Wednesday, July 30, 2008

Fusia Podgorska and the Milgram Experiment

Last night my family and I watched a great movie about a teenager who kept thirteen Jews hidden in her house after the Nazis invaded Poland. It's based on the true story of Stefania ("Fusia") Podgorska, beautifully dramatized in this film written by Stephanie Liss, starring Kellie Martin as Fusia. I had seen it televised on Lifetime in 1996 and waited for years before it finally became available on video in 2002. (Still no DVD, though! Aaaaargh!)

I especially liked the fact that although there are some graphic moments in the film - the bombing of Przemysl, civilians getting shot, Jewish families being herded into a transport train, the body of a work camp victim being carried back to the camp in a wheelbarrow - I felt it was an excellent introduction to the history of the Holocaust for my school age kids. They were both very moved by the story and asked great questions afterward - about war today, and evil, and suffering, and if there are still people like the Nazis.

There are several haunting moments, like the Jews in hiding in an attic partition, crammed together with rats and a bucket for a toilet, half-starved, but having to deal with the smell of delicious food being cooked in a kitchen below; or them kneeling in solidarity with Fusia as she prays desperately for help; the courage of her younger sister, Helena, only seven years old but heroic beyond her years; an unexpected Christmas dinner; and of course all the moments of sorrow and loss as familes got torn apart.

The question that kept going through my mind was how did Fusia come to make the decisions she made, instead of succumbing to intimidation and fear and simply obeying authority? How was she able to listen to the authority of her own conscience and moral convictions, when doing so put her life and the lives of her sister and her friends at risk? When asked about it later, she reportedly said, "I didn't do anything special." Przemysl was liberated on July 27, 1944. At the time of the film's release, she and her husband, one of the survivors she kept in hiding, were celebrating their 51st wedding anniversary.

Just last week I was in a discussion with someone who was criticizing the staff at Kings County Hospital for standing by and doing nothing while a patient coded and died in the waiting room. "I would never have done that," she said. But there are social psychology studies that suggest otherwise, and numerous papers on the now-well-know phenomenon of Bystander Effect. Equally famous is a social psychology experiment on obedience to authority carried out by Stanley Milgram, in which volunteers were commanded to apply electric shocks to a person they did not realize was an actor feigning pain and suffering. Despite the actor's "pain," two thirds of participants kept obeying the authority figure (a man in a white coat) and applying the shocks anyway. Most people feel they would NEVER obey the authority figure's orders, or if they started, that they would never continue. But the experiment has been duplicated with similar results.

The medical simulator used by my anesthesia training program did a low-key version of an obedience-to-authority experiment in the simulator. I'm not allowed to disclose the details of the scenario, but I will say that although I was not entirely disappointed in the decisions I made or in my words and actions during the simulation, I was still a little shaken at the potential fragility of my own resolve - and, I imagine, that of any individual in a high-stakes situation whose convictions are tested against the control of a tyrannical aggressor.

Which brings me back to Fusia. The stakes couldn't possibly have been higher, nor could the aggressor have been more dangerous or more frightening. But she did it. She stood up to one of the most evil forces the world has known, with resourcefulness, diligence, grace, and uncommon valor. Where does that power come from? The answer is implicit in the film: she was a girl of tremendous faith - meaning strength of character, trust in God, and courage of conviction in the right thing to do and in the value of human life, all combined - and her faith, her way of being in the world, got her through, at least as this movie tells it. But where, I wonder, does such spiritual valor come from? Favorable brain chemistry? A transcendent gift? Both? It's a mystery - one the we've been blessed to glimpse through human beings like her, known and unknown, and the stories that leave their mark on this world. (Photo credit: http://www.ushmm.org/wlc/idcard.php?lang=en&ModuleId=10006455)



בָּרוּךְ אַתָה יהוה
אֶלוֹהֵינוּ מֶלֶךְ הַעוֹלָם
שֵהֵחְיָנוּ וְקִיְימָנו
וְהִגִעָנוּ לַזְמַן הַזֶה

Friday, July 25, 2008

Wide Excision


Recently, in the O.R.:

First assist, scrubbing in to help surgeon: Time to put Humpty back together again?
Surgeon: Yup.
Anesthesiologist: Ugh. I hate that.
First assist: Hate what?
Anesthesiologist: That Humpty Dumpty rhyme.
First assist: Why?
Anesthesiologist: Because ALL the king's horses and ALL the king's men couldn't put Humpty back together again.
First assist: Of course not. He was an egg.
Anesthesiologist: SO? That's not the point.
Surgeon: She's just sore about the allocation of resources.
Anesthesiologist: No, no, not exactly. I'm sore that with all those resources allocated, they STILL couldn't do anything to help. I mean, doesn't that BOTHER you?
First assist: You need help. It's just an egg, for heaven's sake. A fictional one.
Anesthesiologist: But the egg is HUMPTY. The egg has a name. And someone loved Humpty enough to round up not just any horses, but the king's horses and the king's men.
Surgeon: DeBakeys, please. And I'll take a 2-0 Vicryl.


***

On another day, in a neighboring O.R.:

The atmosphere in the O.R. is relaxed. With the exception of the scrub tech, the surgical team - surgeon, anesthesiologist, and circulating nurse - consists entirely of women. The anesthetic is in maintenance mode, totally smooth, and periodic checks of all systems, physiologic and technologic, every one to three minutes, consistently show stable signs. We women chat amiably between requests for instruments, adjustments to I.V. fluid, the pushing of medications, pauses for surgically intricate stages of the surgery.

The surgeon hands a mass of tissue to the circulating nurse. "Tell pathology long sutures are medial, short ones are on the axillary side." The mass goes to the lab for analysis.

We continue our conversations, with the scrub tech ribbing us good-naturedly about our chosen topics: the latest reruns of Star Trek Voyager; comparative Klingon and Vulcan cardiac anatomy; the surgeon's recipe for cocoa cookies; the nurse's for peanut butter balls; soap opera story lines from our college days; a horror movie about a telepathic, man-eating plant.

"See, that's exactly why I don't like movies," says my friend Caroline, the surgeon. "What kind of story is that?"

"I love movies!" I counter. "But I'm an easy sell."

"Well, the ones that have a good story are fine. But how many really good stories do you get nowadays? It's all explosions and gore."

"The black-and-white ones have good story. Even my kids can get into those. So what happened after the plant ate the guy's legs?" I ask.

Just then the phone rings.

"It's pathology," the circulating nurse says. She puts the phone on speaker.

"Dr. Walsh? Yes, hi, about that specimen you sent..."

The news is not good. There's not just one cancerous lesion; there are two.

"The second one's invasive," the pathologist says, giving exact details about the type of tumor.

There's a pause. The energy in the room changes almost visibly, as if the lights are being dimmed, while the news sinks in. Our gazes drop, shift.

"Okay," says Caroline. "We'll do nodes, then."

We're quiet for most of the rest of the operation. When we do talk, it's about the diagnosis. That's the nature of diagnosis, after all; it seeps into every thread of life, like a dye.

"That sucks," the scrub tech says.

"Yup. It does," said Caroline.

We do feel it in the O.R., even after years in practice. A sad diagnosis cuts a wide swathe. Even with the patient anesthetized on the table, totally unaware of our presence and our sympathy, we express our pain and our care, in awkward murmurs and pregnant pauses. The dye seeps into our stories as well; the fringes touch and mingle. We are changed.

The circulating nurse wonders how old the patient's children are. I ask Caroline more about the patient's history, why the patient hadn't been referred or hadn't sought her care sooner. Our questions are intermittent, halting - blips of sound in the silence of Caroline's cutting and sewing.  Even though we've seen it before, it still jars us: the patient's life has turned just like that and will never be the same. Though of course, our lives rarely turn on a dime; if medicine suggests anything, it's that tomorrow's story is already being written today, and today's probably began long ago. It's our realizations that come upon us so suddenly, our understanding of what's happening to us as our stories spin beyond our control. The worst part, when you're not actually in the vertiginous center of that spin, is having to tell someone what's going to happen next when you know it's something terrible. And that there's very little you can do about it.

