Lessons in and about Paris: Day 3

[Hat tip to Michael Leddy, author of Orange Crate Art, for inspiring the format of this post! :) ]

* The stained glass in the Sainte-Chapelle comes in five colors (blue, green, red, violet, and yellow).

* Climbing up to street level from the Cité and Lamarck métro stations takes a certain level of fitness.  There are a loooooooot of stairs.

* When the area under the cathedral of Notre Dame was being dug up for parking space, some ancient Gaulic archaeological ruins of Lutece, the Paris before Paris, were unearthed.

* It's a little lonely visiting the Musée d'Histoire de la Médecine by oneself, but interesting nonetheless.  After I lingered over the anesthesia case for several minutes, the lovely attendant asked, <<Vous êtes anesthésiste?>> I mean, who else would linger over the anesthesia case? :)

* It's true what they say.  There are a lot of unpleasant women in Paris.  A lot.  BEYOND unfriendly.  Openly hostile and rude, actually. And apparently if you try to be sweet or if you fail to "stand up to them" with acerbic come-backs of your own, they feel even greater contempt. Sigh...

* Philippine national hero Jose Rizal has a little plaza named after him here (corner of rue Mabeuge and rue Rodier) and a plaque marking where he stayed (up the street) while he lived here (45 rue de Maubeuge).

* The Place du Tertre is lively on a clear evening, and the Sacré-Coeur is at its loveliest with the light of the setting sun on it, around 9 p.m. in the summertime.

* The tiny little green flies here are annoying and, of course, seem to like me.  

* My daughter looks ADORABLE in a purple beret.

* Don't try to take your leftovers home.  Apparently it's frowned upon, and you won't be allowed.  At least not in Montmartre.  So frustratingly silly.  Double sigh...

* Sublingual melatonin doesn't feel like it does anything when you take it but it does seem to be helping with our jetlag.

Only in Paris

As we were coming out of the métro this morning I was stunned to hear beautifully played strains of a Bach Air from somewhere in the tunnels.

"Is that what I think it is?" I asked out loud.

"Sounds like it," my husband replied.

"A recording?"

"I don't think so." 

"You think that's live?  Are you sure?"

We went to check it out, winding our way deeper into the tunnels under the Place de la Concorde, following the sound of Bach's music, followed by some Rodrigo.  You'll understand in a moment why I almost couldn't believe my ears at first, and why I was then moved to tears a little bit when we found this (click "play"):

An oboist in the tunnels of Paris.  Where else in the world?!

(Of course we bought a couple of CDs from him, and he gave me a discount for being a "fellow-oboist."  How embarrassingly gracious is that?  I barely even count as an oboe STUDENT these days, while he is concert master in Ukraine, visiting Paris on business. Out of curiosity I asked him what type of oboe he was playing.  It was a Yamaha, but for "real" concerts he uses a Rigoutat.)

***

After an experience like that to start off our morning, the Louvre seemed almost anti-climactic!  That place is so overwhelming.  We went in with very simple goals:  the Denon wing, some famous statues, some sarcophagi, then out.  Except for the fact that we got totally lost in the Ancient Near East section trying to find the exit, we did really well.  Saw the Winged Victory; the Mona Lisa and some other Da Vincis that I actually prefer; the Venus de Milo; the old medieval walls they've been excavating; sarcophagi; and some artifacts from ancient Iran.  

I was sad not to have the energy to look for Vermeer's Lacemaker, but by midday we were Louvred-out.

I must confess I am not sold on I.M. Pei's glass pyramid.  I have memories of the Louvre without it, and I still think it spoils my view of the building.  On top of that, the greenhouse effect in there can be brutal on a hot, sunny day.  Just saying.

After the Louvre we stumbled upon the rue J J Rousseau entrance to one of Paris's covered passages, the Galerie Vero-Dodat, on our way to the church of St.-Eustache, where we took photos of our kids on Henri de Miller's outdoor sculpture l'Écoute.  The foodie in me wanted to visit the Comptoir de la Gastronomie down the street but the presence of a woman smoking in the doorway just about undid my desire to check out the store.  We had tapas for lunch in the neighborhood of Les Halles, at Les Piétons, then went home for a rest.  Dinner tonight will be simple - crêpes from a crêpe stand near the Champ de Mars, probably.

After the magic of this morning's oboist I think I've hit one of this trip's major highlights already.  

First Day in Paris

It turns out our original flight was cancelled because the plane got STRUCK by LIGHTNING flying out of Paris toward Boston and had to turn around and go BACK!

Twenty-four hours later, we caught a smooth flight - it's amazing how sunny it is above the foggy weather we get on the ground - and landed in Paris without a hitch.  We could tell we were on a French airline: dinner came with wine (no extra charge).  My husband's aunt was at the airport at sunrise to pick us up.

Obligatory first stop:  the neighborhood boulangerie, Weiland, for their delicious petit pain au chocolat.

After a nap, a stroll through a playground that made me sigh:

New French vocabulary word of the day:  crotte.  English equivalent:  turd.  Example:  Il y a beaucoup de crottes sur le trottoir:  There are a lot of turds on the sidewalk. (This situation has actually improved significantly over the last several years.)

