Two Poems by Hopkins

I bid farewell to one of my favorite months on this Pentecost day with two stunning favorites by Gerard Manley Hopkins.

If any writer can get me to feel the rush of Spirit wind, the burning flame of the divine, the miracle of a reversed story-of-Babel  - Babel (and everything it stands for - arrogance, division) now gone and replaced by tongues speaking wonders for all the world to hear - it's Hopkins.  Enjoy.  [Photo:  Verbena by Patty Myrick.]

God's Grandeur

The world is charged with the grandeur of God.

  It will flame out, like shining from shook foil;

  It gathers to a greatness, like the ooze of oil

Crushed. Why do men then now not reck his rod?

Generations have trod, have trod, have trod;

  And all is seared with trade; bleared, smeared with toil;

  And wears man's smudge and share's man's smell: the soil

Is bare now, nor can foot feel, being shod.

And for all this, nature is never spent;

  There lives the dearest freshness deep down things;

And though the last lights off the black West went

  Oh, morning, at the brown brink eastward, springs - 

Because the Holy Ghost over the bent

  World broods with warm breast and with ah! bright wings.

'As kingfishers catch fire, dragonflies draw flame'

As kingfishers catch fire, dragonflies draw flame;

As tumbled over rim in roundy wells

Stones ring; like each tucked string tells, each hung bell's

Bow swung finds tongue to fling out broad its name;

Each mortal thing does one thing and the same:

Deals out that being indoors each one dwells;

Selves - goes itself; myself it speaks and spells,

Crying What I do is me: for that I came.

I say more: the just man justices;

Keeps grace: that keeps all his goings graces;

Acts in God's eye what in God's eye he is - 

Christ - for Christ plays in ten thousand places,

Lovely in limbs, and lovely in eyes not his

To the Father through the features of men's faces.

Beginnings

Sometimes on a lazy Saturday morning, in addition to enjoying a cup of chocolate-flavored coffee and watching Saturday morning cartoons, I like to look at old family videos and albums, upload sepia-toned photos of ancestors, go through old letters and memorabilia, and reminisce a little bit.

This morning I was thinking about what happened when I was born.  It was a bit of a rough, early-ish birth.  Though I was relatively huge - over three pounds - by modern preemie standards, back in the early '70's in a Third World country, with me gasping for air and needing to be resuscitated on more than one occasion (pulmonary surfactant wouldn't be in clinical use until I was graduating from high school), things felt a little dicey for those involved.  In these VERY fuzzy pictures-of-pictures (above and below) I am already at the "feeder-and-grower" stage.

There's a happy follow-up story.  My mother once had lunch at a restaurant called Cafe Juanita, whose owner had gone into the restaurant business after decades in practice as an OB/gyn.  When the owner saw her name in the reservation book, he rushed to her table and said, "Doctora!" (My mom had been a pediatrician.)  "I was the OB resident who scrubbed in during your C-section!  You had a baby, girl, I remember.  Premature."

"She's now grown, married, with kids of her own," my mother told him.

Of course when I heard this story I had to see him for myself, this man who helped yank me from my mother's open womb on one of his weekends on-call.  On our last trip to the Philippines we visited his charming restaurant and got to meet him.  It was a thrill to think, "Wow, he was there the very first moment my physical being saw the light of day.  In fact, he helped make that moment happen!"

 

Happy long-term follow-up is such a blessing in medicine.  I bet he never thought he'd have his youngest patient - literally a fetus when we first met - come back to say hello!

Friendship and Female Physicians

I've noticed over the past several years that it hasn't always been easy for me to make friends.

Sometimes I wonder if I'm the reason. Am I simply un-like-able?

When I was in grade school I constantly found myself blurting out goofy things and wincing afterward. I'm sure my social awkwardness cost me some friendships at that age.

Then there was high school Oy. Recently a friend from high school whom I've always admired told me I could sometimes be intimidating back then. ME?! Intimidating?! But I'm so sweet! And shy, and awkward! And un-tall! But I suppose my love of Renaissance history, French poetry, and molecular biology might have struck some people as off-putting...

I had a great time in college. I found like-minded people, kindred spirits, people in different spheres who loved a lot of the same activities, subjects, books, etc. I made some life-long friends in college, as many of us do (and a few good friends in med school and internship as well, though not as many).

I can think of a few things that can make building new friendships and maintaining existing ones hard after college. Relocation. Marriage. Parenthood. Jobs.

And if your job is in medicine as a resident of some kind, you get the added challenge of sleeplessness, no time, no energy, no patience, high stress, contact with suffering on a daily basis, making lonely decisions in what can be an isolating profession, all free time spent sleeping or running errands. Relationships of all kinds suffer during residency; friendships are no exception.

But I think there's yet an additional layer for female doctors. I can't quite put my finger on what it's made of, but it's there.

When people find out you're a doctor - that's if you can even get around to meeting new people in the first place - sometimes their whole vibe toward you can change. It's almost imperceptible, but there's a turn somewhere. It's there. A pulling back, maybe, or the inexplicable sudden presence of an invisible veil between you and the person you'd like to befriend who happens not to be a physician.

I'm not sure why that happens, or even if I'm making something out of nothing. Women-doctors want to hang out and watch chick flicks as much as any group of women friends, or go to cafes to chat, or cook together. Why the sudden barriers?

I have a friend - a drop-dead gorgeous, brilliant, super-sweet, supportive-beyond-measure, talented, couldn't-be-nicer friend, fellow-mom, and fellow-physician - who meets with a group of women on a regular basis to engage in a much-enjoyed activity. She told me that for a long time she didn't tell the other members of the group she was a doctor. She was concerned they might not be as relaxed, or their attitude to her might change, with the knowledge of her profession. I have another, newer friend - also multi-talented, also a fellow-mom and physician, very nice, with lots of different interests - who has observed a shift in others when she strikes up a conversation but then reveals that she's a doctor.

I don't think we're all just imagining this. There's something about us female physicians that seems to make some people hesitate to get too close, which makes making friends even harder in the context of busy, demanding lives juggling work and family. I tried googling "women doctors" and "friendship" to see if I could learn more, but no one seems to be talking about this much, or I'm not looking in the right places, or no one else thinks there's an issue.