"Okay. Done," Caroline says, sewing in the final stitch.

I've already shut the anesthetic off. It's time for awakening, awareness. Emergence, we call it. And I actively prepare our patient for emergence, working to make it a safe one, a smooth one, for her. Then I watch, and wait, and stay by her side, until she opens her eyes, until her hand can grasp mine.

___________________________________________________________
Photo credit: Egg image originally posted to Flickr by rockymountainhigh and licensed on Wikimedia.

Wednesday, July 23, 2008

Not My Best Moment: A Career "First"


Ordinarily I like friendly chatter. That is, at the right time and place. I think it makes the work day more pleasant.

But when total concentration and focus are required, I dislike chatter. I disapprove of chatter. I think chatter in such a scenario is a symptom of one or both of the following: forgetfulness or lack of understanding of the critical nature of a moment, and indifference to, or disrespect of, the critical importance of a moment.

When a surgeon says sternly, "I need quiet in here right now," I shut up.

When I ask the chief of surgery to turn down his iPod so I can hear my monitors, he does.

When I need to concentrate, and have time to ask nicely, I don't hesitate to tell people I need them to stop talking just for a little while.

None of these requests is ever aimed as a personal attack, to rebuke an individual (who may very well be irritating), or to embarrass anyone publicly. Because the truth is, even in the warmest of environments, patient care sometimes means business only, quick and terse phrases, nothing personal. It's a hospital, after all, not an ice cream social.

And sometimes there just isnt' time for social niceties. Really.

Like during induction of anesthesia and intubation, when your student can't get the airway, and he's softspoken and too inexperienced to be able to verbalize what he's seeing or not seeing when he tries the intubation.

Students like me because I am nice to them. I don't raise my voice. I don't mock them for failing. I reassure them, guide them, try to give them helpful feedback, tell them stories, explain what I mean, more than once if necessary. I try to let them do as much as possible and get them to perform their own corrections, based on the information they give me and my subsequent suggestions. Up to a point. But if it looks like it's not gonna happen, I step in and take over.

But today I yelled. Not at the student; at the nurse in charge of the front desk. This is a woman who can be very nice. But she can also be abrasive and frequently gets stressed out in a way that transmits that stress to those around her.

This woman barged in loudly just as I was trying to elicit important information about the airway from my soft-spoken rookie medic. He had already needed help to improve his mask ventilation, and after listening to my suggestions he had corrected his technique nicely. Now he had the laryngoscope in position and he couldn't see vocal cords.

I was asking him to describe what he saw - was the epiglottis in view? Was there just a tunnel of pink mucosa? Often inexperienced laryngoscopists have a tendency to insert the laryngoscope in a little too far, past the epiglottis, so I told him to pull back a little till he could see it. But I was having trouble hearing what he was mumbling behind his mask.

I had a student who couldn't get the airway and couldn't articulate why, and a patient I was responsible for. Everybody in that room needed to be standing at attention and ready to assist if the situation became perilous. And at that moment the woman from the desk burst through the door speaking at the top of her lungs, without bothering to take note of what was going on and what a critical moment it was.

I didn't even turn my head or stop to understand what she was going on about. I yelled.

"QUIET!"

There was a stunned silence.

"I need quiet in here!" I continued.

I turned to the paramedic student and said, "I'm going to step in and take a look, all right?"

He gave me the laryngoscope. The vital signs were holding. I made a subtle, almost imperceptible adjustment with my wrist and the vocal cords were there, fully visible, plain as day. A "Grade I" view.

"There you are. Wanna put the tube in?"

He started to, but I think I must have scared him, because he changed his mind just as it was touching the arytenoid cartilages and handed the end of it to me. I passed it into the trachea smoothly and secured the tube.

The student thanked me with a little bow and made a quick exit. I didn't even have a chance to debrief with him.

After attending to the last few details of "take-off," I picked up the phone and called the front desk to apologize to the charge nurse for raising my voice.

She hung up on me.

I was frustrated because I knew I had hurt her, without really intending to; perhaps made the student uncomfortable, causing us both to miss out on a chance for a fruitful teaching interaction; and also detected a real lack of respect for what we do at the head of the bed every time we anesthetize a patient. I had the feeling that we make it LOOK easy 99 times out of 100, so people FORGET that it's a LIFE AND DEATH moment up there, getting the airway. It looks easy most of the time, and after a couple of thousand, yes, most of the time it's a comfortable procedure, but there's also nothing more important than that precarious moment right at that moment. As that student found out - and before this, he had been feeling pretty darn good about the few intubations he'd tried - it looks simple until you actually try it yourself.

Anyway, I sought the woman out a second time later in the day, in person, put my hand on her shoulder and said, "I am truly sorry I yelled for quiet like that, but I didn't feel like I had time for more than a word or two right at that moment."

"I know," she said. "And I had to move on to the other O.R.'s right away, and then to the other phone line after you called, because there was a lot going on."

"Understood," I said.

We patched up. But it was a sad career "first" for me. It was the first time I'd raised my voice like that at a co-worker in the O.R.
______________________________________________________

Photo credit: orangutan by Malene Thyssen

Tuesday, July 22, 2008

Excursions in Medical History: Sartorial Musings


Why do we wear scrubs?

Before Lister, surgery was conducted in operating theaters with surgeons wearing their street clothes. Wikipedia tells us, "In contrast to today's concept of surgery as a profession that emphasizes cleanliness and conscientiousness, at the beginning of the 20th century the mark of a busy and successful surgeon was the profusion of blood and fluids on his clothes." Packing gauze consisted of the discarded stuff from cotton mill floors. Yuck!

By World War II, though, sterilized instruments, antiseptic drapes, and surgical gowns had come into common use. They were white at first, but along with the white walls the attire promoted glare and eye strain, so green began to be used for contrast, and later various shades of blue and grey. An article by Susannah Locke on Scienceline explains, "Green may be especially well-suited to help doctors see better in the operating room because it is the opposite of red on the color wheel...Looking at something green from time to time can keep someone’s eyes more sensitive to variations in red, according to John Werner, a psychologist who studies vision at the University of California, Davis...Such deep focus on red, red, red can lead to distracting green illusions on white surfaces. These funky green ghosts could appear if a doctor shifts his gaze from reddish body tissue to something white." The outfits used to be called "surgical greens" but are now called "scrubs" presumably because of their use in "scrubbed" areas.

It's nice not to have to worry about what to wear at work every day, and to have the way you look be of minimal importance. But it can be tedious to mill about in a sea of blue or grey or green where sometimes people don't recognize you in the locker room because you actually have HAIR (messy, of course, at the end of the day) and a FACE (now with discernible expressions). There's not a lot of opportunity to express one's individuality amid all the blue pajamas. Yet it happens - through hats.





Some people go for color and a snug-bonnet look.








Others for poofiness and cheerful designs. For the most fun-filled ones, children's hospitals are unbeatable. I once knew a pediatric anesthesiologist named Bob who wore - you guessed it - Sponge Bob hats every day. Cute.









Some express pride in their personal background or heritage.









And others remind us of the non-medical hobbies near and dear to their hearts. This surgeon, a total sweetheart among surgeons, loves to fly planes...






The World Series sees a host of Red Sox hats and the occasional Yankees covering. The one time I get into the spirit of a season is in the winter, when I wear my Christmasy snowman hats. I've been a "color" person in the past, too, but lately I've been pretty lazy and just wearing the standard issue ones at the hospital. Maybe I should go back to my deep purple, or my bright teal, instead of succumbing to the un-creative convenience of the ones out of the box...




