Just Another Night

Someone's coding in the ICU.

The patient's been coding off and on all day.

I strongly believe that in most situations we should get to know our patients as best we can. Faces. Names. Fears. Hopes.

On occasions like these, though, we often can't know. We show up because a disembodied voice over the loudspeaker announces the code or calls for "rapid response team, stat." We've never seen the patient before. We don't know his or her name.

Nor, I would argue, should we be expected to take the same approach we would for other clinical care situations. A code is not the time or place to be holistic. A code is about numbers and lists. Blood pressure is 50 over 30. Heart rate dropping to 20, 10, zero. Patient with a history of cardiac disease, asthma, and gangrene or sepsis or bowel obstruction or trauma. The patient does become, for a tense, crucial moment, an amalgam of data points.

And we NEED those data. I would argue that people like me - who do feel pain when others suffer, and cry over individuals and their stories, and long to hold people's hands and offer comfort - need those numbers to occupy center stage during a code and obscure for a moment the identity of the dying person, so we can concentrate on the resuscitation. Names, faces, memories, personal connections - these can be a dangerous distraction.

I watch the monitors while the chest compressions are being performed and the epi and atropine are being injected. I am looking for those numbers to change, willing them to go higher. They are our guide and our visible goal. When someone is dying in front of our eyes, the hard realities of math and science keep us grounded and focused; they're both the bad news and the ally.

A code is the only time I allow myself such calculated distance when taking care of patients. I need that mental space. It's important.

After the code team gets the patient back, the other elements of taking care of the patient return in a rush of feeling. Relief. Concern. Sympathy. Even fear, after the fact.

Walking toward the call room I see the walls of the main entrance from a large window in the corridor, feel the weight of the hospital around me. Outside, traffic is slow; the town is winding down. What must we look like to passersby? Just a pile of bricks and stone, housing the sick? But in here lives are changing. In one window there might be a nurse pounding on someone's chest, trying to defy death. In another, a mother weeping tears of joy over a baby just minutes old. In yet another, an anesthesiologist looking out at the world, missing her family, and thinking of a patient who's hanging on to life by a thread. An ordinary night at the hospital, in other words; just another night.

Diagnosis: Writer's Itch

I've just returned from a wonderful medical writing conference.  Intense and exhausting, but informative and inspiring too!

I met some amazing people there. I was privileged to be in a small workshop among talented writers who are also incredibly dedicated clinicians.  There's nothing like finding like minds who share your passion for something (and encourage your growth in that endeavor).  It's so much easier, moreover, to learn from others in an atmosphere of respect rather than an atmosphere of contempt.  We've agreed to continue trying to support each other's writing through a virtual writers' group.

I even got up the courage (despite my intense aversion to public speaking) to pitch an idea for a book in front of a ballroom full of people, mostly other doctors.  I figured if I could do a mock oral exam in public, I should be able to survive a 90-second pitch. It went surprisingly well (despite the fact that I actually signed up for the "pitch" activity without having originally planned to do so).

Writing is my true love, but I didn't have the courage when I was younger to try and pay the bills with it, so I applied to medical school.  Now that I've immersed myself in a conference that has allowed me to blend my love of writing with my love of medicine, I feel re-energized.  I want not only to keep writing but also to write more.  That's to be expected, of course, with any good retreat or conference; there's an initial surge of fervor in the afterglow.  Let's see if I can keep the pilot lit.

***

Here's a passage from Michael Chabon's Maps and Legends that recently took my breath away:

"I could adduce Kafka's formula: 'a book must be an ice-axe to break the seas frozen inside our soul.'  I could go down to the cafe at a local mega-bookstore and take some wise words of Abelard or Koestler about the power of literature off a mug. But in the end - and here's my point - it would still all boil down to entertainment, and its suave henchman, pleasure. Because when the axe bites the ice, you feel an answering throb of delight all the way from your hands to your shoulders, and the blade tolls like a bell for miles." 