Do male physicians experience anything similar? Am I just being over-sensitive? I don't know. But I do think the whole subject of physicians and friendship in general, and women doctors in particular, is worth exploring.

Cross-posted at Mothers in Medicine.

The painting above is by Filipino master Fernando Amorsolo, whose depictions of ordinary country life in the Philippines are among his best-loved works.

Book Blockade Update

"One should never underestimate the collective fury of book lovers when their book supply is threatened."  -Robin Hemley 

I am pleased to report that President Arroyo of the Philippines, in the face of a "torrent of criticism" from around the world, has ordered the Philippine Department of Finance to end the imposition of taxes on imported books that violates the UNESCO Florence Agreement. (See here for my initial blog post about this and here for Robin Hemley's follow-up article.)

To anyone with a cynical attitude about armchair activism, Facebook causes, and the like:  some of that "torrent" came from effective mobilization of social networking.  The Filipino community at home and abroad blogged about this, talked about this, wrote about this, got in touch with each other on Facebook about this, and after venting their opinions with each other across the seas - an important part of the process - sprang into action by sharing ideas about what to do, exchanging links / ways to contact people in authority, generating emails to the President and UNESCO, writing letters and articles, and making phone calls. 

It's a new day.  As Hemley writes, "Together, Filipino book lovers have performed what I consider a miracle in less than a month's time."  People across the world are watching each other and helping each other.  The blogosphere and the laptop can create or perpetuate movement.  Let's keep using these connections and communication technologies to support and add to the good work being done in the field. I've written this before:  even a small effort or act can make a difference!

***

Appendix - E-mails we sent to the President:

"Dear Madam President, If you care about the development of our people as individuals and as a society, you will STOP the corrupt practices of our Bureau of Customs.  By HOLDING BOOKS FOR RANSOM, they are violating a U.N. treaty we ratified and have honored for decades. Please show that you are worthy of your office and of service to our country by taking action against this SHAMEFUL book blockade by a bureau known around the world for being among the most corrupt in existence. We must show the world that Filipinos are not the ignorant, corrupt kind of people our customs officials represent.  With thanks and love of country, [T.]"

"Dear President Macapagal Arroyo, as an attorney and an American married to a Filipina I am deeply disappointed and outraged by the book blockade being enforced by Philippine customs officials.  I know from being married to my wife that Philippine women are intelligent, strong, and principled.  Perhaps you can bring some of those qualities to bear on the actions I hope you will take against this kind of corruption.  The word is being spread internationally, to journalists and on Facebook. We'll be watching eagerly for you to do right by your people.  Sincerely, [Husband of T.]"

***

Click here for another story about access to books  a kid with an ad-hoc library of banned books in his locker...

Facebook

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Anesthesia By Death and Other Mysteries

This post is dedicated to my mother-in-law on her birthday.

This past week NPR presented a series on "The Science of Spirituality."  Barbara Bradley Hagerty, author of the book Fingerprints of God:  The Search for the Science of Spirituality, aired the following articles:

The God Chemical:  Brain Chemistry and Mysticism

Are Spiritual Encounters All In Your Head?

Prayer May Reshape Your Brain...And Your Reality

Can Positive Thoughts Help Heal Another Person?

and Decoding the Mystery of Near-Death Experience.

I enjoyed this series very much despite one or two minor annoyances.  I am always a little annoyed by the assertions that the existence of God is proven or disproven by the existence of specific kinds of electrical or neurotransmitter activity in the brains of people undergoing spiritual experiences.  These findings prove nothing.  If God exists, then of COURSE people's experience of God would manifest neurophysiologically, as all experience does.  If God does not exist, but humans nevertheless have an innate capacity for mystical experience for whatever reason, then of course brain chemistry is the means by which that capacity is expressed.  Maybe Richard Dawkins' brain isn't more evolved than a believer's, as he seems to believe about himself - maybe he suffers from a "mysticism deficiency" disorder!  (I chuckle naughtily - couldn't resist.)

I also get a little irritated when scientists arrive at "conclusions" that have been known to theologians, philosophers, and spiritual thinkers for years.  C.S. Lewis and Kierkegaard both wrote that prayer changes US, not God; now all of a sudden scientists concur that "Prayer May Reshape Your Brain...and Your Reality."  And don't even get me started on all the "revelations" in quantum physics that have been commonplace as ideas - conceptualized a little differently, perhaps -  in the minds of spiritual people for ages.

I enjoyed in particular the article about whether positive thoughts can help heal another person.  When I was a resident some researchers were patting themselves on the back for proving that prayer for cardiac patients not only failed to benefit them but also, in fact, made their outcomes worse.  When I read the study, I had to roll my eyes.  I would not call what the subjects were doing "prayer,"  nor would I necessarily measure prayer efficacy by outcome.

Prayer is not a mumbling of words for disconnected strangers in the hope of happier results; that, in fact, is childish superstition.  To me prayer is something far deeper: an act of humility and, most importantly, an act of love.  Matter cannot move or live without energy; without the energy and connecting force of love behind all the heartfelt words and thoughts, prayer is inert, soul-less, a husk without substance.  The article about physiologic manifestations related to positive thoughts "sent" by one loving spouse to another made me think of the power my own husband's love has had to transform me and our lives, and I felt an instant recognition.  He often tells me, "My life is a prayer, honey."  It's true.

Love has power.  Prayer born of love and fueled by love has power.  The two are meshed together; love is the ultimate prayer, and prayer is mindful love.  To be critical of it (love or prayer) for not being able to cure a kid with cancer or guard a woman's safety as she crosses a park at night or change the outcome of an accident is to fail to understand its nature entirely, I think.  It's not a magic spell; it's an agent for transfiguration that needs to be learned constantly and that cannot be understood in the ordinary language of time, space, observation, and fact.  

Perhaps you believe that love, like everything else we experience including awe and anything transcendent, is merely the result of neurotransmitters and chemical reactions.  Maybe.  But if that's true, than the divinity lies there, in the very stuff of those atoms and molecules.  I think there's more to the story, or we wouldn't be asking so many questions.