Check out Terry's enjoyable post, "Ode to Hat Hair," over at Counting Sheep.

For a much more edifying and serious excursion into medical history, please check out the post about Blalock/Taussig/Thomas on Suture for a Living.

Saturday, July 19, 2008

Ful



My friend Thaer, who just married my dear college friend Sheila, prepared some wonderful Ful for us this weekend while we were all getting some lakeside R&R before a busy end-of-July. I think I'm going to have to do a more in-depth exploration of Palestinian cuisine! (There are versions of the dish in many Arabic-speaking cultures, as well as Turkey, I think - sample recipes here and here.)


Ful

  • Sauté 3 minced garlic cloves in a couple of tablespoons of oil. Do not allow garlic to brown.
  • Add 1 can fava beans plus 1/2 of the liquid from the can.
  • Stir well and season with salt to taste.
  • Cover and simmer 5-10 min.
  • Chop 1/2 of a medium onion and 1/2 of a medium tomato.
    Remove beans from heat (you can mash them up a little first) and place in a bowl.
  • Add onions and tomato and 2-4 Tb extra virgin olive oil.
  • Optional: add a couple of tablespoons of tahini sauce pre-mixed with a little hot water, and a few squirts of lime juice
  • Eat with flatbread, crackers, rice, regular bread, or other accompaniment of choice.

The more I get to know Thaer, the more I admire him. He has a kind smile and a ready laugh. He has a playful sense of humor. He is gentle and affectionate with his wife and sweet with our kids. He's an incredibly talented artist. He has dance moves I've never seen before, and a wonderful sense of rhythm. All that and he cooks, cleans, and does dishes and laundry! But what I find truly inspiring about him is that despite his past sufferings, he isn't cynical, bitter, resentful, or wallowing in the victim role. In fact, I know few people with a greater capacity for joy and gratitude. I've seen people who have had WAY more comfortable lives complain MUCH more about their lot - me right up there with them, I'm sorry to say. What's up with that?


Thursday, July 17, 2008

Tales from Saint Boonie's: Songs in the O.R.


There are a few things that bring the docs and nurses at St. Boonie's together. The Red Sox. Food and drink. On occasion, certain movies or songs or T.V. shows.

And, escape fantasies.

As the nurse preps the abdomen for surgery, and the surgeon gowns up, and the anesthesiologist adjusts ventilator settings, sometimes they can be heard sharing the latest plan: leave St. Boonie's to become a mystery shopper or marry a millionaire; do locum tenens work and freelance for travel or food magazines between jobs; quit medicine entirely after winning the lotto. The same conversation comes back over and over again in different incarnations.

But do we hate our jobs so much that we're constantly joking around about means of escape? Is being in health care so completely odious that we just abhor getting out of bed every morning?

Well, no. I think we all dislike the annoyances, large and small, like workplace politics, and call, and the daily dose of obnoxious behavior from some unforeseen source. But we "have it pretty good" at St. Boonie's. It's a village, a family, and none of us would want to lose that kind of community life at work.

And the work itself has irreplaceable rewards - not always obvious or easy to appreciate. But if we keep ourselves mindful enough, they're there to remind us of why we chose this path in the first place.

Take old Sully Carlton. Sully had a cardiac defibrillator implanted into his body to deliver an electric shock in the event of a potentially fatal disturbance in heart rhythm. He was having dinner one night when the thing went off and jolted him right out of his plate of pot roast. He came to St. Boonie's so the cardiologist could test and adjust the device.

As the PACU nurse and I were putting monitors on him, as well as pads for an external defibrillator and an oxygen mask, he said to us, "You girls fussing over me like this make me feel like I'm important or something."

We both smiled at him and said something like, "Of COURSE you're important! In fact, at this very moment, there's no one more important to us than you."

Sully replied, "I think this is the only time anyone's going to feel that way about me." He sounded matter-of-fact, not self-pitying, but there was a hint of loneliness in his voice and eyes. I looked into his eyes, trying to find something to say. I couldn't think of anything, so I gave his arm an affectionate squeeze instead.

"You ready?" I said to the cardiologist.

I gave Sully the anesthetic through his IV, then started to assist his breaths with a bag-mask ventilator.

"I'm going to induce V-fib now," the cardiologist announced. That's that potentially fatal heart rhythm - the one we don't usually like to see, because it KILLS people.

"Great," I said, a little sardonically. "I can't wait."

The testing procedure went completely smoothly. Sully's implanted defibrillator fired and corrected the abnormal rhythm without a hitch. Five minutes later Sully was back with us. The drug I had given him sometimes gives people a very refreshed, almost euphoric feeling, and sometimes removes enough inhibitions to allow for some fairly intimate disclosures. Sully awoke thanking us and thinking about his late wife.

"I took care of her in the end, you know," he said, his speech still a little slurred. "I cleaned her up when she couldn't do for herself. I combed her hair."

We murmured words of admiration, of praise. Then he dozed off. Sully was a good guy. I wondered if in his dreams he and his wife were young and in love and unencumbered by things like defibrillators and terminal illness.

Then there was little Cassie Molloy. Cassie was a cute, curious, sociable little girl with honey-colored hair. She reminded me of Abigail Breslin's character in the movie Little Miss Sunshine. She had broken her forearm falling off her scooter. The orthopedic surgeon, Dr. Warbucks, was a pleasant, portly man with a poker-faced sense of humor. He sat in the corner of the O.R. waiting as we placed monitors on Cassie.

She began to get a little tearful and said she wanted her Grammy. I tried to console her and asked her if she knew any good songs.

"She likes Hush Little Baby," the nurse helping me said. We started singing to Cassie.

"Hush little baby, don't say a word; Momma's gonna buy you a mocking bird..."

We continued while I searched in vain for a blood pressure cuff of the correct size. Another nurse left the room to retrieve one. I gave Cassie oxygen with a well-cushioned face mask. She asked for Rockabye Baby.

"Rockabye, Baby on the tree top; when the wind blows, the cradle will rock..."

Still no cuff. We started on some songs from The Sound of Music. "Raindrops on roses and whiskers on kittens; bright copper kettles and warm woolen mittens..."

Finally the correct blood pressure cuff arrived, and we put it on. I turned on some nitrous oxide and asked Cassie to pretend there was a little birthday candle inside her oxygen mask that needed to be blown out. "Big breath now, sweetpea. Blow that birthday candle out. Brown paper packages tied up with strings...These are a few of my favorite things..."

Cassie was calmer now, her breathing more relaxed. "How are you doing, sweetheart? Give me one more nice deep breath, that's a girl. Edelweiss, Edelweiss, ever morning you greet me..."

I began pushing the milky white drug into her IV. Her eyes began to show the familiar movements of a child entering an anesthetized state. I started to assist her breathing. Everything was going as smoothly as I'd hoped.

As I gave Cassie the anesthetic I heard a sound coming from the corner of the room. A baritone voice, soft at first, almost distant, singing as I inserted the laryngeal mask airway.

"Perhaps I had a had a wicked childhood. Perhaps I had a miserable youth."

Then, a little louder, "But somewhere in my wicked, miserable past there must have been a moment of truth." Dr. Warbucks, though feeling a little impatient over the delay with the blood pressure cuff, had gotten into the Rodgers and Hammerstein spirit.

As I secured the LMA into place, he stood up, put on his x-ray apron, and belted in my direction, "For here you are, standing there, loving me, whether or not you should!"

So I replied, and we finished together, "So somewhere in my youth or childhood, I must have done something good."

Later in the recovery room, after a smooth awakening, Cassie was sitting up in bed chatting happily with the nurse, totally comfortable and in good spirits. Dr. Warbucks had given her a bright pink cast for her arm. "Hi, sweetie," I said, checking in on her. She gave me a big smile. I asked how she was feeling, and if she remembered anything. She said she dreamed she was wearing a beautiful dress like Cinderella at the ball. And she said, "I remember you sang me a song."