Special treat of the day: dark chocolate, tiramisu, and bacio gelato at Amorino on rue Cler. ("Better than Berthillon," quoth my husband.)

We had dinner in Saint-Cyr with one of my husband's friends from high school, her husband, and their three lovely sons, ages seventeen, fourteen, and eleven.  I've visited Europe many times, and almost every time I am struck by how much more mature, well-mannered, un-spoiled, and comfortable-with-adults French kids are compared to their American counterparts, including our own (and ours are pretty good, in my humble view).  I won't even try to guess how that happens. ("Ils sont bien-elevés," said my husband simply.)

She served us wonderful lamb stew with raisins and apricots and a refreshing salad of greens in vinaigrette topped with peaches and cubes of feta.  Simple but delicious.  And yes, she was as well put-together as one might expect from my previous post!  Sigh...competence to aspire to.

Confessions of a Fashion Failure

Oh, how I envy my friend K.  She is not only completely gorgeous but also impeccably stylish.  We were at a conference together not too long ago and I just sighed with admiration at her perfectly-put-together outfits and beautiful hair.  I borrowed this image from one of her enjoyable "Fashion Fixation" posts.  She knows whereof she writes.

I am a dumpy slob.  I LOVE comfort and find it in pyjama-like clothes and sensible shoes.  Getting a "look" together takes me so much darn effort that I usually just give up before I even start.  I like the way light make-up improves the way I look but usuallly can't be bothered to put it on. 

Anyone who has spent time in Paris, though, will know what I mean when I say that if you schlepp around in sweats and T-shirts, you'll stick out as a tourist, or an American - a sloppy one - and be the object of considerable disdain.  In Paris you're supposed to dress like the model in the above photo.  Chapter Ten of Sarah Turbull's book Almost French summarizes it perfectly.  Please allow me to quote a passage:

"Warm up pants?" He's never seen me wearing them before.

"What's wrong with that?  I'm only going to the bakery."

There is a second pause.  Frédéric's eyes implore me.  Finally, he manages to speak.

"But it's not nice for the baker!"

I stare at him, incredulous, thinking, "You can't be serious."  But he is...His girlfriend is about to step out in public wearing "pantalons de jogging" - an item of clothing he wouldn't even wear jogging...

...Underpinning Frédéric's reaction to warmup pants is a concept that to me is totally foreign:  looking scruffy is selfish.  Not only do you look like a slob but you let down the whole city.  In Paris, failure to dress up leads to instant ostracism...

[Fashion designer Ines de la Fressange says] "It is much more comfortable to wear a jacket that is well cut in a nice fabric than it is to look awful."

She pronounces this last word "offal." And suddenly it's quite clear tome that I've spent a good part of my life looking offal...

...Such is the power of Paris.  It inspires me now to dress up too.  The trouble is I'm inconsistent.

Turnbull isn't the only one.  Here's a word from David Lebovitz's book The Sweet Life in Paris:

"The unspoken rule if you plan to live here - but equally good to adopt even if you're just coming for a visit - is knowing that you're going to be judged on how you look and how you present yourself.  Yes, even if you're just dumping your garbage.  You don't want anyone else, such as a neightbor (or worse, one of those garbagemen in their nifty green outfits), to think you're a slob, do you?"

My husband's Parisian mother and relatives would be the first to protest at this characterization of Parisian culture.  But as an outsider coming it, I do feel it when I'm there - not at all from them, the warmest, loveliest people there - but from THEM:  the other Parisians.  I've never been one to put much stock in appearances, but there's an unspoken code there that says, "If you don't care how you present yourself, you don't care who you are, or who we are, and that's a FLAW.  Shame on you."  It's a tougher code and ritual than I'd want to accept for something so trivial as clothing, but I'll admit part of me admires it. Maybe because it reminds me of medicine:  You're always supposed to be at your best, and anything less is just plain weak.  Impossible standards, but familiar ones.

Once in a while you find a dress that's both nice looking and comfortable, that's made of just enough Spandex to feel like cool second skin on your body and make you sigh at the way it feels and falls draped over your body, but not so much Spandex that it clings to the embarrassing bulges and makes you wince when you sit down. I have ONE dress like that, and a couple of other "nice" casual outfits.  So I pack them and hope they'll suffice.   What really matters to me is to be able to get on the flight tonight, at last, get there safely, and have a chance to spend some R&R time with my family.  They, at least, know that whatever they see on the outside, they have with them someone who's pretty happy with herself and absolutely in love with them!

Sign That We're Not Meant to Head Out Just Yet

So, my flight is cancelled.

My reaction?  Oh good -  I need more time to get ready anyway. Not to mention the fact that I'm always relieved to hear I don't have to get on a plane any time soon.

My husband, though, is bummed out.  He went to go hit some tennis balls.

My girl is a little disappointed but also totally psyched that this means she can see The Color Purple again tonight, this time with her dad.

