musicianship in an environment in which they were also expected to excel academically.

I envy these undergrads, who like me and my friends probably won't fully realize, till they bring their own children back to Arts First in fifteen years, how precious this opportunity is to pour themselves completely into their arts and to explore their creativity with such abandon. But mostly I am inspired, and I feel that the work of art continues on in us even after some of us leave a more active participation in it, through our continuing love of the arts and the passing-on of its practice and appreciation to our children.

Friday, May 2, 2008

A Wish for Divining

I met a teenage girl who had a devastating familial neurologic disease. She couldn't walk. In fact, she couldn't move any voluntary muscles. She couldn't speak, swallow, wipe away her own drool, protect her airway, or breathe on her own. She was trapped inside her own body but fully aware. This happens to people sometimes, in certain kinds of stroke or trauma, but this poor girl was born to this state of progressive, incurable, unimaginable silent horror. Alive but unable to live. Conscious only of a life-experience filled with sensory input but also the torment of being totally cut off from the world, walled-in, paralyzed.

According to my colleague who gave her anesthesia, her mother had left her and her father after finding out that the condition was genetic, from the father's side.

Her father had been caring for her every need - feedings, tracheal tube changes, diaper changes, wheelchair adjustments, ventilator maintenance - and bringing her to all her medical appointments, until he developed the condition and died.

Now she is cared for by visiting nurses who shuttle her to doctor visits and minor hospital procedures and perform all the tasks for which she had been entirely dependent on her father.

I have a heroic friend (yes, another one!) - she has visited here on occasion: speducatorlvc - who has spent her career courageously and lovingly serving devastated children like this girl. I don't know how she does what she does, but I long to have that kind of open-hearted, brave, unselfish spiritual energy.

The nurse that brought her to one of our hospitals for a tracheal tube change under anesthesia claimed that the girl could communicate with her by telekinetically manipulating a dowsing rod. I wanted it to be true. Doesn't everyone wish for superpowers? Invisibility? Flight? Telepathy or telekinesis? I went to visit the girl and her nurse in the recovery room to learn more, trying to keep an open mind, but knowing that the possibility of there being any observable truth to this assertion was remote at best.

"Her spirit, her energy, fills this whole room," the nurse said, "Whereas yours and mine are much smaller, much closer to our own bodies. She'll move this and make it turn when she means 'yes,' " explained the nurse, holding up an upside-down-L-shaped brass thing, "and makes it stop when she means 'no.' "

She asked the girl a question. The top part of the upside-down L began turning in its little brass dowel. I could see that the nurse's hands were spinning it. She asked another question. The rod stopped.

"See, she says she's not in a lot of pain. Where is it on a scale of one to ten, honey? Ten? Nine? Eight?..." The rod magically came to a halt at 6. I think that's actually a lot of pain. More than I would have expected.

There's a remark in the Wikipedia article about dowsing which states, "Both skeptics of dowsing and many of dowsing's supporters believe that dowsing apparatus have no special powers, but merely amplify small imperceptible movements of the hands arising from the expectations of the dowser. This psychological phenomenon is known as the ideomotor effect. Some supporters agree with this explanation, but maintain that the dowser has a subliminal sensitivity to the environment, perhaps via electroception, magnetoception, or telluric currents."

I asked to hold the dowsing rod. The nurse asked the girl questions. Nothing happened with the rod in my hand. The nurse tried moving it around in relation to me and the girl, then physically moving me around, then holding her hand over my hand as it held the rod, but the rod was silent. Like the girl.

"Come on, honey," the nurse said to the girl. "Let's make a believer out of this doctor. Are you glad the procedure's all done?"

The rod drifted a little, swinging in its brass sheath, but otherwise didn't budge. The sound of the ventilator rhythmically sighing, the other equipment ticking, and the steady beep-beep-beep of her pulse-ox monitor filled the silence among us.

"She's still got some sedation on board," I said to the nurse. "I'm sure she's tired."

"She can move out of her body, you know," the nurse told me. "She visited her last nurse while she was on vacation in Hawaii. Her spirit has power and energy that's way bigger than ours."

I believe if we do have souls, some of the greatest souls on earth, those closest to "the Kingdom of God," are in these catastrophic lives, prisoners in these suffering-ravaged bodies. But as far as I can tell, we're bundles of parts at the mercy of our own cells and chemicals. If we are more than the sum of our frail little parts, I'm going to have to take it on faith. The day I met this girl I didn't know what to believe. What I could see was that there was a lot of pained wishfulness around her, but very little visible good, except perhaps in our wish for her healing.

It was one of saddest stops I've made on PACU rounds.


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Photo credit (bottom image): diseased rose by Richard Cocks, license under Creative Commons Attribution ShareAlike 2.5