Sigh. Okay. The lotto can wait.

Tuesday, July 15, 2008

Why The O.R. is NOT a "Meat Market," Grey's Anatomy Notwithstanding; and, Looking a Patient in the Mouth: What's That About?


(West Side Story music intro blares - tararararum-tum-tum ta ra-ra):

"I feel pretty,
Oh, so pretty,
I feel pretty and witty and bright!
And I pity
Any girl who isn't me tonight..."


***

Now for some more prettiness.

I've been asked time and again by patients why I examine the interiors of their mouths. "What'd you do that for?" They say with puzzled, sometimes curious, expressions.

I'm doing a physical exam of the airway to determine its Mallampati Class - based on a classification system that allows anesthesiologists to assess and document visible landmarks and to communicate those findings with other anesthesiologists.


A "good" Mallampati class (Class I), however, does not always portend an easy intubation, nor is a disfavorable one (Class III) always a harbinger of airway trouble. I use the Mallampati classification in conjunction with other physical features that over the years have seemed to point to ease or difficulty of mask ventilating or intubating a particular airway.

I get a general idea of the amount of soft tissue around the face and neck as well as the quantity of facial hair.

I look at the size of the jaw - particularly the "thyromental distance" from, roughly, the tip of the chin to the neck, I specifically try to evaluate how "well" a person's tongue fits into the jaw interior, or the floor of the mouth, because that's where I'll be trying to tuck it with my laryngoscope when I put the breathing tube in.

I look at whether the front of the chin lies slightly in front of or behind the front teeth when examining someone from the side. I also try to get a general idea of the shape of someone's chin-to-neck profile.

I try to pick up on any unusual features like a high-arched palate, very prominent structures, loose teeth, etc.

When I was in school and thought I would be a medical geneticist, I studied pictures in a book entitled Smith's Recognizable Patterns of Human Malformation. It's at times an alarming and saddening volume. After getting to know that book fairly well I started to see genetic syndromes all around me, in people walking down the street or corridor, much as medical students learning about pathologic symptoms suddenly start to think they're coming down with every disease in the pathophysiology textbook.

Now I've narrowed down my scanning bias to four things that I can't help but notice about people almost immediately:






Good veins,











Bad veins,








Favorable airway (ok, I'll admit it - I just wanted an excuse to put Prince Caspian on this blog somewhere),




and





Scary airway.







I think it's interesting how different meanings can be assigned to external appearance. For some it's a suggestion of ethnic heritage, and all the assumptions, correct and incorrect, that can accompany the impression. For others it's a potential mating signal. For anesthesiologists in work mode, it comes down to the very basics, the crucial stuff: does what I see give me clues about whether I can protect your airway, and thus your very life? It may be a very narrow scope through which to focus on and view the world, but for those few hours when we're on duty, it's an important one.

So open wide, please. It helps us do our job.

Saturday, July 12, 2008

Excursions in Medical History: In Memoriam


Michael Ellis DeBakey


September 7, 1908 - July 11, 2008



How to begin to honor this true medical pioneer, who was cited as a "Living Legend" by the Library of Congress in 2000?

DeBakey. I hear his name almost every day. He developed over 70 medical instruments. Every time I hear a surgeon ask the tech for "DeBakeys" - forceps, or perhaps clamps or a needle holder - I think of him.

He was born Michel Dabaghi to Lebanese parents in Lake Charles, Louisiana. At the age of 23 he invented the roller pump which contributed to the development of bypass machines that allow for heart bypass surgery. He was among the first to perform coronary artery bypass surgery, as well as to develop an artificial heart, a left ventricular assist device to bridge patients waiting for a heart transplant, a surgical camera stand to allow surgery to be captured on film, MASH units, and vascular grafts. He pioneered clinical assessment tools and procedures, including the first carotid endarterectomy in 1953. He developed the DeBakey Classification to describe aortic dissection - a condition which took the lives of Lucille Ball, John Ritter, and Rent composer Jonathan Larson - and the Debakey Procedure to correct it. In February of 2006 he became the oldest person, then 97, to undergo and survive his own procedure. Done by a surgeon HE trained.

The list of awards and honors he has won is too long to post but can be found here. Among them was the Congressional Gold Medal, which placed him in the company of Edison, Salk, Washington, and Churchill. He operated on Hollywood stars, heads of state, and ordinary folks who meant more to their families than any performer or politician ever could. He trained THOUSANDS of surgeons, passing on a legacy of good work to future generations and countless patients. What a life!

By many accounts, he was TOUGH. By some accounts (this I have third- or fourth-hand, through an attending who knew a resident who trained at Baylor years ago) he had an ego about the size of the state in which he practiced, and expected doors to be opened for him in every corridor. I don't know if this is accurate. On film, though, what we see is what we see; a Nova documentary entitled "Electric Heart" gives us a brief glimpse into what it was like to train under him:


NARRATOR: Dr. Michael DeBakey is a pioneer of the artificial heart. In the 1960s he was one of a handful of leading heart surgeons. Known as the Texas Tornado, he both inspired and terrified those around him.

MICHAEL DeBAKEY [film footage]: What do you mean, "it's not flushing"? No, no, no, no, no. Put your finger over that. You're not concentrating, you're watching me.

BUD FRAZIER: Dr. DeBakey was quite a task master. It was like working under a Marine drill sergeant. He was very tough, he expected actually much more of you than you could actually do.



His career was also not without its share of academic drama. In 1969 Dr. Denton Cooley, a heart surgeon at St. Luke's Hospital, somehow pilfered the artificial heart Dr. DeBakey had developed in a lab at Baylor, with N.I.H. funding, and implanted it in a patient at St. Luke's. DeBakey found out about the heist by reading about in the paper. He felt that Cooley had committed theft and the unethical act of using an unapproved, experimental device in order to claim a medical first (transplantation of an artificial heart into a human patient). Cooley claimed it was a desperate effort to save a patient's life.

I thought the following story quoted in The New York Times, about a trial involving Dr. Cooley, spoke volumes about his character:


Dr. Cooley recalled that a lawyer had once asked him during a trial if he considered himself the best heart surgeon in the world.

“Yes,” he replied.

“Don’t you think that’s being rather immodest?” the lawyer asked.

“Perhaps,” Dr. Cooley responded. “But remember I’m under oath.”


Dr. DeBakey's character, by contrast, is revealed by the way "he refused to testify in the litigation that followed; he did not want his rival to be found guilty. 'Much as I regretted what he did,' Dr. DeBakey said, 'I didn’t think vengeance would solve anything.' ”

Very often when we think of someone who is faraway or who has passed away, their words come back to us. We can hear their voices in our minds and hearts, and it's these memories that evoke the person's presence and spirit. Here are some more of DeBakey's own words:

On his work: "I like my work, very much. I like it so much that I don't want to do anything else."

and..."I guess it's the same gratification an artist gets from painting a beautiful painting, a poet gets from writing a beautiful poem."

On faith and God: "Practicing Christian physicians do not necessarily kneel and pray as they administer to their patients. It is, rather, a matter of communing with God on a continuous basis. God guides us; we are his instruments."

Requiescat in pacem, Michel Dabaghi. Millions of people for years to come will owe their lives and lessons to you.

Photo: a cedar of Lebanon

Sources:

CBS News article 7/12/08: http://www.cbsnews.com/stories/2008/07/12/health/main4255275.shtml

Wikipedia: http://en.wikipedia.org/wiki/Michael_E._DeBakey

Baylor College of Medicine website: http://www.bcm.edu/news/packages/medinnovations.cfm

Transcript of Nova program "Electric Heart": http://www.pbs.org/wgbh/nova/transcripts/2617eheart.html

NY Times article on the Cooley/DeBakey rift: http://www.nytimes.com/2007/11/27/health/27docs.html?ex=1353819600&en=bcf0c7c7d8ea289e&ei=5124&partner=permalink&exprod=permalink

Inspired: The Breath of God - Conversations with Gifted People about their Faith and Inspiration, collected by Joanna Laufer and Kenneth S. Lewis (currently out-of-print)

Friday, July 11, 2008

Sign Here, Please


I have a confession to make.