My boy is totally sad he can't sleep over at the neighbors' house even though we're not flying out tonight and just might have to have a breakfast-for-dinner kind of night with his mommy.

I am trying not to let my usual travel anxieties get the best of me.  I was feeling so calm all afternoon.  Now that we're not going tonight, the demons are back:  They're having equipment problems.  Maybe your plane is unsafe.  Maybe your pilot will make a mistake.  Maybe there'll be storms over the Atlantic.  How will you stay calm if disaster strikes?  What can you say to your children to make it easier for them? Isn't it awful to think of being alone and in terror?  Wouldn't you rather just stay home?

No, demons, thank you very much, I wouldn't, not this time.  

Usually I am a home body, I'll admit, but I've earned this vacation, and I intend to enjoy it.  I want to eat some yummy foreign food and walk some charming streets and learn some history and art and just escape to distant shores far away from the work grind.  I want to ooh and aah at beautiful things with the people I love most in the world and laugh with them and be wowed.  If none of that is meant to be, there's nothing I can do about it now.  We're rebooked on this flight tomorrow, and we're just going to have to hope this one actually goes and gets us where we wanna go!

Sign That It's Time To Head Out

I'm off for a couple of weeks.  Blogging may be sporadic...or not!  We'll see how it goes. :)

Do NOT Miss This Show!

My daughter and I have just returned from musical adaptation of The Color Purple.  I've been to a LOT of musicals, but never to one at which I've both been moved to tears AND laughed so hard I could barely breathe!

We were blown away by the incredible singing and acting talent of the touring company, the athleticism of the dancers that brought Africa to life in the main character's mind and ours, the power of the story.  Book, movie, and musical are all so different from one another, yet all so rich and compelling in their own ways.

GO AND SEE IT!  It's a journey unlike any other. (Click on the third video down on this page to get a "feel" for what this show inspires.)

It's here in Boston at the Wang Center until Sunday, June 28.

Then it's going to

Washington, D.C. June 30-August 9

Houston, TX August 18-23

Charlotte, NC August 25-31

Chicago, IL September 2-13

Atlanta, GA September 15-27

Rochester, NY October 6-11

Schenectady, NY October 13-18

Birmingham, AL October 20-25

Miami, FL October 27 - November 1

Norfolk, VA November 10-15

Jacksonville, FL November 17-22

Naples, FL December 8-13

Newark, NJ December 16-27

Indianapolis, IN December 29-January 3

Book Break

Anyone ready for a break?  I know I am!  I have a couple of weeks off coming up very soon, so I'm now contemplating my annual hope-to-read summer reading list. 

I just started The Help by Kathryn Stockett - gripping so far, about the travails of African-American maids in Mississippi in the 1960's.  

Here are some other books I'm thinking of looking into this summer - with the hope of finishing at least a couple of them. (In light of our vacation plans, I have a theme this year: "I see London, I see France, I see medicine, music, and dance."  Corny, huh?) 

If anyone has read anything wonderful lately, please let me know!

I See London...

London Calling by Edward Bloor

Neverwhere by Neil Gaiman

The Duchess of Bloomsbury Street by Helene Hanff

The Daughter of Time by Josephine Tey

The last two Harry Potter books by J.K. Rowling (I'm so behind)

I See France...

Almost French by Sarah Turnbull

Belonging by Isabel Huggan

Sarah's Key by Tatiana de Rosnay

The Sweet Life in Paris by David Lebovitz

A Moveable Feast by Ernest Hemingway

On Rue Tatin by Susan Loomis

I See Medicine...

My Stroke of Insight by Jill Bolte Taylor

Music and Dance...

The Cellist of Sarajevo by Steven Galloway

Appassionata by Eva Hoffman

Dancing on Thorns by Rebecca Horsfall

and, because I just rediscovered the beautiful film version of The Color Purple with my daughter (and am aghast it didn't win any of the Oscars for which it was nominated - if you haven't seen it in a while, do see it again!), I'm trying to dig up my old, beat-up, high school copy of this Pulitzer Prize-winning African American classic.  I think at least one book on everyone's summer reading list should be a re-read. :)

Click here to read Elaine Fine's review of Eva Hoffman's Appassionata and here for a review of David Lebovitz's The Sweet Life in Paris.

"Iran Bans Prayers for 'Angel of Freedom' Neda Agha Soltan"

Oh yeah?  Ban you.

The world has seen and heard.  

You can't silence our lives by destroying our bodies, or muscle your way into being right by doing so much wrong.

Six Uninteresting Things I Love

I got tagged by my friend K. to name "Six Uninteresting Things I Love." Not so easy! Naturally things I love are interesting to me, and discerning what might be considered uninteresting in general seems a little tricky. 

Here's my list:

The house I grew up in after my family and I moved to the U.S.

The morning coffee I drink when I'm at home (AND the particular mug I like to use for it, which has on it a snowy Christmas scene with a dusk-blue sky in the background).