At first I wanted to say, Wait!  Entertainment and pleasure aren't everything!  What about insight?  Then I realized even insight is a reward once-removed:  insight brings exhilaration, which is, in the end, just another form of pleasure - which the language in Chabon's sentences definitely inspired.

Oh, to write like Chabon, or McEwan, or Kingsolver.  At the conference an idea was brought up about mastery: the idea that 10,000 hours of practice are required before a person can claim expertise at something.  Why do I have the feeling that good writing is different, somehow - a little more precarious?  I do think writing more makes you write better, but not necessarily with greater ease, if Hemingway's statement about sitting at a typewriter and bleeding is any indication! I guess that's what keeps people who love to write both challenged and inspired.  The quest for that "truest sentence" never really ends.

Sick

I am sick.

Yesterday at work my eyes were so swollen and my cough so toxic-sounding that even the surgeons were sympathetic. My head hurt. My throat hurt. My joints ached. My nasal passages were so congested I had to breathe through my mouth all day. Sick, sick, sick.

What on earth was I doing at work?

The answer is simple. Doctors don't call in sick. Or, I should say, doctor rarely, rarely call in sick.

We are held to a very high (unspoken) standard of dedication to duty. We are expected to put the comfort of others before our own, our patients' needs before ourselves. If there's work to be done, we are simply expected to DO IT. No right to "go on break" at regular intervals, like some other health care professionals. No lunch if it's too busy. No sleep if there are cases to do at night. And yes, no sick days.

The week after I broke my arm during internship I was back at work, performing my duties with the other arm. No extra time off. No strong painkillers allowed. My boss once hobbled around with a walker after a foot fracture. I've put IVs into my colleagues at work so they could keep functioning. Patient care first, at almost all costs.

There's a stigma attached to calling in sick. You'd better be practically DYING if you do. Even if half your guts are on the floor, you still get a version of the snippy, skeptical, "Oh, OK, MAYBE that's true, so I GUESS we can find someone to cover for you" at many places - by "vibe" if not by verbal utterance.

There are other unspoken judgments that accompany sick calls. That's WEAK, Doctor. Can't you suck it up? Are you as dedicated to your patients as you pretend to be? And now you have to tax your colleagues to do YOUR work FOR you? Weak, weak, WEAK.

I am counting my blessings: I am on call tonight, which means at my current place of work that I don't have to be at work until 3 p.m. So I slept last night and slept in this morning and will rest in bed all day until I have to report for duty. My mother-in-law graciously came over to get my kids off to school.

"Can't you call in sick?" She asked.

"No," I replied, perhaps a little resentfully, blowing my nose.

"That's crazy. You look terrible. Won't your patients get sick too?"

"I can avoid breathing on them and touching them ungloved. One advantage of my particular specialty."

"It's still crazy. You're sick. You should be in bed resting."

"But I'm on CALL. The only thing worse than calling in sick for a regular work day is making someone else do your CALL for you. Doctors don't call in sick, Maman. It's just not DONE. There are patients to take care of, and with two docs out on vacation, we're a little overstretched as it is. "

Doctors don't call in sick because they feel they can't. It's not culturally acceptable - and that's a culture code that's very hard to break, or to change.

But maybe with enough orange juice, Tylenol, and a squirt of phenylephrine into my nasal passages, I'll be better by this afternoon. Fingers crossed.

The "Success" That Means the Most To Me

I put up a post today at Mothers in Medicine that explains how I really feel about my "accomplishments."  If you happen to wander over there don't miss the recent "Topic Day" featuring posts on the residency Match, as well as other thought-provoking pieces.

Grammar Pet Peeves

"There is a satisfactory boniness about grammar which the flesh of sheer vocabulary requires before it can become a vertebrate and walk the earth." -Anthony Burgess

I think I know why I watch T.V. so infrequently these days.

I abhor bad grammar.

The only thing more irritating to me than detecting faulty grammar in someone else's speech or writing is lapsing into grammatical error myself. Grrrrrrr.

I know I've taken some grammatical liberties in the informal writing on this blog. I write in incomplete sentences, start sentences with conjunctions, and cut a bunch of grammatical corners here and there, I'm sure. I can do that, but a journalist for a major periodical or on CNN shouldn't, nor should a head of state, teacher, or any person occupying some kind of leadership role and publicly exercising it.