I don't believe in informed consent.

Or rather, I believe that informed consent is occasionally possible (and should always be the goal/intention), but also that achieving true informed consent is rare.

Even if I spend an HOUR talking to a patient about every possible common effect or complication of every drug and piece of equipment I use, maybe even if I get to the UNcommon things, I don't think I can adequately convey the amount of information that would enable anyone except another trained anesthesiologist to give me genuine, fully informed consent for an anesthetic. Fairly well informed consent I can get, probably, but not fully informed.

If an orthopedic surgeon spends a very long time explaining the ins and outs of, say, a radial head resection to me, I'll get a general idea, perhaps even a very good idea, of what I'm in for if I need the surgery, but I won't have his or her years of experience witnessing and doing the procedure and dealing with all the possible events it might generate. Even with medical school under my belt and some surgical experience, the intimate knowledge that comes from hard-earned expertise will never be mine.

That's why I don't want my orthopedist to just list statistics about possible complications for me. I want advice. I want medical guidance in light of the knowledge and education I lack. I want HELP making the decision that's the best fit for me and my problem.

For this reason, just as I believe a paternalistic approach to doctor-patient communication is wrong, I believe the "independent choice" model, in which patients are given information but not recommendations, is wrong: a disservice and a failure to provide the patient care we took an oath to provide when we all promised we'd try to be good doctors. I favor a more collaborative approach that allows me to put my expertise to the service of another and also preserves my patient's right to make decisions in as informed a way as possible.

I do not think of patients as customers. I think of patients as patients. Customers buy things they want for themselves. Patients seek help that they lack the knowledge, skill, and expertise to provide for themselves, and often that help comes in the form of experiences they really don't want but which might be necessary in order to recuperate or preserve their health and safety. That is, unless they are truly unwilling to experience those unwanted things and would literally rather die than undergo those experiences. If someone is competent to come to that decision, I am duty-bound to respect his or her wishes. But if patients are willing to let me offer the help I know how to offer, then sometimes I have to put patient safety ahead of patient comfort, though I always strive for both.



I studied basic principles of medical ethics in med school. There are four principles written about extensively by Beauchamp and Childress that have given medical practitioners a common language to use in discourse and practice, regardless of differences in cultural background, value systems, and religious or moral views. These principles or ethical goals are

  • Patient autonomy
  • Beneficence
  • Nonmaleficence and
  • Justice.
I never think much about the way I am confronted daily with small ethics issues, but lately I've been noticing that they're actually a pretty prominent part of my practice of medicine, especially the first principle: patient autonomy. My job actually entails taking away people's autonomy entirely, at least temporarily; once they are anesthetized, they have little control over the treatment decisions I make. But usually there's a chance to discuss the important points beforehand, and during those discussions I try to respect patient autonomy while also expressing my preferences and plans.

An example: a woman whose preop history I was recording asked me if she would be given the drug Versed (generic name: midazolam) without being told before her surgery. I told her that I personally never administer it without making sure a patient wants to receive it and knows of possible effects such as memory loss of events around the time of the drug's administration. Very rarely, patients report experiences with this drug that are so awful for them that there's even a website on which hundreds of vitriolic comments (including some exceedingly ignorant and bigoted ones) against anesthesiologists have been posted, one even comparing us all to people who commit date-rape. While I try to be as thorough as I can about explaining my anesthetic plan, I do think it's unrealistic, not always useful, and often downright impractical for us to give patients a full run-down on every single drug we administer as part of the anesthetic.

Another example: a morbidly obese pregnant woman needed to have a cesarean delivery for a fetus in breech position. She adamantly refused to have an IV inserted. My colleague informed her that he absolutely could not and would not provide anesthetic care without IV access and would have to have her sign a form stating she was refusing care and aware of the risks. She eventually agreed to an I.V. He also tried to explain the relative danger of a general anesthetic versus a spinal or epidural for the procedure, but she would have none of it - she wanted a general anesthetic, no regional anesthetic, but she wanted to be woken up as soon as the baby was pulled out of her body and she wanted her husband to cut the cord. He had to tell her that this plan just would not be possible. Sometimes full patient autonomy is not only impossible but also inadvisable.

Another: a mother at Children's once told me that under no circumstances did she want a breathing tube inserted in her child. I told her that we would have no choice but to cancel, or at least postpone, the surgery. An un-secured airway was just not an option for the procedure; proceeding without one would have constituted malpractice. She then relented a little and began to ask questions - why the tube was necessary, what it meant for her child, whether her child would experience discomfort from it. I answered all her questions as thoughtfully as I could, and in the end she gave us permission to take care of her child.

One more: a former nurse refused to give consent for a general anesthetic for a procedure we most commonly performed under general. She told me she would cancel and go home if she couldn't have a spinal. I told her I could safely provide a spinal anesthetic but was professionally and ethically obligated to inform her of the possible complications before we proceeded. When I started explaining these, she was irritated at first, saying, "The other anesthesiologist I talked to in the preop clinic didn't tell me any of this!" In the end, though, with some investment in a thorough conversation, she felt reassured, and happy that I respected her wishes despite the fact that it wasn't the usual m.o. at our institution for her surgery.

I'll listen intently to what's important to my patients, and I'll do everything in my power to provide the experience they want if I can do so safely. I won't force a patient to submit to something against his or her will. But I won't practice bad medicine against my will either. My patients' safety matters too much.

Thursday, July 10, 2008

L.F. Eason, You're My Hero

L.F. Eason III, former director of the North Carolina Standards Laboratory, resigned rather than lower a flag to honor the late Jesse Helms. Here are some excerpts from his NPR interview (on today's All Things Considered) that made me admire the way he stood up for his convictions:

"I gave the option of either not putting the flags up or to put them at full staff...I didn't feel that I could support anyone who had voted against every civil rights act that came before him and filibustered the Martin Luther King holiday...yes, the bricks and mortar are the state's, the flag is the state's flag, but I feel that everything that comes from that lab, good or bad, I am responsible for...I said, 'If I can't take them down, I can't work there,' so I agreed to take retirement..."

"...I'm a North Carolina native. I love this state. I feel very strongly that the amount of racism, segregation, and all that we have in this state wouldn't be nearly what it is today if it hadn't been for Jesse Helms...The first time he was elected, I was still in high school, and a good friend of mine just dropped to his knees as soon as he saw me and said, 'Yessir, Massuh, I be pickin' your cotton now, 'cause Mister Jesse's in office.' "

"What have you heard from the folks you worked with...especially the people who disagreed with you?"

"Well, so far the nominations for president are balancing out the death threats...From my counterparts in other states, in other countries, the response has been a hundred per cent supportive...People have said this is a brave thing. I have to agree with my detractors here: it's not brave. It was a very safe decision for me at this point in my life."

That may happen to be true, but it's still much easier for good people to stand by and do nothing than to go against the grain in order to uphold their own convictions.

The Charlotte Observer notes that Eason wrote the following to North Carolina Governor Mike Easley and Agriculture Commissioner Steve Troxler: “I … understand that my decision is not acceptable. You cannot ignore that fact. There is the law, but there is also a higher law I must follow as a matter of conscience.”

Thank you, Mr. Eason, for not obeying orders even when it would have been much simpler to do so. Some points will always be worth making.