Children's art. I'd quibble with characterizing children's art as categorically "uninteresting;" I actually think it's very interesting. But then again, I took a whole course on it in graduate school, so I guess you can't go by me. I think love of children's art might strike some as similar to the fascination of watching a sleeping child: very enjoyable if it involves one's own, but otherwise, no doubt, singularly dull to most folks. I happen to think my son's cats are fabulous, though. :)

Notebooks and journals. Empty ones. Filled ones. Old ones. New ones. Love 'em.

Supplies. School supplies.  Art supplies.  Artisans' tools.  Pictures of artists' supplies. This is Kyoko's reed-making stuff; other examples of images I've enjoyed perusing include those of old medical kits, dancers' pointe shoes, a row of cellos just waiting to be played, writers' desks...that kind of thing.

Storefronts and doorways. This is the French book shop at Rockefeller Center.

(These are K.'s six things. You can find more examples of beloved "uninteresting" things at Simply Natural, Sixpence and a Blue Moon, Mimi Charmante, and Beach House.   Anali has a variation of this up on her blog too - "Six Unimportant Things That Make Me Happy.")

This meme got me thinking about personal taste. What accounts for it? What possible brain mechanisms could there be to cause one individual to like the color turquoise while another prefers chartreuse? 

There's certainly nothing rational about our aesthetic loves. I'd like a biophysical or biochemical explanation for how (and why) they develop. Our appreciation of beautiful things is one facet of human experience that makes me want to thumb my nose a bit at all the rationalist and reductionist explanations medical people bandy about when it comes to the human mind.  Click here for an article entitled "Our Brains Are Not Us" which reflects on this in greater depth. (Hat tip to Daniel Goldberg, author of the Medical Humanities Blog, for the reference.)

If you're reading this, consider yourself tagged to share your own six uninteresting yet beloved items.  :) 

Just in time. There goes my beeper again...

13th Anniversary

[Photo: Carlos Acosta and Tamara Rojo as Romeo and Juliet, photographed by Tristram Kenton. From The Guardian.]

No piece in the performing arts captures young love like the Balcony Scene from the ballet Romeo and Juliet as choreographed by Kenneth MacMillan, with music by Prokofiev. All the over-the-top ecstasy, passion, can't-get-you-out-of-my-head delirium is there, as well as some of the innocent joy and tenderness of genuine affection, the kind that hints at a gentler, steadier love that could blossom once the intitial blaze quiets down.

Today is my 13th wedding anniversary. As I watch this rhapsodic pas de deux I still find myself getting goose bumps and getting a little teary-eyed, familiar as it is to me. Sometimes I still daydream about ballet, and whenever I imagine myself in the role of Juliet, it's my husband's face I see across the balcony, his arms tossing off the romantic cape and opening to embrace me. The music still expresses today what I felt about him when we were first married - more so, actually, now than ever.

"Why is it still like that for us?" he once brought up in conversation.

"I know!" I agreed. Then, "I don't know - we're totally hooked."

We took a leap of faith and got lucky, I guess. This is the kind of love I want my kids to have when it's their turn. What's our secret? How can we maximize their chances of finding it? I have no idea. A patient once told me your partner should supply the parts of your brain that are missing.  There's something to that! I don't subscribe to the idea, or the magical thinking implicit in the idea, of soulmatess; that's too easy. I think human beings are (or should be) versatile enough to find magic with any number of other individuals. I prefer the idea of soul partnerships, and I think those take real, taxing, committed WORK - 1% magic, 99% sweat! - so easily forgotten or brushed aside in the concept of soulmates. 

In some ways partnership in life is a little like partnership in dance. I was just watching a clip of Darcey Bussell and Jonathan Cope in rehearsal, and I found myself thinking, "They're like an old married couple!" There was such an ease and comfort about them - the way they knew each other's bodies and minds so well, the trust they had that each would be there for the other, would help the other. They had a kind of chemistry - not romantic; they have their own spouses - but an ineffable connection nevertheless: a spark. They clearly had a strong friendship, too. They knew each other and were open to each other and trusted each other. That trust was built on a lot of hard work, work they had to continue to do to make the partnership functional. They could be honest, they could laugh together - they were just very, very comfortable, but also able to bring out some exciting energy and push beyond their limits.

Sometimes I wonder what I might say to my own daughter if she were to ask me how to cultivate such a partnership. Her next birthday will be the last one before official teenage-hood. It's bittersweet for her father and me: we've so loved her childhood and will miss its relative simplicity and joy, yet we're so full of wonder at the young woman she's just starting to become. She's grown three full inches since last summer and is now big enough to wear some of my shoes and clothes; yet we can still enjoy stuffed animals and cartoons together.

A couple of years ago she announced, to no one in particular, "Marriage is life's great happiness." When I asked where she got that idea, she answered, "You two," meaning her dad and me. I was so happy to know we've given her a view of marriage that's full of love, happiness, and respect. I do have the kind of marriage right now that I would wish for her and her brother. What suggestions would I have if she were to ask me how to find such a match?

I'd encourage her to look beyond love. What I mean is, it takes much more than being in love to be ready for marriage. Love's the easy part, in a way. There are many people with whom one might find an irresistible "chemistry" as well as the ability to be "best friends." This is just the baseline. But to make a marriage work, she'll need a partner with whom she can build a real future - one made with common dreams and priorities, with shared values and vision.