Almost every time I watch anything on T.V. I find myself wanting to hurl a stuffed animal at the screen and ask, "Did you NOT pay ATTENTION in SCHOOL?"

"This is the sort of bloody nonsense up with which I will not put." -Winston Churchill.

Here are my top ten language pet peeves:

1. People saying "between him and I" or "between you and I" instead of "between him/you and me." UGH. Go get a copy of Warriner's English Grammar and Composition, please, which you should have studied in middle school, and learn to speak your native language correctly - especially if you have a reputation for eloquence, out-of-this-world oratory skills, and great writing (ahem, Mr. President).

2. "Different than." I know this is commonplace and universally accepted, but it grates on my nerves. Something is bigger or smaller than something else, prettier or uglier, older or younger; but something differs FROM something else. Than is used for adjectives delineating quantity, size, or degree; but this is different from that.

3. Failure to agree subject and verb, especially in a neither/nor construction.

WRONG:

• "Neither Maria nor Carlos are here."
  
• "Each of the girls sing well."
  
• "Every actor playing these roles are expected to be different."

YUCK. Just corrected my latest mothers-in-medicine post for this very thing.  Shame!

4. Use of "would have" instead of "had," as in, "I wish he would've taken the trash out last night." UUUUUGGHHHH! Figure out what you want to say - "I wish he HAD taken the trash out last night" or "I wish he WOULD take the trash out some time before the four horsemen of the apocalypse appear."

5. Hearing people ask a patient to "lay down." Lay down what? Their lives? They don't need to do that. They do, however, need to LIE down.

6. Inappropriate possessives and other misplaced apostrophes. It's such a simple matter to see that "it is" can be contracted to it's, and that a dog scratching its hind leg is NOT scratching "it is" hind leg. My attending your birthday party when you're fifty also seems straightforward. I have to wonder, though - is the name of a nearby road "Soldier's Field" or "Soldiers' Field?" I've seen it spelled both ways. Does it belong to the generic soldier who represents all soldiers, or to a group of soldiers? (There's a similar problem with Professors Row at Tufts University.)

7. "Dangling" participles and clauses. I was just watching the opening episode of Season 3 of The Tudors, and I had to cringe when the character of Thomas Cromwell said, "Sir Edward. As the brother of His Majesty's beloved wife, Jane, it is His Majesty's pleasure today to create you Viscount Beecham of Hash in Somerset." Somebody please send me a diagram of THAT sentence. Oh no, wait - you CAN'T, because the anaphor and antecedent don't relate.

8. Misused/incorrect words. Irregardless is not a word. We don't loose our keys or turn prisoners lose; and I have one or two more things to add: we go to school, and we should have learned our grammar there, too. Don't feel badly if you didn't, though - just feel bad. We can all make fewer mistakes in our speech and writing if we spend less time ignoring them and more energy correcting them.

(Note: I am also irritated by the "evolution" of language to accommodate wide-spread incorrect usage that has become universally accepted. Such is the case with the word nauseous. When I was growing up I learned that nauseous doesn't mean "nauseated" but rather "nauseating" - so when people say anesthesia makes them nauseous, they're really saying it makes them make other people sick; but now the dictionaries declare that because the use of the word nauseous to mean "nauseated" is essentially universal, it's now the acceptable correct use of the word. C'est la vie. Grammatici certant et adhuc sub iudice lis est.)

9. Failure to include " also" in a not only/but also construction.

10. People saying "revert back" insead of "revert" and "The thing is, is that" to begin a sentence.

Runner-up: failure to make appropriate use of the subjunctive.

Perhaps some might call me a grammar snob or language elitist. So be it. I think we should CARE how we articulate our thoughts and use the tremendous gift of written and spoken language. I believe correct use of the English language promotes clarity and conveys the intelligence that has allowed its use at all. Sharing ideas is one of the most important things we can do; we should share them well.