________________________________________________________

Thanks to Big Ass Belle for this possible contact information for those who want to express support of / solidarity with Mr. Eason:

L.F. Eason III
c/o:The Standards Laboratory
4040 District Drive
Raleigh, NC 27607

Or comment on a piece in the Huffington Post at this link:
http://www.huffingtonpost.com/greg-mitchell/american-hero-worker-orde_b_111701.html

Tuesday, July 8, 2008

The Deep Satisfaction of Demonizing Our Doctors


Doctors are human.

Just like everyone else.

I would never assert that it's okay for doctors to make mistakes. And I would certainly never want to imply that patients who have been wronged are owed nothing for their suffering. But why do people seem to find it so compelling, almost pleasurable, to blame the doctor when something goes wrong? Do they really hate us so much? Do people really think we can and should be absolutely perfect all the time? Will blaming us, making us pay, taking revenge, making sure we are dragged through as much as punishment as possible, ensure that we are "put in our place?" And will it bring healing of whatever loss has occurred?

I will try not to generalize here. I'll just repeat what The Hunk has to say about it.

The Hunk hates hospitals. And doctors. And medicine. Yes, we are happily married. And yes, he still hates hospitals, and doctors, and medicine.

He also hates...
-being sick
-relinquishing control to another
-being talked down to / the arrogance of others
-not knowing enough about what's wrong
-not knowing what might happen
-adverse events

Fair enough. We all do.

But when those things come into play one way or another, somehow all that dislike of all those things gets channeled into doctor-hatred.

Will our human frailty every be forgivable? Ever?

What doctor HASN'T made a mistake, ever?

Who on God's green earth HASN'T screwed up royally?

And what if our frailty wasn't even to blame?

Sometimes I'm convinced people think we have no feelings at all. When I told someone once that a resident I knew was in the lounge weeping over the suffering endured by a patient and family, because of the patient's injuries at the hands of another, the reaction I got was one of incredulous surprise. We feel just as bad when people get hurt because of something we've done or failed to do. I truly believe the majority of us carry those mistakes or failings with us. We feel terrible about them. We feel deeply sorry for increasing the pain of others where we were supposed to decrease suffering. We practice better medicine because of what we learn, take BETTER care of our patients, and teach the students under our tutelage to learn from our experiences as well as their own. I think the worst kind of physician is one whose arrogance is cultivated, preserved, or increased by the fact (or perception) of never having done wrong or the feeling that s/he has never failed.

Errors in medicine are hot stuff in the press these days. We could do a mini-blog carnival right here on the subject.

There's the latest edition of SurgeXperiences, the surgical blog carnival. Jeffrey over at Monash Medical Student has made "Better" his theme - better practices, getting better as doctors.

Then there's the news from Beth Israel Deaconess Medical Center, about the surgical procedure that was performed on the wrong side, even in this era of checking and double checking and marking and confirming and reconfirming the correct site.

TBTAM at The Blog that Ate Manhattan reflects brilliantly on a nuisance malpractice case that may have more far-reaching consequences than anyone realizes. Doesn't anyone think beyond the pay-out? Is it too much to expect an angry plaintiff to do so? Probably.

But I think it's Mike O'Connor over at The Ether Way who really hits the nail on the head with this example (emphasis mine):

"It is now widely accepted that intrapartum asphyxia is the cause of no more than 10% of the cases of cerebral palsy in our world. The remainder, that is to say the vast majority, seem to be caused by some combination of intrauterine infection and the demise of an intrauterine twin; both of which precede delivery by weeks to months. Given this, it is unsurprising that escalating monitoring and aggressiveness in the management of fetal hypoxia had no effect on the overall incidence of cerebral palsy. In retrospect, the absolute inability to make any forward progress on this problem should have made it obvious: the vast majority of CP is not caused by intrapartum asphyxia...

..Who are the casualties here? Not just the patients. How many doctors and nurses were devastated by the idea that they might have caused CP in a child? How many careers were ruined? How many millions of dollars were paid for events that were beyond the power of those held responsible? Who is going to apologize to those practitioners? Who is going to pay them back? Who is going to make it right? (The answer to the last three: No one.)"

Instead of blame, I wish people would choose dialogue. Because I think what patients and families want (though I could be totally wrong) is for their pain to be known and heard and acknowledged by those who caused or contributed to it, and to hear from those people, and know, beyond a shadow of a doubt, that deep in their hearts they are, in fact, truly sorry.

Maybe this could work. Then we really focus on getting ever-BETTER. Maybe genuine humility expressed by doctors could supplant the humiliation and retribution desired by plaintiffs who feel the latter to be necessary to create justice and healing for their losses...but then again, maybe not. We are all human, after all.
______________________________________________________
Addendum 7/9/08: this quote from E.R. doc Shadowfax, who writes the blog Movin' Meat, is too important not to share. It describes doctors who are haunted by the fear of making a mistake. Hat tip to KevinMD for the link.

"I don't know what separates the doctors who practice scared from the rest. Maybe there's a difficulty in accepting the responsibility that comes from the life-and-death decisions we make. Maybe there's a fear of or past trauma from the criticism that invariably follows a bad outcome. Perhaps it's a simple fear of failure -- that the patient who does poorly is necessarily a reflection on you and your judgement, and your worth as a physician. Curiously, most of the docs I've known like this have never been sued, but there is a constant genuflection to the altar of 'I don't want to get sued.' I suspect that they use the bogeyman of malpractice as a proxy for their real fear -- the imagined consequences of making a mistake."

Monday, July 7, 2008

The Burden of Practice

Perelandra - my oboe - is heavy. I think she may be the heaviest oboe out there. Sorry, old girl, but it's true - you are way harder to lift and hold for long periods of time than your Lorée, Fox, and Fossati counterparts. You have a big butt - er, bell.

I've always thought it interesting that two things that are so significant for me both have bells. Oboes, and stethoscopes. One for "speaking," the other for listening.

Anyway, those thumb hazards I mentioned before...well, it's official. I have it from one of my orthopedic surgery buddies at work. I have tendonitis (or is it tendinitis?). Probably from last week's Baroque Boot Camp.

I'm pretty sure of the exact muscle and tendon involved, too: it's no doubt my extensor carpi radialis longus. I have a very tender spot right between my thumb and my wrist where it attaches, and when I massage the muscle belly, it's like there's lactic acid squirting out into the surrounding tissues, burning with every rubbing motion.

I am feeling blue. I use my hands so much at work that I am reminded of my thumb problem almost every moment of the day. On top of that, I haven't been able to play for a week. And putting an elastic over my hair for a ponytail, so I can stuff it into an O.R. head cover, has been excruciating.

On the up-side, it's slowly getting better. Ibuprofen helps. But I may have to rebuild some music skills when I can get back to it.

"Practice" is of paramount importance to many aspects of my life. I practice medicine. I practice music. I practice (or try to practice) my faith. Practice: "to perform or work at repeatedly so as to become proficient." Important not only in the process of becoming what we want to become, but also in keeping alive what we've already learned. Without it, acquired skills fade, whether it's speaking a language or inserting an I.V.

But what about that well-known saying, "It's like riding a bike?" Is there a level of training so well-ingrained, so high, that even after a long period of disuse, a group of muscles and neurons can be recalled to a task and still "know" how to perform it well?




The marvelous thing about so-called "muscle memory" is this: it's a concrete example of the idea that experience - all experience - is learning, as far as our brains are concerned, and learning can occur so frequently and profoundly that it resculpts us physiologically - through our brain-muscle pathways, cells, neurotransmitters, even in the expression of our genes.

I imagine this applies not only to tasks but also to relationships. I am convinced that people who have been "trained" to receive abuse, over time, have catastrophically altered brain chemistries. I think in our strongest bonds we "teach" and "learn" in ways that truly transfigure our make-up - physical, mental, and spiritual - depending on what "lessons" repeatedly get transmitted.

As we shape what we practice, what we practice shapes us.