My favorite article in the series, of course, was the one about the person who had a near-death experience under anesthesia.  Now, this was no ordinary anesthetic.  This was circulatory arrest:  a stopped heart, blood drained out of the patient, body cooled to cadaverous temperatures.  Tell me that's not a DEAD person right there.  Anesthesiologists prefer to conceptualize the state as "suspended animation":  the closest you can get to death without actually crossing the line.  I am not a specialist in cardiac or neuroanesthesia; I've only done this twice in my life, with help.  I can still remember noticing my patients' eerie pallor - the phrase "white as a ghost" came to my mind - as I packed ice around their heads during cardiac standstill.  It's very cool (no pun intended) but very...spooky, too. 

Hagerty's article tells the story of singer-songwriter Pam Reynolds, who had a near-death experience in 1991 during surgery for a large aneurysm on her brainstem.  During the operation she felt her consciousness leave her body through the top her head and found herself looking down at the operation from above.  She overheard a discussion about narrow blood vessels in her leg.  She saw the bone drill used by the surgeons.  She saw twenty people in the room.  She chatted with her dead grandmother and uncle.  She heard "Hotel California" playing in the operating room as she re-entered her body.   "The line was, 'You can check out any time you like, but you can never leave.' And I opened my eyes and I said, 'You know, that is really insensitive!' "

Her neurosurgeon, Robert Spetzler, later confirmed all these details (with the exception of the dead grandmother and uncle) and said he could think of no scientific explanation for Reynolds' experience. Skeptics ascribe it to "awareness under anesthesia."  Um, yeah - with her eyes taped shut, noise-generating, molded ear speakers placed into her ears, and zero bloodflow to the brain.  If that's the answer, it's unlike any case of anesthesia awareness I've ever read about.

Alas, cases like this probably have to be relegated to the "we may never fully know" category - unless you're a staunch materialist and have an explanation for everything. I prefer a worldview that honors reason and science but also embraces mystery and stays open to the possibility that there's more to us and our world than the usual models can explain or express.  On that note, I think I'll go alter my brain chemistry a little, and do a little meditation...or at least a little meditative oboe playing...

Missing Pieces: Who Was the Dark Lady?

On this day 400 years ago - May 20, 1609 - William's Shakespeare's sonnets (supposedly) were published (supposedly) by Thomas Thorpe.

I like this one, because it's refreshingly realistic about "true love" for a change, and it reminds me of what I often teasingly tell my husband is our marriage theme song - "If You Wanna Be Happy":

Sonnet CXXX

My mistress' eyes are nothing like the sun;
Coral is far more red than her lips' red;
If snow be white, why then her breasts are dun;
If hairs be wires, black wires grow on her head.
I have seen roses damask, red and white,
But no such roses see I in her cheeks;
And in some perfumes is there more delight
Than in the breath that from my mistress reeks.
I love to hear her speak, yet well I know
That music hath a far more pleasing sound;
I grant I never saw a goddess go;
My mistress, when she walks, treads on the ground:
And yet, by heaven, I think my love as rare
As any she belied with false compare.

-William Shakespeare

Who isn't intrigued by literary or musical clues of a possible secret love, such as Beethoven's "Immortal Beloved," and Shakespeare's "Dark Lady?"

Was Shakespeare's "Dark Lady" a woman of African descent, as Anthony Burgess imagines in his novel Nothing Like the Sun, or a Mediterranean fellow-writer of sonnets as in Carol Goodman's book The Sonnet Lover?

I've often wondered about all the anonymous, completely-lost-to-history individuals who have enriched the lives and art of famous creative geniuses. Who were they? Were they "ordinary" people with inspring stories to tell? Were they incredible talents in their own right for whom these great artists pined in a kind of ecstatic self-torment, or seemingly unremarkable people with whom these historic greats could find a special, sheltered intimacy, or perhaps an overpowering, wild passion?

We'll never know, of course. Isn't that deliciously frustrating?

Sometimes the most significant, life-altering moments are those that seem to be the smallest, and the greatest influences, those that most people might overlook. As I think of the people and experiences in my life that seem to hover in its tiny moments, I wonder what shape my life might have taken without them, and I realize how important even the most fleeting moment can be. The moment a doctor taught me how to mask ventilate a patient manually couldn't have taken more than a few seconds, but it altered the course of my whole life.

Perhaps there's really no such thing as a small moment or an insignificant interaction.

SurgeXperiences 223

"We have been fighting a long time.  We are outnumbered by machines.  Humans have a strength that cannot be measured."  Terminator Salvation trailer.

Welcome to SurgeXperiences 223!

In anticipation of the upcoming release of Terminator Salvation, the loose theme of this collection will be "Man and Machine."  When I use the term man here I'm referring to humanity in all its facets - flawed or perhaps even evil at times, but also noble and capable of surpassing goodness.

First, the machines.

Where would we be without them?  Here's a list of "12 Amazing Robots That are Revolutionizing Medicine."

Karen Little writes the enjoyable blog Just Up the Dose from South Africa (and, incidentally, will host SurgeXperiences two weeks from now).  Read her impressions of a machine I use every day, and of how the more things change, the more they stay the same.

Sterile Eye, who works at the interface between man and machine, takes us through a carotid endarterectomy from his perspective as a medical photographer.

Ramona Bates, who writes Suture for a Living, recently had to face life on the other side of the surgical drape when her mom underwent cardiac bypass surgery, clearly a situation in which the coordinated work of human hands and sophisticated machinery achieves great good.

Now let's turn to humans - some showing their darker side, others their best and brightest.

What's worse than a doctor who makes an honest mistake?  A doctor who does something dishonest on purpose.  Arun Shanbhag and Buckeye Surgeon weigh in on the orthopedic surgeon who falsified research about wounded soldiers in Iraq.

But what about this news item about a surgeon who was nowhere to be found after his patient had been anesthetized for her scheduled surgery?   A second surgeon was called to do the procedure, and he refused because he was unfamiliar with the patient.  The anesthetic was reversed and the operation didn't end up getting done.  What happened here? Should BOTH surgeons be accused of wrongdoing, or just the original surgeon?

Here's another article that might spark some controversy, about suicide and organ donation.  I wasn't entirely comfortable reading it...but perhaps we should be reflecting on ethical questions that make us uncomfortable, and ask ourselves why we have the convictions we have, when we might bend them, and how we make the decisions we make.