What's in a Name

I wonder if the way people feel about their names has some influence over the way they feel about themselves in general?  

My daughter, who's a pretty confident, exuberant kid, wrote an essay not too long ago describing her name as something that "inspires" her.  We were so happy about that!  I think it can be hit or miss, though - parents pick names they themselves love for their children, but often the kids end up not really liking those names.  

When I put in epidurals for labor or give spinal anesthesia for C-sections, I always ask, just out of friendly curiosity, what names the parents have considered.  Sometimes they prefer to keep them private, but more often than not, they're happy to share.  

Someone I know was recently going through some papers and suddenly let out a noise of surprise.  "This person's name is Anesthesia!"

"Anastasia?"  I asked, thinking I'd misunderstood.

"No, Anesthesia - you know, like what you do for a living."

"That's her name?  Is it spelled differently?

"Nope.  See for yourself.  An-es-thesi-a."

This got me thinking about medical words not to use as names for people.

I don't mind the name Carina pronounced ca-ree-na, but the medical word carina, in English often pronounced car-eye-na, means the bifurcation of the trachea, which might not appeal to some people.

Then there's...

Candida - yeast infection

Coryza - inflammation of the nasal mucous membranes (in other words, a head cold)

Verruca - wart

Milia - the tiny little whiteheads newborn babies get on their noses (which clear up on their own)

Morpholino - a synthetic molecule that blocks other molecules from binding to a particular sequence of nucleic acids

and, my "favorite" among the medical-words-to-avoid-as-names,

Melena - black, tarry stool

...though I can't really imagine anyone choosing any of the above names for their children, except perhaps the one most to be avoided, Melena.  You never know, though - with unusual celebrity baby names like Moon Unit, Bronx Mowgli, Sage Moonblood, and Satchel, perhaps it's just a matter of time before we see a Morpholino.

For more medical-name fun, click here for a page on medical terms that would make good names for rock bands.  I could amuse myself indefinitely trying to think of a few more!

Oboe in the O.R.

Last night's call was QUI-ET!  Nice to have respite like that after last Saturday's call, which was non-stop activity from 8 a.m. to 4 a.m.

So I sat in the anesthesia office surrounded by darkened operating rooms, recovery room, and corridors and played a little Rimsy-Korsakov.  I love the oboe part from the second suite in Scheherazade.

This morning Kyoko and I worked on that, plus some Bizet, and the Corelli-Barbirolli.   She really wants me to move on to the Cimarosa, but I don't think I can do it. How can she have that much faith in me after my sluggish tonguing this morning?  I watch these pre-pubescent oboists on Youtube toss it off seemingly effortlessly, and I think:  I am too old to get my finger muscles to learn that kind of accuracy and agility.  What was I thinking?!

But I'm still enjoying the instrument, and making some progress, and indulging in musical "treats" for myself at home (Zipoli adagio, passages from Les Miserables, stuff we sing in church; maybe I'll throw some Borodin in now), so I go on, glad to be allowed this chance to live with music for its own sake, without pressure.

The Untold Stories

When I was a little girl one of my favorite books was the short, 1942 novel Snow Treasure by Marie McSwigan - still in print after over 60 years - which tells the story of how during the German occupation in 1940, some Norwegian children helped smuggle a town's gold stores to

 safety by hiding the bullion in their sleds and sledding past the Nazis.  

Who wouldn't love a story in which some kids stick it to the Nazis?

It's supposed to be based on true events, but of course some might say we can never really be sure.  In any case, it's a thrilling, well-written book.

I happened to have a Norwegian patient recently, and as I was setting up a procedure for him I began to make small talk about this book.

"You know, when I was a child one of my favorite books was about Norway.  About some Norwegian children that smuggled gold in their sleds right past the Nazis."

The soft-spoken man gave a smile.  There was something in it that made me pause what I was doing and look at him for a second.

"My uncle had a boat.  He helped transport some of that gold to the Shetlands, and to Orkney, on his boat so the Germans wouldn't find it."

I can't explain why, but that moment made my day.  That, and getting his arterial line in on the first shot.