It's easy for me to see right in front of me what it is I'm teaching when I guide a paramedic student through an intubation. But what am I teaching my kids, my husband, myself? Is it all good? Sadly, I think not...I think there may sometimes be some spiritual lactic acid squirting out at those I love most...

I guess I need more mindfulness of each moment of teaching and learning. And more practice.

________________________________________________________
For a thought-provoking and entertaining article about how the brain is "wired" and how its responses to the world / "self"-expression can be visualized, click here (hat tip to Dr. Deb for that one).


Update 7/23/08: I had our highly astute and skilled hand surgeon to take a look at my wrist. It's better after a week prescription strength ibuprofen, but it's still painful to do certain things. "My snuffbox hurts," I said to him. "Let's see if you have a positive Finkelstein's," he said. He took my thumb and yanked it down in the direction of my pinky. "Yee-OOOOOOWWWW!!!" I said, practically jumping off the stool I was sitting on. "Yup. That's a 2+ Finkelstein sign. You have de Quervain's. If it doesn't get better with the Motrin you might need a steroid injection." Painful as it was, it was kind of fun to just be able to walk up to a buddy at work and get a diagnosis between cases. Just as I was about to resume my oboe regimen...

Sunday, July 6, 2008

More summer reads, including a great blog - but first, HOMAGE

First, before I get to the literary stuff - DARA TORRES, you are a hero! You were a champion before Michael Phelps was even born, and you're STILL a champion now! Gorgeous! Strong! AMAZING! Athlete, mother, inspiring woman who takes our breath away! (Kneeling and banging forehead to floor repeatedly:) We're not worthy! We're not worthy! (Photo: AP)




Ok...had to get that out of my system...


Now for some great reads:


I totally dig Edwin Leap. He's a marvelous writer. Check out his fantastic article on the virtues of work/"giving back to society" here at KevinMD, and his poignant explanation of marital symbiosis here.

Here he is facing his July 4th night watch in the emergency room. This is EXACTLY how it feels to be giddily staring a night shift in the face, to know one should be catching some zzz's beforehand in preparation, and to want to say to the hours to come, "You wanna piece-a-me, hah?" -


...These isolated nights embolden me. On nights like this, I hear my ancestors, skin and leather wearing Celts, Gauls and Saxons, waving their axes in the face of Rome’s legions. (They’re saying, ‘don’t be stupid, it didn’t work out for us!’). Nights like this, lone nights, make me want to stand outside the ER and scream to the steamy, pit-smoked night sky, ‘Do your worst, previous and future patients! I’m not afraid of you! Dr. Leap is on the wall tonight, so bring it on! Bring me your cut-off jeans, your flip-flops, your Pit Bull bites! Bring me your ball-bat injuries, roll-over car wrecks and anaphylaxis from pouring gasoline on the nest of hornets to which you’re allergic! Bring me your years of dysuria, pet rattlesnake bites, your discharges of all sort! Bring me your spider-bites, MRSA abscesses, puncture wounds and blistered, tanning-bed induced burns! Make some improvised munitions! Throw catfish at each other! Try to parachute off of the house with a bed-sheet! I’m here for nine hours, and I want to see what you can do!’

Great. Now I can’t sleep. I’m too jazzed.


Dr. Leap, you're brilliant!


And because the summer reading is going surprisingly well, I'm tempted by a few more books (much as I love blog-browsing and magazine-perusing):



Uwem Akpan's short story collection Say You're One of Them. Akpan, a Nigerian Jesuit, according to Pub Weekly, "transports the reader into gritty scenes of chaos and fear in his rich debut collection of five long stories set in war-torn Africa...Akpan's prose is beautiful and his stories are insightful and revealing, made even more harrowing because all the horror—and there is much—is seen through the eyes of children." I have heard nothing but great things about this writer.




A Step from Death by Larry Woiwode (there seems to be an inordinate amount of death-mention among my summer reading titles!)









On Chesil Beach by Ian McEwan (though it sounds emotionally painful, as one might expect)






Divisadero by Michael Ondaatje, given an exquisite review on Amazon.com by another genius writer, Jhumpa Lahiri.








and The Traveling Death and Resurrection Show by Ariel Gore, which lured me after I went to Eggbeater and read Shuna's warm recommendation of Gore's book How to Become a Famous Writer Before You're Dead, which I think I just have to read too.


If anyone has had experience with these, let me know what you thought!

Friday, July 4, 2008

Freedom


Every July 4th I watch my family playing in the sand or eating corn on the cob and I start thinking about what freedom is.


Freedom.


Ability to choose.

No fears.

No limits.

No interference.

No constraints.

No burdens.

No hunger.

Peace with self.

Peace with others.

No need to rely on prejudice or violence.

Being who you want to be.

Saying what you want to say.

Thinking how you want to think.

Going where you want to go when you want to go.

Respect all around.


Freedom.
Worth fighting for. Worth helping each other attain.
Impossible without justice.
Without reverence for human life and rights.
Without peace.
Without thoughtful stewardship of our life on this troubled, fearful earth.

Freedom.
What we're here to learn.


In the U.S. we celebrate freedom on this day and enjoy most of its components every day.


But imagine for a moment being
...a woman under Taliban rule in Afghanistan
...a journalist in China
...an immigrant in South Africa
...a member of the "wrong" side in Zimbabwe
...a hostage in Colombia
...a resident of Iraq
...a street child in the Philippines
...a refugee in Darfur
...a quadriplegic in an ICU
...a wrongfully imprisoned person
...a teenage girl forced to marry against your will
...an elderly man whose friends have all passed away and who depends on the help others just to go about his daily activities
...a sex slave in any number of countries around the world
...a tortured prisoner of war
...an abused wife who fears for her own life
...a man struggling to provide food and shelter for his family
...a family forced to flee their home because the resources around it have been irrevocably altered or destroyed


Is it possible for us all to be truly free?

I don't know. But I do know I haven't done enough to contribute to the world's freedom, and that I too often take the freedoms I have for granted.



_______________________________________________________

A follow-up thought / question that's been bugging me since I jotted this post down: whether for individuals or for nations...is freedom possible without wealth?

Thursday, July 3, 2008

Nulla Per Orem (or, Anesthesia 1, Theology 0?)


Recently, in the holding area...

Preop Nurse (to cute little nun in full habit from the order of Penitents of the Blessed Virgin Mary*): Sister, did you have anything to eat or drink this morning?

Sister Mary Immaculate: No, dear; Sister Rita even put a post-it on our kitchen fridge so I'd remember.

Preop Nurse: That's good, Sister. (Starts applying blood pressure cuff to take vital signs.)

Sister Mary Immaculate: I was just thinking during Mass how easy it is to slip into a routine and forget these things, isn't it?

Preop Nurse: I know it. It's just like...wait, did you say you had time to go to Mass?

Sister Mary Immaculate: Of course, dear. We go every morning at six.

Preop Nurse: Did you receive communion?

Sister Mary Immaculate: Oh yes, I always do.

Preop Nurse: By any chance was it just wine, or was it bread and wine both?

Sister Mary Immaculate: Oh, no dear, it was just the host. Why?

Preop Nurse: Because I think we have to let your anesthesiologist know. (Gets on the phone.) Dr. T? Um...your next patient received communion at Mass this morning...does that count?

My initial reaction, from a phone in the operating room: Huh? (Then, recovering my bearings:) Sure. It counts. (Chin-stroking moment ensues...)


Usually I don't hesitate to delay a case in order to adhere fairly strictly to widely used NPO, or nil per os / nulla per orem, practice guidelines for fasting prior to a surgical procedure. I require the following time intervals before administering a general anesthetic to a patient:

after ingestion of clear liquids (water, apple juice, black coffee): a minimum of 2 hours
human breast milk for infants: 4 hours
light solids (e.g. toast & tea) and non-human milk/formula: 6 hours
heavy meal / fried foods: >6 hours, 8 if possible.