Surgeons see a lot of blood.  They do get used to it.  Sometimes doctors look back on some really bad clinical scenarios, even some of the bloodiest, and can still find a kernel of ironic humor in a moment or a phrase. You can't make some of this stuff up - so I'm always glad when Bongi, who writes so vividly, peels back the curtain and gives us an inside look.

Does being used to blood and gore mean you get blind to it or

 numb to others' suffering?  Surgeon-author Pauline Chen has written about this in a recent column for the New York Times and on her blog.

Sterile Eye reflects too on why his job doesn't nauseate him.  It's clear from this post about meeting patients for the first time that exposure to surgery on a daily basis certainly hasn't made him lose his humanity.

In one of the best recent posts I've read in the medical blogosphere, RT describes what happened after an hour-long code in the surgical ICU for a ruptured aneurysm, and how dehumanizing protocol can be.  He himself hasn't lost his humanity either, though.

Finally, Chris, military surgeon and author of Made a Difference, calls us to remember why we're able to be free and encourages us to enjoy that freedom mindfully .

Thank you for stopping by this edition of SurgeXperiences, a blog carnival about experiences involving surgery. It is open to all who have a surgical blog post or article to submit. I'd like to thank Vitum at Vitum medicinus for creating our SurgeXperiences logo (above).

The next edition of SurgExperiences can be found at Just Up the Dose, the blog of South African resident Dr. Karen Little, on May 31.

Please submit your blog posts via the carnival submission form.  Please also note that different hosts use or omit posts at their own discretion; I tend not to include submissions that are clearly ads for products, services, or sites or that are not actual blog posts, but other hosts may include any and all submissions.

Click here for a catalogue of past editions of SurgeXperiences.  

You can also subscribe to SurgeXperiences via RSS feed or email.

If you would like to host a future edition, please contact Jeffrey Leow, who's in charge of the carnival.

Blogiversary Day: the Interview

[Photo shows an entry in a Russian cake contest; photo source here.]

Welcome to the second edition of "T. Interviewed by Her Readers," wherein I answer some questions sent in by you and, perhaps, inspired by Michael Leddy, some questions not sent in by you! :)

What made you start blogging?

I was most directly inspired by reading Hilda's blog, Dominican Oboist. She's a wonderful writer and an incredibly talented woman. My blog has become a relaxing space for me - my "room of one's own." See this old post for a reflection on why I blog.

Is there a particular oboe piece that made you want to start taking oboe lessons?

"Gabriel's Oboe" in The Mission of course, but even before that, all the oboe passages in the Tchaikovsky ballets (Swan Lake, Sleeping Beauty, Nutcracker).

Do you have a favorite oboe piece right now?

To listen to, Ralph Vaughan William's Concerto for Oboe and Strings is still my absolute favorite. I love the adagio by Zipoli. I also really enjoy concertos by Albinoni and Cimarosa, the sonata by Saint-Saens, Schumann's second Romance, the trio by Dring, and There is No Rose by Stroope.

As for playing: I think Baroque music's always quite satisfying to play, especially in a group. I really enjoy the fourth of Gordon Jacon's "Ten Little Studies," (though they're all good in their own way). And I love playing songs from church - we use the Gather collections, with a lot of liturgical music by Marty Haugen and similar composers. I think if I get to the point where I could play the second oboe part of the Shepherds' Dance from Menotti's Amahl and the Night Visitors with someone, I'd be thrilled.

Did you have the most fun in high school, undergrad, med school, residency, or work after training? Which year of med school and residency did you enjoy the most? Is there any test harder than USMLE Step 1, or does it get easier after that?

College was wonderful despite the stress. I always tell people who are considering going to medical school to major in the one subject they love above all - music, Russian, physics, literature, astronomy, art history, anthropology, or whatever it is - because if they do go to med school, college may be their last chance to enjoy that one subject to the fullest.

The first two years of medical school are enjoyable because you're so sheltered - all the joy of learning with none of the frightening responsibility. But fourth year was the most fun, I think - clinical electives! I got to go to the N.I.H. for a month to do a rotationin clinical genetics. I was all set to become a clinical geneticist "when I grew up," in fact, but the future had other things in store for me.

As for the boards, you know what they say about the amount of time you need to prepare for USMLE Steps 1, 2, and 3: "Two weeks; two days; two pencils." A GROSS exaggeration, if you ask me! I never found test-taking easy. I thought the USMLE steps were easy relative to the anesthesia boards, though. I recall that after the written anesthesia boards, the entire group walked out completely ashen. But nothing compares to the experience of taking the oral anesthesia boards. I think the written was actually harder, but the oral was more terrifying for me.

What was the best course/module you've ever taken? High school, undergrad, med school - the one or a few courses which have influenced you the most?

Best single course overall: a summer writing workshop taught by author Larry Woiwode as part of the C.S. Lewis Foundation's program "Cambridge '94." Larry Woiwode is a phenomenal instructor who gave me the faith to keep writing, even after having put writing aside for a time.

Residency: our time in the simulator

Internship: working with Dr. Dasgupta

Med school: anatomy, pathophysiology, and an elective in clinical genetics

Grad School: a course in child art by Prof. Sylvia Feinberg & courses in child development by Prof. George Scarlett

College: Seamus Heaney's course on contemporary Irish poetry

High School: the intensive unit on New Testament studies my freshman year

Grade School: my 8th grade English class changed my life (it was the first time I found myself compelled, absolutely compelled, to write, and write often); my fourth grade reading class probably did too; my entire time at Stone Ridge was probably the best educational experience of my life, but before that, my Montessori experience in grades 1-3 was pretty influential and memorable.

Would you recommend your profession and specialty to your kids? If not, why? If you had a chance to go back in time and pick another medical specialty (i.e. pediatrics / emergency medicine), would you do it?

I would like my kids to be happy in their work. While I've written in the past that I hope they don't choose medicine because of the grueling training process, I do feel that if they truly loved medicine with a passion, then by all means I would support them and, of course, recommend that they consider the best specialty in all of medicine: mine! :) If I had a chance to go back in time, I MIGHT change my profession, but if I were to choose medicine again, I wouldn't want any other specialty but this one. I truly love it, much as I moan about some of the day-to-day work frustrations that go with it.