***

We're told in med school that taking a good history is crucial to arriving at an accurate diagnosis and effective treatment plan.  But I love the stories that sometimes emerge after those clinical details get skimmed off the top and put to their proper use.  The medical history helps us provide good care; the stories of a person, though can help us catch a glimpse of what that care might mean.  Stories both express and define our humanity; they help us learn who we are, ask (and answer) why, and make connections.  I've always believed story is everything.

It can be easy to forget that behind the alphabet soup of medical conditions listed on patients' histories - CAD, HTN, NIDDM, CVA, PVD, COPD, AAA, CHF, CRF, PUD, GERD - there are people who are so much more than their lists reveal.  It's easier to just get the work done - more efficient, too, supposedly, and more logical.  But there's something worthwhile about getting to the real stories.  Why the almost-hundred-year-old woman with so-loud-you-can-hear-it-across-the-room aortic stenosis refuses to take her earrings off for surgery.  Which patient has gone home from his job every day feeling the most content (so far it's the brick-layer from O.R. 9).  How the quiet Asian couple up on labor-and-delivery met.  Of all tattoos, why that tattoo.

People are more like poems than textbooks.  I hope I keep getting better at listening and understanding, at picking up on people's real, human side even as I'm trying to piece together the clues to their illnesses.  I've never regretted learning more about the story behind the history.  Everyone has one.  I don't ever want to forget that.

***

Speaking of arterial lines...

 Check out posts with an anatomical theme and some wonderful illustrations from Gray's Anatomy at Oystein Horgmo's FANTASTIC edition of SurgeXperiences, now up at his blog The Sterile Eye.  A great blog, and a great blog carnival!

Dropped into the Ether Acre

Here's proof that our experiences color the way we read what we read. (Text isn't everything! Reading, writing, and being are dynamic and interwoven!)

Emily Dickinson wrote this in 1863. My last call - fifteen hours in the O.R., followed by epidural and C-section joy on O.B. till 4 in the morning - definitely influenced the images that came into my mind as I read it.

Dropped into the Ether Acre -

Wearing the Sod Gown -

Bonnet of Everlasting Laces -

Brooch-frozen on -

Horses of Blonde-and Coach of Silver -

Baggage a strapped Pearl -

Journey of Down-and Whip of Diamond -

Riding to meet the Earl -

***

And one last mention of ether in poetry before I go to bed:

"Let us go then, you and I,

When the evening is spread out against the sky

Like a patient etherized upon a table;"

-T.S. Eliot, from The Love Song of J. Alfred Prufrock

Epidural Elegance: A Bit About Anatomy and Neuraxial Anesthesia

In medical school I wrote a poem in honor of my cadaver from anatomy class. I wish there were some way to tell her family that even now, years after her passing, her generous gift continues to be part of my daily life as a physician.

Anesthesiologists use a fair amount of anatomy. We have to know the larynx well, obviously - structure, nerve supply, possible distortions, etc. We have to know too, for example, about the interscalene muscles and the brachial plexus; the division of the sciatic nerve into tibial and common peroneal; where to apply P6 acupressure on the wrist to combat nausea and vomiting; where all the dermatomes are; how to tell the right upper lobe bronchus from the bronchus intermedius on internal examination of the lungs; how to place large IV lines into the great vessels of the thorax; and how to adjust needle angle and position when placing lumbar or thoracic epidurals.

I get this question a lot: "What's the difference between a spinal and and an epidural?"

First, location, location, location.

A spinal anesthetic is placed right into the fluid-filled spinal canal (A). An epidural is placed into the area just outside the spinal canal, in a circumferential space pocket surrounding it (B).

Secondly, technique.

A spinal is simply a shot. The skin on the back is numbed with local anesthetic; an introducer is inserted sometimes to help guide the spinal needle through; and the super-thin spinal needle is inserted through the introducer into the spinal canal (A) and used to inject a small dose of anesthetic, often with a little narcotic, to achieve the desired effect. Then the needle and introducer are removed.