The theory behind preoperative fasting is that stuff taken by mouth - even the act of chewing a stick of gum - can increase acid production and volume of contents in the stomach. This then poses an increased risk of aspiration of dangerous material into the lungs under anesthesia. If the surgical procedure is urgent and must proceed regardless of a patient's food intake status, there are a couple of measures we can take to reduce gastric acidity, facilitate gastric emptying, and mechanically reduce the risk of pulmonary aspiration.

I made my decision in Sister Mary Immaculate's case by taking into account the nature of her intake - a small, quick-to-dissolve, paper-thin wafer - and the nature of her surgical procedure, which would not require a general anesthetic.

I was talking to my boss and colleague, Maddog, later about it, and said, as an aside, "Theologically speaking, of course, it wasn't bread any more."

"True..." he said, pausing to think about it for a moment. "But technically it was heavier than bread, right? Theologically speaking? I don't know - I'm a Protestant."

"Oh yeah...that's true...Well, I guess it was good that I gave her Bicitra, then."

Bicitra is an antacid. A nasty, sour-tasting, highly effective antacid that tastes like licorice, sea water, and a sour margarita all mixed together. Yuck.

His eyes widened with feigned shock: "You washed the Body of Christ down with Bicitra?! Hey, I think we're supposed to have lightning later...Maybe you should stay indoors!"

I had to laugh. The surgeon chimed in as he passed us in the corridor, jokingly coming to my "defense," "Just think of the complications we would have risked, though, Maddog, if her patient HADN'T gone to Mass and received communion."

Banter aside, it wasn't the mystical issues that gave me pause when I was first asked how I wanted to proceed. It was the culinary issues. Is a communion wafer considered a solid rather than a liquid, even though it practically melts in your mouth? If so, is it a light solid, and if so, would it have required me to impose a 6-hour wait had Sister Mary Immaculate's procedure required a general anesthetic? Or could I proceed without waiting but with the usual precautions we take for a "full stomach?" And would those HAVE to include a rapid-sequence intubation? How much increase in gastric volume and acidity could a eucharistic host possibly induce? Certainly less than chewing a wad of gum, I would guess. But that's just it - I'd be guessing. Guidelines aren't answers or rules set in stone. They're guidelines. There's research to back some of the concepts up - there's even a paper on the chewing gum issue - but not detailed research on every possible scenario.

In the end we just have to pool all our facts and experience together and make the safest judgment we can.


***

I often think about issues of faith versus science. Never did I think such esoteric details of religion, however, would come up like this, specifically, during my day-to-day practice of medicine! I guess it's fitting that I be reflecting on this particular experience today, the Feast of St. Thomas the Apostle, the quintessential mystical-belief-versus-empirical-reality guy, if ever there was one. I've always felt a kinship with "Doubting Thomas."

I love the intimacy with which Caravaggio paints the moment during which Thomas insists on examining, probing, Christ's wound - much as a modern surgeon would do a blunt dissection of fascial planes in the body as s/he tries to gain access to a person's inmost reaches. Thomas will not believe without tangible proof. Without a study.

Christ's response? Feel free. Go ahead, study, examine, learn, don't be afraid to "get your hands dirty" doing the work of seeking truth and understanding.

The result: Thomas got the biggest "Aha!" moment of his life. Recognition. Clarity. Epiphany. He was put in touch with the sacred, literally, and saw a truth bigger than himself, something his beloved teacher wanted him to understand.

I can't say that my personal truths have ever arrived so dramatically, either in faith or in scientific understanding, and I may be stuck in the "blunt dissection" phase indefinitely, but I cherish this story because for us spiritual-special-needs students out there, it's ultimately full of hope - hope that for every kind of learner, moments of doubt and confusion needn't preclude the possibility of real insight and transformation; hope in the patience of teachers who try to guide us; and hope that the way we go through the process ultimately matters more than our "success."



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*(name changed)

Tuesday, July 1, 2008

Tales from Saint Boonie's: One of the Gang (a fictitious true story)


"You don't deserve to live."

There's rage on his face. Rage and outrage. How dare you diss me, it says. Me. ME! He pulls out a handgun without a whisper of doubt or hesitation. Not a whiff. I will not be loathed. The thought comes not as a bunch of words - he has little use for those - but rather as an overpowering urge, strong and sure as his own heartbeat. And with it comes the dark satisfaction of his own hatred - the certainty of it, which lends steadiness to his hand - and a certain smug pleasure in his own entitlement.

He shoots the other teenager twice, then snickers as the boy's body falls against the steering wheel, the deep brown skin of his neck now staining purple with a wash of blood.

You don't deserve to live. Those words hadn't crossed his mind, exactly, when he'd shot at other people. But he knew well what feeling them felt like - the weighty power and intoxicating sense of justice they gave him, almost palpable across his chest with every breath he took, like armor, a breastplate to be respected. No one had the right to diss him. No one. And no one would dare. He would make sure of that.

***

The radio in the emergency department at St. Boonie's crackles. Personnel are already scurrying to get ready to receive an ambulance en route with a seventeen-year-old shooting victim. Fragments of conversation between the E.D. nurse and the paramedic on the radio are audible above the hubbub. GSW to the chest...Copy that...What's your ETA?...Five minutes...Thank you, St. B's...

As doctors and nurses swarm around the patient to try to attend to his injuries, a boy of about fourteen bursts into the emergency department demanding to be allowed near the patient. He's screaming at the top of his lungs that he's going to finish the job. The patient had shot his brother while his brother had been sitting in a parked car. The boy is using foul language and gesturing violently with one hand; the other he keeps stuffed into the pocket of his jacket. He threatens the staff and all who try to come near him.

"Scumbag," mutters a woman in scrubs, safely out of earshot. "Worthless animal scumbag."

***

The storm passes without further harm done. Conversation in the break room is tense. Bitter. Like the dregs at the bottom of the coffee pot that's been sitting un-refilled all day.

"I think those pieces of sh__ should just curl up and die. They wanna kill each other? I say let 'em."

"Oh, you're no fun - then they'd have to spend your taxes on something that might actually HELP society."

"Those people are beyond useless, man. They're a waste of space and oxygen. No, lemme take that back. A lazy lump on the couch is a waste of space and oxygen. THOSE people are WORSE."

"Yeah - they exist just to MAKE life miserable. Not better, not neutral, MISERABLE. Worthless, worthless, worthless."

The undercurrent is clear. There's resentment there - lots of it. Even hate. And it isn't hard to understand. Why wouldn't anyone feel inexpressibly frustrated? Angry? Not just angry - enraged. Enraged and outraged. Not hard to understand at all.

We've all felt that way at one time or another, especially in health care. That our efforts are a futile waste of energy. That our patients don't even deserve the help we're working so hard to give, so why on earth bother?

We're entitled to those feelings. Aren't we?

We've all felt the feeling, if not thought the thought.

You don't deserve to live.

In a way you have to wonder how different we really are.

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The real-life St. Boonie's hospitals, though situated in "the boonies," do on occasion have to deal with local gang violence. Although at one of the hospitals there was a time when members of the staff were indeed threatened by an angry youth, the above scenario is essentially fabricated - an exploration of the ambivalence and occasional hopelessness we face and experience in our day-to-day work. This post is fiction, but the issues it's trying to grapple with/meditate on are very much non-fiction. I aspire NOT to be so bitter as to resent the patients whose life choices make me cringe, and intellectually I know we are called to rise above such judgment, but I'll be the first to admit that I don't always have an easy time practicing, or even sometimes continuing to believe in, some of my own ideals. I think I may not be alone in this, though...And I also think that on the whole, we who choose to take care of others for a living try our best to really stick to our duty and be of real help and service, despite some of our inner struggles.