I'd be asking,

• Does he care about her dreams and want them to come true for her, and vice versa?
• Is he threatened by her dreams or gifts at all, in any way, or rather is he excited about and supportive of them?
• Can they have a real conversation on the same level about anything she might want to have a conversation about, be it a current event, a scientific theory, a piece of literature or history, a silly movie, a way to fold laundry, a flash of insight in the middle of doing groceries?
• Do they have the same priorities?
• Is he secure enough about himself to let her be herself, and in fact love that self?
• Does he bring out the best in her?
• Is he humble enough to admire her, caring enough to admonish her, courageous enough to stand by her?
• Can he open up to her, and she to him?
• Will he be affectionate with her each day, as she deserves?
• Are they mature and humble enough to admit their own faults and failings, and not resolve conflicts by assigning blame, or deal with stress by hiding from it in some way?
• Will he continue to speak to her politely, with common courtesy, even after they've known each other a long time?Express delight when she comes home from work? Show small signs of appreciation daily? - in other words, KEEP WORKING ON THEIR RELATIONSHIP moment to moment, even when it's going well, so as not to slip into taking her for granted?
• Is he mature enough to love her wholeheartedly even when she starts to get wrinkles and saggy parts?
• When she fractures a hip, will he love her enough to help her on and off the commode, with kindness, and compassion, and affection?
• Is he the one she's completely comfortable with?
• Can they laugh together?
• Cry together?
• Enjoy a sense of wonder together?
• Is he willing to truly know her?

• Can she trust him?

This last question is, I think, the one to which all other questions point. Trust. There's something deeply intimate about it, and this profound intimacy is really what she was referring to as "life's great happiness." It's Darcey knowing Jonathan will catch her when she leaps, will focus his attention on their work together, will know her movements and needs and respond by being there for her. And all these things I hope and dream a partner will provide for my daughter someday, my daughter should also have the capacity and willingness to provide for him.

Marriage takes virtue. It takes patience, generosity, acceptance of imperfection, a well-formed sense of self, kindness, and mutual respect. If these aren't present at the beginning of marriage - and I admit with all sheepishness that I certainly had much growing to do in many of these areas thirteen years ago, and still do - there should at least be the potential and intention to develop them.

To my daughter and son, I want to say, I hope you find partners who appreciate and love how special you are and support you wholeheartedly in your journey toward being your best self.

To my husband, I say, Thank you for being the kind of partner who makes me feel truly known and truly loved, and for letting me be me, and helping me be a better '"me."

It Could Happen To You

One thing anesthesia training is supposed to do is teach people always to be prepared for the worst - to "wear suspenders AND a belt," as one CRNA I know often says. It may strike some people as a pessimistic mentality to be constantly looking for lurking trouble or signs of impending disaster, but it's a huge component of our job, and without that kind of intense vigilance we can't protect people from the many potential dangers that anesthesia and surgery can present. So we make a habit of forming a plan A, plan B, and plan C at the very least, with equipment and drugs to carry out those plans ready for action.

Sometimes we are haunted not only by scary moments and near-misses from our own experiences but also by the stories carried by others. Everyone knows someone who has lost an airway, seen a patient wake up paralyzed or blind from spine surgery, run a code in the O.R., or had some other dreaded complication that people who practice anesthesia, even the best and most skilled, inevitably face more than once in their careers.

Someone I know experienced a horrific loss on the table of a very young patient involved in a motor vehicle accident. The surgeon felt there was no time to wait for family members to arrive at the hospital. The patient was brought to the operating room, and when the incision was made, blood came pouring out of the patient's body. The aorta had been sheared almost in two during the accident and had been held together by internal organs until those organs were dislodged by the surgeon's incision. The anesthesiologist tried hard to keep up with the blood loss but resuscitation was impossible, and from the surgeon's perspective so was repair. "Fix it," urged the anesthesiologist. "I'm not losing this kid." But it was not fixable. By the time the family arrived it was all over. The patient had exsanguinated.

This is every anesthesiologist's nightmare. So the last time my pager went off and it was because there was a young kid in the E.R. with a ruptured spleen, I immediately thought of this story. A ruptured spleen could mean a relatively stable patient with a slow ooze or a rapidly deteriorating patient in shock needing immediate resusciation. Even with patients who appear stable at first, surgical incision can be a prelude to all sorts of difficulty, or to none at all. You never know what you're going to get, and you have to go in prepared for disaster.

It's for dangerous cases like these that we go through all that training. They can still be scary, but at least you have an arsenal of options at the ready. Knowing how to set up and plan for tough situations is half the battle; executing the plans is the other half. The training helps us maintain a calm demeanor and keep our hands moving, taking action. When that call came in, I worked as quickly as I could to prepare for the case: large bore IV's ready, bags of fluid attached to multiple stopcocks, fluid warmers, blood tranfusion sets, invasive monitors, suction, airway equipment, multiple drugs already in their syringes.