Why are anesthesiologists/CRNA's the go-to folks for impossible IV's? Do you have any tips for hard sticks?

We're good at them because of practice, practice, practice. We've done TONS (just as we've done tons of airways).

I always used to tell medical students that half the battle is choosing the right place to try. Sometimes that means being willing to go "outside the box" / to "non-traditional" veins. Besides that, I would also suggest applying enough traction on the vein to prevent it from rolling, to insert the needle right on top of the vein (rather than beside it), and to ease needle and cannula straight in together, slowly, until you have a few mm inserted, before sliding the cannula straight off the needle. This of course only applies to the NICE I.V. equipment that can be used with ONE hand (so the other hand can hold the traction), not the CRAPPY I.V.'s that require an inelegant, far less smooth, TWO-HANDED technique that I simple can't stand.

Do anesthesiologists-to-be undergo anesthesia, of various sorts, as part of their education, so as to know what their patients will experience?

No, actually - though once, one of the critical care docs in the ICU gave us a taste of artificial ventilation, through a T-piece, just so we could understand the differences among the various ways of administering it, and also know how unpleasant it could be.

Many if not most doctors, come to think of it, haven't had their various patients' experiences first-hand and can't truly know what their patients are experiencing - heart attacks, pregnancy, surgery, anesthesia, fractures, the various procedures we perform, major illness, tumors, strokes, crippling diagnoses, loss of quality of life, etc.

This is why I think the study of literature, theater, music, language, anthropology, history, and the other arts and humanities is such a valuable part of a physician's education. Our patients are more than just cells and biochemical pathways. If we can't physically inhabit another person's experiences, we should at least have trained our minds and 'hearts" to do so by entering as intimately as we can into the experiences of others through conduits such as these. (My pro-humanities, arts-loving bias can't help but chime in here!)

Now, I don't want people writing in and saying, "What! T. believes reading story books will make you a good doctor?" That would be a huge misrepresentation of what I'm trying to express here. But I've always believed in the importance of a strong education in the humanities as well as the sciences for all physicians, not only to develop those aspects of the brain not exercised by studying science, but also because I really do believe compassion and the capacity for empathy arise from a combination of actual experience, lessons that form character, and stories that contribute to a greater consciousness of human experience.

What's your feeling on nurse anesthetists? There seems to be some rancor among doc-bloggers towards NP's and MA's; do CRNA's tend to get the same grief?

They do. There can be tremendous tension and resentment between MDA's (M.D. anesthesiologists) and CRNA's, depending on where they're working. I've been fortunate to have worked in places where relations are pretty respectful. My feeling on CRNA's is the same as my feeling on docs: there are good ones and there are bad ones; the good ones are GREAT to work with, and the bad ones can be dreadful. Many CRNA's know a lot and have excellent clinical judgment; others seem almost under-trained, or the fact that they've spent fewer years in training seems glaringly apparent. It just depends on the individual.

What mistake or patient encounter during your training or career bothers you the most?

In general, I am deeply troubled any time I find myself thinking "Hindsight is 20/20" or feeling, "Oh! I should have done this" or "I should have done that." I've written here about one patient encounter I wish I had handled differently; there are certainly one or two others that make my heart ache even now. I think the only doctors that have no regrets are the ones that haven't seen enough patients.

What are your "ten commandments" for a successful intubation?

• Thou shalt have a comfortable, well-practiced mask technique.
  
• Thou shalt be aware of any elements of the patient's history that might have an impact on his or her airway.
  
• Thou shalt perform a conscientious examination of the airway.
  
• Thou shalt place the patient's head, neck, and shoulders in the best position possible.
  
• Thou shalt give enough drug to ensure the patient is adequately anesthetized before attempting to secure the airway.
  
• Thou shalt sweep the tongue into the hollow of the mandible.
  
• Thou shalt not have a "wimpy lift," as one of my attendings told me I had my first month or so in residency, when I hadn't quite developed that laryngoscope arm yet.
  
• Thou shalt aim for the tunnel above the arytenoids.
  
• Thou shalt have an LMA ready and a bougie handy.
  
• Thou shalt call for help promptly if you need it.
  

Do you have any tricks on keeping calm in the OR when things are completely out of control?

No tricks. Just know what you're doing, stick to the facts, keep your eye on the numbers, take charge and delegate, and if you need help, ASK.

Have you ever had a kitchen disaster?

Absolutely! My earliest one was a comical attempt to make a Philippine roll called a pan de sal - one of the most delicious breads I know. I killed the yeast with water that was probably way too hot for it, and my "rolls" turned out hard as rocks.

Then there's my "nemesis," as my husband fondly calls it: Spanish tortilla. I LOVE Spanish tortilla. I'm part Spanish - how could I not? But I cannot get that dish right! "The center will not hold." I am definitely doing something wrong.

Finally, most recently I had a disastrous attempt at lobster mac-and-cheese. I accidentally rubberized the cheese, so I had to convert the dish to linguini with lobsters and shallots in a light, creamy, white wine and garlic reduction. That actually turned out well.

If you could have any superpower, what would it be?

You mean, if I had to choose from among invisibility, flying, telepathy, super-strong spiderweb cables shooting of my wrists, and that sort of thing? I think I'd want telekinesis. Clean-up would be so much easier...

Finally, from my friend Anali, one of my favorite questions: I think that you've neglected to address a very important issues on your blog. I'm actually surprised that it even needs to be asked, with someone like yourself who doesn't shy away from the issues.

But it's been far too long. Your evading this truth must come to an end. Two years of evading a quintessential question. Where do you stand on frosting? Buttercream, glaze, boiled, or ganache?

That's easy. Buttercream all the way, my friend. Smooth, not-too-sweet, satin-on-the-tongue buttercream.

Thanks, everyone, for attending my Blogiversary Festival! I've had a great time with it. It concludes officially tomorrow with SurgeXperiences: the surgical blog carnival. Keep in touch!

Writers' Rag-and-Bone Shop: a new book corner for my blog

Welcome to The Writers' Rag-and-Bone Shop, my new blog-café for all things literary (inaugurated on the anniversary of Emily Dickinson's death from kidney disease in 1886).  I've looked back on a number of posts in which I've shared passages of literature and poetry that have lingered in my mind after I've read them (see here, here, here, and here for examples), and I've decided I'll make a point of sharing such finds here from time to time.