An epidural needle is a much larger, 9-centimeter 17-gauge instrument that is inserted initially into the ligament between vertebral bones. An air- or saline-filled syringe is then attached to the end of the epidural needle, and the epidural needle is advanced while gentle, intermittent pressure is applied to the syringe to see if there is any ability to compress its contents. This little "give" or moment of compression should not occur until the needle traverses the ligament and enters the epidural space (B). Once this happens, the syringe is detached from the needle and a slender catheter is threaded through the epidural needle, to be used for injection of local anesthetic into the epidural space. The epidural needle is removed and backed out over the catheter.

Finally, timing. A single-shot spinal has a time limit, depending on the type of local anesthetic used. Its effects - pain relief, sensory block, lower blood pressure - appear more abruptly and with greater intensity than those of an epidural, but it will eventually run out, whereas an epidural can be extended for hours or even days. Epidurals are often used to administer post-operative pain relief after abdominal, thoracic, or orthopedic surgery.

Epidurals are fun to do. Lumbar epidurals, such as those done for women in labor, are somewhat different from thoracic epidurals. The vertebrae themselves are anatomically distinct, with the spinous processes on thoracic vertebrae (first illustration below) jutting out at a much steeper downward angle than those on the lumbar vertebrae (second illustration). Thoracic epidurals are often approached from off-center because of this steep angle; the epidural needle can use the bone as a guide to find a wide gap between the vertebrae that leads toward the epidural space. For lumbar epidurals it's usually no problem to insert the needle in the midline between the bony prominences. For some great answers to women's questions about epidurals for labor, see this page at Storknet.

When epidural catheters are in the right place, patients' pain can turn from being a scary, hard-to-control enemy to something much more manageable. We love 'em.

***

Nowadays technology is reducing the necessity for "blindly" done procedures. Have a tough airway? Use a fiberoptic scope or video laryngoscope. Can't find the vein for your central line, or the nerve sheath for your peripheral block? Roll out the ultrasound machine. Maybe soon there will be hand-held fluoroscopy for those tough-to-place thoracic epidurals.

I'm glad my training occurred on the cusp of these new developments. We learned to use external landmarks and to train our sense of touch to do most procedures, but we got enough exposure to the new devices to be able to integrate them into our practice. I don't want to lose the ability to manage a tough airway safely without the convenience of direct visualization, or to adjust an epidural needle based on my analysis of the contact point with certain tissues or portions of the vertebrae, or try an alternate, off-midline approach for a spinal in a patient with scoliosis. I want my familiarity with human anatomy to be like a current flowing through my movements and skills and not dependent on the ability to see what I am aiming for.

That said, I have to admit that being able to watch the human body at work from within never ceases to amaze me. If you're interested in seeing a human heart beating in the chest (time index 1:30) while undergoing surgery in an AWAKE patient, click here or see the video below, which describes the bold, innovative use of thoracic epidurals in India in order to allow patients to undergo cardiac surgery without a general anesthetic. Creative, daring, and impressive.

Literature Meets the DSM-IV

We saw half of Lowell House Opera Society's production of Otello last night, in which our daughter sang in the children's chorus, then brought her home at intermission.

That's ok. I prefer Puccini to Verdi anyway, and I had no desire to watch Otello strangle Desdemona. I always find intensely frustrating the problems that arise in books, movies, operas, and plays that could be so easily avoided by simple communication among the characters. Why didn't Emilia go to Desdemona right away after Iago forced her to hand over the handkerchief? Why didn't Otello just confront Desdemona directly about Cassio, instead of getting himself all worked up over hearsay? But I suppose a lot of relationship problems stem from completely unnecessary misunderstandings.

Sometimes I enjoy applying diagnostic criteria I learned in medical school to literary figures. Shakespeare's work is replete with DSM-IV disorders. Poor Desdemona was the innocent victim of Iago's Antisocial Personality Disorder working on Othello's Paranoid Personality Disorder. Hamlet was a veritable poster-boy for major depression.