Then I went out to meet the patient, who was deathly pale, and the family, who were worried sick. My colleague's voice echoed in my mind: I'm not losing this kid.

My own mental voice tried to nag me: Did you remember to set up everything? What if something totally unexpected happens? What will you do if you can't protect this patient? What will you do if you try, but fail?

I shushed it. I'm ready for this. Done it before. I know what to do.

Hours later I was in the family waiting room telling this family their young loved one had done well and was dozing comfortably in the recovery room. Thanks to a competent surgeon and a supportive, physically and mentally available nurse and tech, I was able to do my own job effectively and make sure this kid got through the operation. But such successes are never enough to take the edge off the tension of similar cases that follow. Knowing how you want to approach such situations makes them more manageable, and can make the work proceed more efficiently, but I don't think it makes them less scary.

I think that's as it should be. The worst thing we can do in this job is lose that edge, that watchful anticipation that things may not go as planned. It may be a somber approach, this perpetual state of "red alert," but it keeps our patients safe.

A Little Self-Medication

SurgeXperiences 225 is up at Jeffrey Leow's blog.  This cartoon featured in the blog carnival, shared by Scanman, from the strip Mythtickle by Justin Thompson via Gocomics, put a smile on my face on this rainy, lonely Sunday on call:

THANK YOU, SCANMAN!

***

Top 5 Things That Can Usually Cheer Me Up When I'm Feeling Blue

5) Reading nice, stress-free, well-written articles in magazines or blogs. My current pick is "Castles in the Mind" from the July issue of O magazine - wonderful article about writing, featuring the authors Jim Shepard, Toni Morrison, and Michael Cunningham.

4) Peanuts comic strips.  I love those characters.  Every time I attend one of my kids' school functions I feel like I'm IN a Peanuts comic strip.

3) Certain video items: my daughter's video clips from her recent performance of Annie, and the movies The Trouble with Angels, Elf, and By the Light of the Silvery Moon.  (I know the gender politics in the latter are obsolete and totally jarring to modern sensibilities, and it's totally corny, but somehow I just LOVE that movie.)

2) Laughter in good company, such as I had last night at my sister-in-law's house over tostones with yummy mojito sauce.

1) Smiles, hugs, and kisses from my husband and children.

From the Boondocks

[Photo: my great-great-great grandmother, who gave birth to my great-great-grandfather in 1853.]

boondocks \ˈbün-ˌdäks\ Etymology: Tagalog (bundok = mountain); 1) rough country filled with dense brush 2) a rural area: "sticks"

"The term boondocks refers to a remote, usually brushy area, or to a remote city or town that is considered unsophisticated. The expression was introduced into English by American military personnel serving in the Philippines during the early years of the 20th century." (Wikipedia)

Tomorrow is Independence Day in the Philippines, but I don't feel entirely right celebrating our independence on June 12.

The Philippines made a Declaration of Independence from Spain on June 12, 1898, after almost 400 years of colonial rule.

But with the Treaty of Paris signed on December 10, 1898, ending the Spanish-American War, the Americans forked over $20 million and Spain ceded the Philippines to the U.S. along with Puerto Rico and Guam.

I'm impressed by the forward-thinking remarks of Republican Senator George Frisby Hoar of Massachusetts, who said, "This Treaty will make us a vulgar, commonplace empire, controlling subject races and vassal states, in which one class must forever rule and other classes must forever obey."

Mark Twain wrote this in the New York Herald, October 15, 1900:

"I have read carefully the Treaty of Paris, and I have seen that we do not intend to free, but to subjugate the people of the Philippines. We have gone there to conquer, not to redeem. It should, it seems to me, be our pleasure and duty to make those people free, and let them deal with their own domestic questions in their own way. And so I am an anti-imperialist. I am opposed to having the eagle put its talons in any other land."

After a bloody Philippine-American War during which American soldiers were reportedly ordered to kill all Filipinos over the age of 10 and in which there were up to a milllion civilian casualties in a country with a population of 7 million; a period of "tutelage" as an American territory, then as a commonwealth; and occupation by the Japanese during World War II, during which Americans and Filipinos fought against a common aggressor, the United States finally recognized Philippine independence on July 4, 1946.

Americans probably spent a lot of time hiding in the bundok during the Spanish-American War, the Philippine-American War, and World War II. The last generation to have such close contact with our culture is disappearing. My current impression of American knowledge of the Philippines is that most people here mistakenly lump us together with other Asian cultures when we are actually more hispanic. The Spanish language has almost completely fallen out of use, sadly, with my generation, but Spanish was my first language. My parents spoke it at home. They use it conversationally with many of their friends. One can find recipe notes and personal diaries from my grandparents' and great-grandparents' generation written in Spanish.

We have Americans to thank for the gift of the English language, which is still the language of business and the professions. But it, too, is in decline, thanks to a misplaced sense of nationalism that has failed to motivate the preservation of some of the more positive aspects of a sometimes dark and bloody history.