Today's feature is the beautiful passage by Joyce Carol Oates entitled "My Faith as a Writer" (from her book The Faith of a Writer). It summarizes on this blogiversary eve what this blog, at its best - most importantly, the community and exchange of ideas within it - has meant to me.

    I believe that art is the highest expression of the human spirit.

    I believe that we yearn to transcend the merely finite and ephemeral; to participate in something mysterious and communal called "culture" - and that this yearning is as strong in our species as the yearning to reproduce the species.

    Through the local or regional, through our individual voices, we work to create art that will speak to others who know nothing of us.  In our very obliqueness to one another, an unexpected intimacy is born.

    The individual voice is the communal voice.

    The regional voice is the universal voice.

Isn't that brilliant?  

***

It's time at last for the Blogiversary Book Give-Away!

If Singular Intimacies is the must-read for those who want to know more about the general practice of medicine, When the Air Hits Your Brain by Frank Vertosick is the absolute must-read for those who enjoy learning about the surgical side.

Vertosick is an expert writer whose powerful stories and vivid details "hit your brain" and leave permanent marks. Particularly unforgettable are chapters like "Ailments Untreatable," a gripping account of the attempt to save an un-save-able patient, and "If It Was Easy, Everyone Would Do It," in which he captures both the seemingly heartless cynicism that can infiltrate physicians-in-training and the redeeming humanity that can take root and grow from a significant connection with a patient.

And the winner is (my son drawing name out of a hat as I write)...

...Angela A.!  

Congrats! (And thanks to all who submitted questions for tomorrow's interview!)

Festival Interlude: Last Chance to Get In on the Book Give-Away!

I'll be announcing the winner of the Blogiversary Book Give-Away TOMORROW evening, so if you'd like to be considered, please send in an interview question (for Saturday's "Interview of T. by Her Readers, 2nd Edition") by midnight tonight to anesthesioboist@gmail.com!

The Cadaver Room and Other Memories: a blogiversary reminiscence

Two Views of a Cadaver Room by Sylvia Plath

1
The day she visited the dissecting room
They had four men laid out, black as burnt turkey,
Already half unstrung. A vinegary fume
Of the death vats clung to them; 
The white-smocked boys started working.
The head of this cadaver had caved in, 
And she could scarcely make out anything
In that rubble of skull plates and old leather.
A sallow piece of string held it together.

In their jars the snail-nosed babies moon and glow.
He hands her the cut-out heart like a cracked heirloom.

2
In Brueghel's panorama of smoke and slaughter
Two people only are blind to the carrion army:
He, afloat in the sea of her blue satin
Skirts, sings in the direction
Of her bare shoulder, while she bends,
Fingering a leaflet of music, over him,
Both of them deaf to the fiddle in the hands
Of the death's-head shadowing their song.
These Flemish lovers flourish; not for long.

Yet desolation, stalled in paint, spares the little country
Foolish, delicate, in the lower right-hand corner.

***

Every year in the month of May - the month in which I graduated from medical school - I think back to those years before I encountered patients face to face.  Med students are in some ways like Bruegel's Flemish lovers - oblivious to the carnage, not yet involved in it, in fact quite shielded from it, yet with a front row seat and hearts full of interest. 

At some point we have to enter into the fray.  We have to see blood spilled, watch people die in front of us, take part in a person's very first moments, hear people's hidden thoughts and fears, see and touch parts to which even their most intimate loved ones haven't had access.

How do we prepare for that kind of intensity and intimacy?

We do it in stages.  Our first patient, our cadaver in anatomy lab, doesn't risk suffering harm at our hands.  Through this generous individual we confront death, the signs and scars of disease, internal organs.  We place our fingers into the portals of the human heart.  We trace the paths of nerves both delicate and tough, touch the glossy surfaces of liver and spleen, dissect the structures of the head and larynx.

We start seeing live patients as observers standing awkwardly behind seasoned preceptors.  We learn to take a medical history and perform an exam, and we start doing a few. (Embarrassingly, my salient memory from my earliest preceptorship is of my turning visibly green and almost wretching when my preceptor had to lance an abscess in her office.  I held it together...but just barely.)

Then there's the first time we have to deal with someone else's private parts. Tears and suffering I wasn't afraid of...but I felt very shy about invading others' bodies. At my school we were guided through our first pelvic exams by trained models, male and female, who would permit us to examine them and give us feedback on our technique in order to provide us with a greater degree of competence and comfort when we ventured to examine real patients.  We all tried to be cool, almost nonchalant, as we inserted digits and metal objects for the first time into the orifices of strangers.  Predictably, we uttered awkward things. But we learned.  We learned to be careful without being afraid, and to be correct and professional.  I can't say I found this training experience enjoyable, but I certainly found it extraordinarily helpful.

Eventually we are turned loose in the hospitals, to learn how to gather information from and about real patients, examine them well, and make judgments about their needs.  In the end our patients are our most valuable teachers.  We learn from them the mechanics of our profession, but we also learn the things that can't be taught in a classroom, except by simulation - how to discuss bad news; how to console someone who's weeping; how to convey sympathy, to touch people in comforting ways that don't involve percussing or applying a stethoscope. How to feel a portion of someone else's pain without being distracted or destroyed by it.

For most of us, these are recurring lessons to which we'll return for the rest of our careers.  The word doctor in Latin means teacher, and perhaps the best doctors are those who are great teachers.  But no doctor can ever be a great doctor without being a committed life-long learner, and being open to the teaching treasures other people and their lives have to offer.  If this is true, then no doctor can be really good without being genuinely humble - not with the false modesty of someone whose insecurity causes constant self-deprecation, but with the true humility of someone who acknowledges that knowledge and power must be constantly earned and shared.

Best of Notes of an Anesthesioboist 2008-2009

In the tradition of Grand Rounds, up at Health Blogs Observatory today (Great edition!  Check it out!), and the upcoming SurgeXperiences blog carnival, I'd like to welcome you to my own mini-blog carnival, part of my week-long Blogiversary Festival.  Below is a compendium of posts written since last year's blogiversary.  Enjoy!