I found my psychiatry rotation during medical school fascinating. It did shake my faith, though: things that we, in common parlance, often call "character flaws" or even "moral failings" are attributed in medicine to brain chemistry and the interplay of environmental influences, gene expression, and neurologic development - a highly deterministic view that many argue is largely supported by research and observation. If no one can really help their behavior (although some people feel they can), is anyone ultimately responsible, or despicable, or laudable, for it? Perhaps the human brain only seems to have free will...("Seems, Madam! Nay, it is; I know not 'seems.' ...I have that within which passeth show...")

I've just reread a book I consider one of the greatest achievements in contemporary fiction: Mark Haddon's The Curious Incident of the Dog in the Night-time, which is narrated by a gifted but highly challenged teenager with Asperger syndrome. Like George Saunders entering into his character Morse's intractable anxiety in the short story "The Falls" and Robert Morgan living through a patient's dementia in "Night Thoughts," Haddon is able to inhabit the mind of his protagonist, Christopher, and give the reader an intimate, vivid look into his perceptions of the world. It's a truly brilliant piece of work.

What makes these stories, and any story, so good is the way they bring about fresh recognition of some part of ourselves as readers, even if the characters are nothing like us. "I'm totally like that sometimes!" we think, or, "I SO get how that could happen." We diagnose our our own humanity, like med students leafing through the DSM-IV, exclaiming, "That's me...and so is that!" and in the process, come to some better understanding of mysteries our inadequate words can barely express.

So we should keep reading stories, and watching them, and listening to them, and writing them. We should do it for our patients, our families, ourselves. Maybe someday, then, we'll actually be able to say, "Oh yes! Now I understand." At least for a moment, until the next mystery unfolds.

Acupuncture Chronicles II: Waking the Dead

One of the reasons I enjoy the conference I'm currently attending is that in recent years there's always been at least one lecture or workshop on the use of acupuncture in medicine.  I'm reminded today of a story from my days at St. Boonie's.

This happened over a year ago to my colleague, Xiao Lin, who is both a medical doctor and a practitioner of acupuncture.

She was called stat to the ICU to reintubate a relatively young, obese smoker with community-acquired pneumonia.  During the intubation the patient's heart rate slowed to the point of ventricular fibrillation and arrest.  Xiao Lin immediately began resuscitation efforts, directing the team around her to administer CPR, epi, atropine, defibrillation.  After several interventions the patient was still in v-fib. With the airway secure and a respiratory therapist ventilating the patient, Xiao Lin decided to try an emergency acupressure point as a last resort, believing that the possible benefit of attempting the maneuver outweighed any possible risk of harm.

She forcefully pressed the blunt tip of a 5-cc syringe into the KI 1 (Yong Quan) point on sole the patient's left foot.*

Within fifteen seconds, the EKG changed visibly from v-fib into v-tach, then almost immediately into a sinus rhythm.

"Someone check for a carotid pulse," Xiao Lin ordered.  She pressed the syringe into KI 1 on the other foot.

Sinus rhythm held.  Blood pressure was normal.  Oxygen saturation was 100%.  The patient never required pressors after the resuscitation and was discharged to rehab eleven days later.

I found this story astounding on many levels.  I don't know that I would have had the guts to try such a maneuver, simple and harmless as it was.  It's so much easier to persist in accepted Western protocols even though they've been FUTILE for several minutes.  Xiao Lin never departed from ACLS standards, but she dared to try an adjunct from another field that's been around since the Stone Age - 5000 years - but for which the stodgy, self-important traditionalists of Anglo-European medical science have had much disdain and distrust (though this is beginning to change, particularly in Europe, and actually in the U.S. as well, though perhaps more slowly).  

What happened that day in the ICU - did emergency acupressure work as part of the resuscitation, or was the event an example of the Lazarus phenomenon, as this anesthesiologist once experienced in a surgical ICU?  I helped Xiao Lin write a poster presentation of this case for an American Academy of Medical Acupuncture symposium.  I think we should be discussing stories like this one and encouraging the NON-CONTEMPTUOUS exchange of ideas, including those that come from outside the tightly circumscribed borders of "modern" medicine.  