I have not been abused by a Spanish cleric or mocked by an American racist imperialist, so I have the psychological luxury of being free to enjoy this rich heritage. I can close my eyes in the middle of a plaza in front of one of our colonial churches, hear the sounds, smell the aromas, and feel at home with them:

...a Spanish priest entering the rectory, saying to someone "Si, a la izquierda por favor, gracias..."

...a street vendor chanting, "Bili na, bili na mam..."

...the aroma of churros con chocolate wafting over from a nearby cafe...

...a radio playing an American pop song: "All I wanna do / is have some fun..."

...the crackle of our version of spring rolls, lumpia, frying in a pan...

...murmurs of the Lord's Prayer audible from the Mass inside the church: Ama namin, sumasalangit ka...

...the loud honks of backed-up traffic

...the smell of smog and the occasional whiff of urine from a street puddle

...spoken English mixed with Chinese mixed with Tagalog coming from various passersby...

When I open my eyes, for a moment I can almost see the ghosts of centuries past. My great-grandmother selling ensaymadas on the church steps to earn a living for her seventeen children...an American soldier with a Hershey bar meeting up with my ten-year-old mother as she and her relatives emerged from a trek through the bottom of a ravine while the screams of people being massacred above were still echoing in their minds...men and women dancing folk dances from Spain and Mexico with a decidedly Philippine touch...veiled women in church, then at home jotting down recipes in Spanish, dishes with names like guiso de carne de puerco con camarones and sopa de arroz...then later, diaries and letters in English...strong women, women doctors and lawyers, professors and senators, for decades more numerous than their American counterparts...a great legacy!

Each Independence Day I am glad to celebrate my country's freedom, but I also celebrate its rich and colorful history - our collective memories, good and bad, which have made us who we are today.

Simplify

Everybody loves the latest gadget. Medicine folks are no exception.

A couple of years ago the latest hot item in anesthesia was the video laryngoscope. People looooooooooooooooove the video laryngoscope.

A laryngoscope is an instrument used to intubate, or place breathing tubes into the windpipes of, patients. It consists of a blade and light bulb that snap onto a handle, forming, more or less, an L shape. A Macintosh or "Mac" blade gives you an L with a slight curve, to follow the contours of the tongue, and a Miller blade gives you a perfectly straight "L." Macs are the most common first-line choices for intubating patients.

Most of the time when the laryngoscope is inserted into a patient's mouth and used to lift the tongue and epiglottis out of the way, the vocal cords come into view and a tube can then be passed into the trachea. For beginners confronted with challenging airways, this is harder than it looks; for most seasoned anesthetists, this maneuver does the trick nine times out of ten.

Over the years many life-saving back-up devices have been developed to assist in difficult cases. The gum elastic bougie, perhaps the lowest-tech of low-tech devices, is one. It's basically a floppy rubber rod that can be eased blindly into the windpipe such that a breathing tube can then be threaded over it into the right place. Others include the fiberoptic bronchoscope - a camera at the end of a slender, flexible, snake-like tube that can be used to navigate through tough anatomy; the intubating laryngeal mask airway (LMA); the light wand; and other such technologically snazzy gadgets.

Lately, though, the sexy video laryngoscope has been the go-to guy (or gal) in many centers. Have a set of vocal cords so far behind the epiglottis you practically need a periscope? Grab the Glidescope or the McGrath or the Storz Camera or whatever brand of video laryngoscope your hospital orders. You'll see those cords sans problème.

Except when you can't - when even the flashy, Fifth Avenue, glamourous device du jour can't show you squat past the epiglottis. This is rare, admittedly, but I have seen it happen to one of my colleagues, and it happened once to me.

What then? You're at the supposed crème de la crème of airway devices. Do you demote yourself to the lowly bougie?

Here's what I've learned from intubating people three or four times a day, day in, day out. Fanciest isn't always best. The bougie is by no means lowly, and the basic laryngoscope blades will save someone's life.

I see many clinicians around me jump right to the video laryngoscope at the slightest suspicion of difficulty. I've had people in the O.R. ask me with a hint of criticism in their voices after a tough airway, "Why didn't you just go right to the video laryngoscope?"

I once saw a patient and realized I had been her anesthesiologist for a previous operation. When I looked at my record of that event, I noticed I had myself jumped directly to the video laryngoscope because my physical examination of the patient and a couple of features in her history suggested a very challenging airway. I also noticed, though, that the device had proved inadequate, and I had achieved the intubation with the help of an intubating LMA instead.

For this patient's second operation under my care I took no chances. I asked a second clinician to be present in the room to help me in case of trouble. I had the difficult airway cart, the video laryngoscope, and a prepared intubating LMA ready for immediate use. I gave the anesthetic, then snapped a Miller blade onto my regular laryngoscope handle.

I took a look. No cords.

I adjusted the blade position and asked my assistant to apply pressure to the cricoid cartilage. Still no cords.

I manipulated the cricoid myself and found if I shifted it over to the side, voilà! - lovely white vocal cords, as far away from me as they could possibly be, but visible. This was why the video laryngoscope hadn't given me a good view. Her glottic structures were totally deviated from the midline - a feature that was not obvious externally.