(See here for an older best-of list.)

My Favorite Post This Past Year:  Code Indigo

Posts About Medicine:

General Medical Posts

The "F" Word

Brief Walk Through Medicine in Art

One of the Gang:  a fictitious true story

Not Even the Most Frustrating Conversation of the Week, But Unbelievable Nevertheless

Cadaver Poem

Before Dying, Leave Word

See One, Do One, Teach One

The Orange Bag

Sick

Anesthesia Posts

Father's Day Thoughts from Behind the Blue Drape

Songs in the O.R.

Wide Excision

"Hit the Road, Jack, and Dontcha Come Back No More, No More, No More, No More"

Losing Patients

One of the Ones that Stay with You

Truth Serum

Candy Cane Time

Ode to Vocal Cords

The Black Box: Aviation, Anesthesia, and the Debt We Owe Those Who Came Before Us

Epidural Elegance:   a bit about anatomy and neuraxial anesthesia

Just Another Night

Surgeons v. Anesthesiologists:  Why the Tensions?

Ironing Out the Teamwork Kinks

Controversies in Medical Life

The Deep Satisfaction of Demonizing Our Doctors

Sign Here, Please

How Much is Too Much?

Conscientia Recta

Surgeons v. Anesthesiologists II:  Disagreement

Medical Posts In a Lighter Vein (so to speak)

Gross, and I mean GROSS, Anatomy

The Ad Hoc Anatomist

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

Why the O.R. is Not a Meatmarket, Grey's Anatomy Notwithstanding; and, Looking a Patient in the Mouth - What's That About?

Don't Say the Q Word:  Doctors' Superstitions

The Quincke and the Pain

Flatus

Posts About Music:

Playlists

Discovering Dring

Why I Love Elaine Fine; and then, some ramblings

"Play the Bach, Dear"

Bells in the Air

Chocolate and Cimarosa

Posts About Books / Writing / Literature / Film:

To Write or Not to Write:  a question for doctors who blog

Happy Birthday, Little Sage

Fusia Podgorska and the Milgram Experiment

Equus

A Christmas Carol and Other Stories

Anesthesia in the Movies

For the Love of Humanity, Please "Waste" Your Time on Dead Languages

More on the "Canon":  Words by Heart

Literature Meets the DSM-IV

Dropped into the Ether Acre

The Untold Stories

Grammar Pet Peeves

Diagnosis:  Writer's Itch

Singular Intimacies

Book Blockade

Posts About Food:

Excursions in Medical History:  Shaker Medicine

Chocolate Chip Cookies from the Island of Reil

Chicken Soup for the Filipino Soul

Anesthesioboist in the Kitchen

The "Success" That Means the Most to Me

Posts About Family:

Reed-Making Tips, Time Capsules, and Trampoline Secrets

Whose Gifts Will We Accept?

Mushroom Love

yes I said yes I will yes

Mark 4:39

Ninoy

Journeying Home from Home

Acting

Love and Wonder in a Carcass

Annie

Posts About Faith:

Keeping the Faith

How a Plate of Broccoli Got Me Thinking About God

A Doctor at Calvary

The Empty Tomb:  Moving Toward an Easter Poem

They Don't Screen For It On Med School Applications

Other:

My Favorite Things

A Few of My Favorite Fabulous Things

Lament Over Education

The Man Who Came to Dinner

Today's Blogiversary Surprise

Welcome to the official opening day of Notes of an Anesthesioboist's Blogiversary Festival, a week-long celebration of two years of blog fun.

I have much to celebrate in the month of May:

• Mother's Day (which was lovely)
  
• My birthday (which was great!)
  
• This year, my daughter's debut in a musical (which was STUPENDOUS!)
  
• The anniversary of my graduation from medical school
  
• The anniversary of my first oboe lesson
  
• My blogiversary

In accordance with these many reasons to celebrate and be thankful, I'm hoping to dedicate each day of the Festival to a different topic often covered on this blog (each of which happens to be in-line with at least one of the anniversaries listed above).  These different subjects -medical life, oboe life, writing, food, faith, and family - keep me energized and enriched both in the blog world and in the real world.

I started off by honoring family yesterday with a festival preview - a mini-retrospective of posts related to motherhood.

Today it's a nod to my oboe lessons.  

Anali suggested that I upload some audio of me playing.  Though it goes against all my instincts, I have done so, and let me warn you, it is NOT great.  I tried and tried and tried to sound ok, but I couldn't get over being nervous, and I think it was making my reed crow. As I've emphasized many times on this blog, when it comes to oboe I have only desire, not talent!  But don't worry - it's less than ten seconds long. :)  No pity comments from real oboists - it's okay, really! 

Stay tuned (so to speak) for tomorrow's Blogiversary special: "Best of Notes of an Anesthesioboist," a compendium of favorite posts from the past year.

Happy Mother's Day!

My friend Kirti, whose blog has a wonderful feature on Fridays called "Fine Art Friday," reminded me of how much I love Mary Cassatt's paintings of mothers, or women doing "motherly" things, and children.

I decided I would kick off my Blogiversary Festival a little early by offering some samples of past motherly posts on this occasion.

First, the blog Mothers in Medicine has honored me by highlighting two of my posts on this Mother's Day weekend: click here to check it out.

Second, a couple of posts that mention my daughter:

Birthday Cake with a Side of Deep Thoughts

Mark 4:39

And, a couple of posts that mention my son:

Whose Gifts Will We Accept?

Love and Wonder in a Carcass

Finally, a relatively early post about how I regard my kids: What's a "High Pay-off" Kid?

Happy Mother's Day!

Annie

She was great!  

Her joy, humor, lovely singing voice, spunkiness, and warm, loving spirit came shining right through.

Two more shows to go.  Will resurface afterward!

***

The following (rather blurry) video from the second performance is shared with the performer's permission.

***

Moments she and I don't want to forget from the run:

• Her great-grandmother's 102-year old sister, who had seen the original D.C. production of Annie way back, making it up here from D.C. to watch the second show.
• A three-year old girl wanting to meet her and get an autograph after one of the shows.
  
• One of the girls who had openly expressed resentment toward her approaching her after the show to say, "You deserved the part" before walking away as abruptly as she had come.  A striking lesson in the way you can sometimes earn the respect even of people who don't really like you, through hard work, good character, and humility.
  