Incidentally, there's another emergency acupressure point, GV 26, on the philtrum, a third of the way from the nose to the upper lip, which apparently causes sympathetic activation in animals.  

Makes you wonder.

*between the second and third metatarsals, a third of the distance from the toe webs to the heel

P.S. - Please do NOT try this at home; do NOT assume I am claiming it works; and above all, do NOT take the telling of this story as the dispensing of medical advice!  If anyone you know or observe requires medical attention, please seek help from a trained professional.  

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N.B.: Van Gogh was being treated in the psychiatric center at Monastere Saint-Paul de Mausole in Saint-Remy when he painted La Resurrection de St. Lazare (above).

The Only Time I Don't Despise CME's

I'm off to my annual anesthesia conference in Vermont - some truly EXCELLENT anesthesia lectures and workshops combined with much-appreciated R&R at a ski resort.  Beats boring online quizzes, that's for sure!

Will check in soon from in front of the cozy fireplace...

***

The conference is PACKED this year.  It seems the economy has made a lot of the big conferences disappear...so folks are flocking to these smaller (and, in my opinion, often better) ones.

Besides learning the latest hot anesthesia things and reviewing some useful medicine, there are a few things I look forward to when I come to this one every year:

-my annual bowl of Prince Edward Island mussels with garlic cream, scallions, almonds, and tomatoes and a side of garlic-asiago fries (I almost NEVER eat fries, but for these I'll be a little naughty)

-dutch pancakes stuffed with all kinds of goodies at the inn down the road

-an aromatherapy massage by K. at the spa (20% off for conference folks!)

-a trip to the local chocolatier for their hazelnut pralines

I hope THIS conference will stay afloat for years to come despite the recession.

Anatomy of a Snowy Post-call Day

6:53 a.m.: Beeper goes off. It's one of the CRNA's calling to say she's stuck in blizzard traffic and won't be at work on time.

7:03 a.m.: Offer to stay past the "official" duty time to help with pre-ops, IVs, and case starts if needed, considering half the staff are experiencing snow delays. Luckily half the patients are too.

7:35 a.m.: Go to locker room. Get dressed. Pack up stuff from being on-call.

8:08 a.m: Stop at grocery store to pick up stuff for meals.

8:43 a.m.: Hit the road. Drive slowly and try not to skid.

9:36 a.m.: Drop off car at the shop to figure out, finally, why the engine warning light's been on for about a month.

10:13 a.m.: At last, a cup of coffee, with a side of e-mail checking.

11:30 a.m.: Fix lunch for family (curry chicken salad sandwiches).

After lunch: hunt all over the house for daughter's gloves, without success. We find an old pair, and the kids and their dad pile into the minivan to go sledding. Ordinarily this is my cue to practice oboe or do a little reading...but I'm sleepy...

1:30 p.m.-ish: Torn between taking a nap, doing laundry, and filling out forms for various things. Do none of the above and have a cup of honey vanilla chamomile tea instead. Then load dishwasher while listening to Slumdog soundtrack.

2:03 p.m.: Start working on party invitations for son's birthday party which is being held about, oh, seven months LATE.

2:55 p.m.: Start ultra-jejune blog post about what I've been doing on my post-call day.

3:14 p.m.: Kids and hubby back from sledding. Realize there is no apres-ski prepared. They eat Cheerios.

3:43 p.m.: Start roasting the chicken breasts for tonight's chicken pot pie.

Cooking, cooking, cooking...

6:15 p.m.: Wave goodbye to daughter as she goes to dress rehearsal for Lowell House Opera's production of Otello.

7:15 p.m. Hubby's parents, brother, niece, and nephew over for dinner. Chicken pot pie is a success.

But the best, best, best moment of the day, besides Daughter's return home, is

Son reading to me from the Natalie Babbitt's laugh-out-loud book The Devil's Storybook at bedtime. This book is MEANT to be read aloud - especially by a child who enjoys reading and reads well. We laughed together till my sides hurt.

It just doesn't get better than that.

And now it's time to go to bed, in anticipation of the alarm going off at 5:40 tomorrow...