"Can you just put your finger where mine is right now and hold it right there?" I asked the person who was helping me.

"To the side like that?"

"Yes, just like that."

The breathing tube slid right into position. I hooked up the oxygen, gave a manual breath, looked for chest rise, for condensation in the breathing tube, for carbon dioxide exhalation on my monitor. I listened with a stethoscope: breath sounds on both side of the chest. Now I could breathe. I sent the bulky equipment away, keeping only what I thought I might need if I needed to repeat the intubation.

Not too long before or after I took care of this patient, I went to evaluate another patient up on the floor who wasn't sure her epidural was working. When I walked in with an ice-filled vinyl glove, her eyes widened with curiosity and some amusement. "What is that?"

I wasn't able to find a tongue depressor nearby to snap in half for pin-prick testing or an alcohol swab to check for cold sensation, but the ice dispenser was right outside her door. "It's my super-duper sensory exam device," I replied.

The patient chuckled. "I like it. I like home-made stuff. Too many gadgets these days."

I do like the gadgets, but I agreed with this patient. I will never underestimate the importance of the basics - basic stuff, basic skill. I believe in them, and in keeping things as simple as possible. The sophisticated technology has its place, and I appreciate it, to be sure, but I also believe we should know what to do, or try to do, or how to improvise, if all we have are a pair of hands, a flashlight, a stick, and a rubber hose.

Difficult Conversations

Medicine can be full of difficult conversations.  

If we're lucky we get some guidance with these during our training years, and I believe there are movements afoot in training programs across the country to help clinicians learn how to manage these better, but there's no getting around the fact that they're hard.  Hard for patients, hard for doctors.  Everyone wants to be sure all the right things get said, ideally with clarity and grace.

Before I walk into a patient's room to have one of these difficult conversations, I try to have a mini-conference with the patient's nurse and, if possible, other doctors involved in the patient's care.  I still find that I ask myself the same questions I used to ask when I was a student. 

What am I going to say?  

How can I possibly say that?  

What can I do to make this easier for them?  For me?  

Will they understand everything they need to?  Will I?  

How can I make sure they know I'm listening, too?

What's easier now, a few years down the pike, is that I've had more experience from which to draw answers and examples.  I'm more confident about what I know and what I think, and pretty comfortable admitting what I don't know or am not so sure about (although the latter was already true back when I was in school).  But the conversation itself - coming up with the words, the actual words - isn't that much easier now.  It's still hard to talk about the important stuff - life, death, love, sex, fear, hatred, secrets, pain - face to face.

I find that difficult conversations revolve around one or more of the following underlying themes:

• "You suck."
  
• "You're wrong."
  
• "I'm wrong."
  
• "I can't..."
• "You can't..."
• "I don't want to..."
  
• "I want/need you to..."
  
• "We've got trouble."
  

With patients, some of the most common difficult conversations are along the lines of "We've got trouble."  Sometimes it's relatively small trouble:  I have to postpone your surgery by a few hours because of the chewing gum you were chewing when you walked in.  Sometimes it's a little more serious: I have to cancel this entirely because the monitors suddenly show you in a bad heart rhythm.  Sometimes the trouble is huge:  You're probably going to die.   

One type of conversation that can be particularly challenging is the negotiation to suspend a DNR/DNI order when a patient needs to be intubated for surgery.  I always try to let patients and their families express what it is that they really don't want - usually it's a long, drawn-out dying process in the presence of life-sustaining machines.  Then we go item by item down a list of possible interventions during the resuscitation process that providing anesthesia requires in all patients to some degree, in some patients to a greater degree:  drug intervention, arterial and central lines, CPR, defibrillation, open cardiac massage, blood transfusion, temporary assisted ventilation in the recovery period.  So far I've been able to reach a consensus with families - a detailed plan that clarifies what they give me permission to provide while I'm in the operating room with their loved one.

Another type of difficult conversation is the one informing a patient that for safety reasons, he or she needs to be intubated while still awake.  I guess this would fall into the "You can't" or "I can't" category ("For your own safety, I can't knock you out before putting the breathing tube in") or the "I want/need you to" category ("I need you to let me place this instrument into your wind pipe with you not entirely asleep so I can make sure we can secure your airway").  

I find this one even tougher than the preceding example.  At least in a DNR suspension there's some room for negotiation; for a really tough airway, though, there isn't much wiggle-room at all.  Even with fancy video laryngoscopes that have come into clinical use in the last few years, we still occasionally encounter those scary, impossible airways that make your blood run cold.  I once worked with a surgeon who transferred a patient to a tertiary care facility because he was nervous about the patient's airway in the middle of the night in a small hospital with only a skeleton crew.  We heard later that the awake intubation at the tertiary care place took an hour to do.  It's serious business.

Med school and residency train us to know what to do and when.  As for what to say and how (or how not) to say it, well...I suspect most of us get the bulk of training where we learn most of our communication skills:  from our relationships, mostly outside the classroom.  For most of us that means the training is ongoing, and we're all going to be works in progress for a very long time.  May all our difficult conversations be imbued with attentiveness and a gentle spirit!