• Standing ovations the second two nights.
• Playing "Psychiatrist" at the cast party.
• Her school friends hugging her and presenting her with a bouquet of red roses.
• The family and friends who traveled from miles and miles away just to see her and support our family.
• The entire cast and crew showing up to school after the run wearing their "Annie" T-shirts in solidarity.

Now we deal with the post-show let-down.  But with glorious memories to help us get through it!

Book Blockade

When I was a child in the Philippines, really great books weren't so easy to get.  The best ones were abroad, and I'd look forward to the moments when my father would unpack his suitcase from a business trip and hand me his latest acquisitions.  These I would read over and over, relishing the weight of them in my hands, the aroma of the binding glue wafting up from the open pages, the illustrations.

Does everyone who's had access to books have special "reading memories?"  There are a few significant reading memories that stand out in my mind.  I remember enjoying a two-volume collection of Grimms' fairy tales; a children's Bible with striking, colorful, folk art illustrations; a worn yellow copy of Brer Rabbit tales; a couple of books with titles like "365 Bedtime Stories;" and my mom coming home with a hardback edition of Harriet the Spy.

When we moved to the U.S. my parents enrolled me at a school called Stone Ridge, which I still consider the greatest educational experience of my life (including some wonderful college years at Harvard, graduate school at Tufts, and med school!).  I remember realizing what a thick accent I had when I was asked to read aloud and switching it off almost immediately.  I can still switch from one accent to the other depending on which country I'm in.  I also remember feeling incredibly competent during read-alouds.  But the experience that's seared into my memory forever is the moment I first walked into the Lower School library.  My mouth just dropped open when I saw all the books - shelves and shelves of books, some extending from floor to ceiling.  And the whole room smelled of books - a leathery, delicious, bookish smell.  It was heavenly.

I checked out Anna Elizabeth Bennett's book Little Witch and read it in a day.  I read John Bellairs, E.L. Konigsburg, Katherine Paterson, and Madeleine L'Engle.  I read and read and read and read.  Our assigned reading, Natalie Babbitt's Tuck Everlasting, opened my mind to the way language can be used evocatively and is still one of my favorite books.  To this day just walking into a book store or a book-filled room makes me sigh with pleasure.

Books are precious because they contain human thoughts, ideas, and stories.  They are repositories of our souls, in a way.  They have power.  They can connect and divide us. They can keep us present even after we've gone.

In the Philippines some corrupt customs officials are violating a U.N. treaty (the 1950 Florence Agreement on the Importation of Educational, Scientific, and Cultural Materials) and exploiting people's love of books and need to import them by imposing tariffs on all book imports.  In effect, they are holding books in locked storage for ransom.

Now, I am proud of certain aspects of my Filipino heritage, but one thing I have always been frustrated by and ashamed of is how corrupt our society is.  You can't even get out of being cited for a non-existing - yes, literally NON-EXISTING - violation of some sort (traffic, utility, you name it) without bribing some official.  It's like that Cameroon police officer who was reported by David Torrey Peters as saying to a taxi driver, "You think just because there isn't an AIDS vaccine I can't arrest you for not having one?"  It's TOTALLY like that over there. To expect corrupt officials to appreciate the sacredness of books, understand what they're doing, and CARE about any of it is a hopeless idea.  They know not what they do; but in many ways they know exactly what they're doing - and they're getting extra pocket money for it and grinning all the way to the bank.

Robin Hemley, director of the nonfiction writing program at the University of Iowa, who is on a Guggenheim Fellowship in Manila for the year, wrote an article about the book blockade by the Philippine Bureau of Customs which I have to excerpt here (there's also a good blog post here about this and a follow-up letter from Hemley here):

Over coffee one afternoon, a book-industry professional (whom I can't identify) told me that for the past two months virtually no imported books had entered the country, in part because of the success of one book, Twilight by Stephenie Meyer. The book, an international best seller, had apparently attracted the attention of customs officials. When an examiner named Rene Agulan opened a shipment of books, he demanded that duty be paid on it.

"Ah, you can't be too successful in this country," I said. "If you are, then people start demanding a cut..."

...The importer of Twilight made a mistake and paid the duty requested. A mistake because such duty flies in the face of the Florence Agreement, a U.N. treaty that was signed by the Philippines in 1952, guaranteeing the free flow of "educational, scientific, and cultural materials" between countries and declaring that imported books should be duty-free. Mr. Agulan told the importer that because the books were not educational (i.e., textbooks) they were subject to duty. Perhaps they aren't educational, I might have argued, but aren't they "cultural"?

No matter. With this one success under their belt, customs curtailed all air shipments of books entering the country. Weeks went by as booksellers tried to get their books out of storage and started intense negotiations with various government officials.

What doubly frustrated booksellers and importers was that the explanations they received from various officials made no sense. It was clear that, for whatever reason—perhaps the 30-billion-peso ($625 million) shortfall in projected customs revenue—customs would go through the motions of having a reasonable argument while in fact having none at all.

Customs Undersecretary Espele Sales explained the government's position to a group of frustrated booksellers and importers in an Orwellian PowerPoint presentation, at which she reinterpreted the Florence Agreement as well as Philippine law RA 8047, providing for "the tax and duty-free importation of books or raw materials to be used in book publishing." For lack of a comma after the word "books," the undersecretary argued that only books "used in book publishing" (her underlining) were tax-exempt.

"What kind of book is that?" one publisher asked me afterward. "A book used in book publishing." And she laughed ruefully.

I thought about it. Maybe I should start writing a few.Harry the Cultural and Educational Potter and His Fondness for Baskerville Type.

Likewise, with the Florence Agreement, she argued that only educational books could be considered protected by the U.N. treaty. Customs would henceforth be the arbiter of what was and wasn't educational.

"For 50 years, everyone has misinterpreted the treaty and now you alone have interpreted it correctly?" she was asked.

"Yes," she told the stunned booksellers.

If you love books, reading, or writing, please spread the word about this shameful situation to as many people as you can.  You can also join the Facebook cause "Filipinos Against the Taxation of Books by Customs,"  flood the office of the President with emails here, email UNESCO here, or click here for other ideas.