Sunday, April 26, 2009

Bloggers Are Dying: Join Our Blog Rally (Updated - See Below)




I have never been a person who would stoop to self-censoring and I never will be. I'd rather not write at all if I have to stop being frank and honest in my words. -Omid-Reza Mir-Sayafi



Today Roxana Saberi spends her birthday on a hunger strike in Tehran's Evin Prison, where she has been incarcerated for espionage. According to NPR, "The Iranian Political Prisoners Association lists hundreds of people whose names you would be even less likely to recognize: students, bloggers, dissidents, and others who, in a society that lacks a free press, dare to practice free expression."

Hearing reports like these made me want to do a ribbon campaign. Blue for blogging.  So I've emailed a group of blog friends to ask them to join me, and if you're reading this and have a blog, website, or facebook page, I'd like to ask you to join me as well.

It's been thought of and done before, of course, as I found out soon enough when I did a quick search for blue ribbon campaigns. So I went ahead and borrowed a blue ribbon and am "wearing" it on my blog this week in gratitude for the very fact that I can do so, openly, without fear of suppression, persecution, or death.

Please consider placing a blue ribbon on your blog / website / facebook, myspace, or twitter page this week in honor of the journalists, bloggers, students, and writers who are imprisoned in Evin Prison, nicknamed "Evin University," and other prisons around the world, for speaking and writing down their thoughts.


Omid, incidentally, means hope in Farsi. Omid-Reza Mir-Sayafi is dead. Hope has to live on.

***

If you would like to join my fellow bloggers and me in this blog rally, please consider posting one of the following (modified as you wish) or an adaptation of the above post on your blog or website with a blue ribbon.

Version 1:

A group of bloggers is holding a blog rally in support of Roxana Saberi (who is spending her birthday on a hunger strike in Tehran's Evin Prison) and of others who have dared to express their thoughts freely only to be imprisoned, abused, or killed.  

Please consider placing a blue ribbon this week on your blog, website, and facebook / myspace / twitter page, and invite others to do the same,  in honor of the journalists, bloggers, students, and writers who are imprisoned in Evin Prison (nicknamed "Evin University") and other prisons around the world for speaking and writing down their thoughts. 

Version 2:

The Universal Declaration of Human Rights states, "Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference, and impart information and ideas through any media regardless of frontiers."

Journalist Roxana Saberi has been incarcerated in Tehran's Evin Prison, where she is spending her birthday on a hunger strike. Around the world, people continue to face similar violations of their rights to freedom of expression, free speech, and a free press. Let's show the international community that we won't be silenced by intimidation and tyranny  - that we won't stop believing in and fighting for these rights.

Freedom of the press is not a luxury.  It lies at the heart of making this world healthier and more just. People without a voice and without a clear line of sight into the things that would threaten or corrupt their societies cannot hope for equitable growth and meaningful change.

A group of bloggers is holding a blog rally in support of journalists, bloggers, students, and writers who have dared to express their thoughts freely only to be imprisoned, abused, or killed.  

Please consider "wearing" a blue ribbon online this week on your blogs, websites, and facebook / myspace / twitter pages, and invite others to do the same.  Get the discussion going, and keep it going!

***

Free Press Map of the World from Reporters Without Borders:


***

Suggestions from Amnesty International:

RECOMMENDED ACTION: PLEASE SEND APPEALS TO ARRIVE AS QUICKLY AS POSSIBLE, IN PERSIAN, ARABIC, ENGLISH, FRENCH OR YOUR OWN LANGUAGE:

- calling for the immediate and unconditional release of Roxana Saberi as, on the basis of the available evidence, she is a prisoner of conscience;

- calling for her “confessions” to be disregarded as Roxana Saberi may have been deceived into making incriminating “confessions” while held in pre-trial detention.


APPEALS TO:

Head of the Judiciary

Ayatollah Mahmoud Hashemi Shahroudi

c/o Director, Judiciary Public Relations and Information Office

Ardeshir Sadiq

Judiciary Public Relations and Information Office

No. 57, Pasteur St., corner of Khosh Zaban Avenue

Tehran, Iran

Email: info@dadiran.ir (In the subject line write: FAO Ayatollah Shahroudi)

Salutation: Your Excellency


Leader of the Islamic Republic

Ayatollah Sayed ‘Ali Khamenei

The Office of the Supreme Leader

Islamic Republic Street – End of Shahid Keshvar Doust Street

Tehran, Islamic Republic of Iran

Email: info_leader@leader.ir

via website: http://www.leader.ir/langs/en/index.php?p=letter (English)

http://www.leader.ir/langs/fa/index.php?p=letter (Persian)

Salutation: Your Excellency


COPIES TO:

President

His Excellency Mahmoud Ahmadinejad

The Presidency

Palestine Avenue, Azerbaijan Intersection

Tehran, Islamic Republic of Iran

Fax: + 98 21 6 649 5880

Email: via website: http://www.president.ir/email/


Director, Human Rights Headquarters of Iran

Mohammad Javad Larijani

Howzeh Riyasat-e Qoveh Qazaiyeh / Office of the Head of the Judiciary

Pasteur St, Vali Asr Ave., south of Serah-e Jomhuri

Tehran 1316814737, Iran

Fax: +98 21 3390 4986 (please keep trying)

Email: info@dadgostary-tehran.ir(In the subject line write: FAO Javad Larijani)

Salutation: Dear Mr Larijani


and to diplomatic representatives of Iran accredited to your country.


You can also write to:

His Excellency Ambassador Mohammad Khazaee, 
Permanent Mission of the Islamic Republic of Iran
622 Third Ave.
New York, NY 1007
e-mail: iran@un.int 

To read samples of Roxana's reporting, click here.

To contact the White House, use this link/URLhttp://www.whitehouse.gov/contact/

Friday, April 24, 2009

Surgeons v. Anesthesiologists II: Disagreement


The operation itself had gone smoothly, but after about half an hour in the recovery room the patient's heart rate had almost doubled and his blood pressure was low.

I went to check on the patient and found the surgeon already there.  "I've sent a crit," he said.  "He could be bleeding."  Crit.  Short for hematocrit.  From the Greek words hema, blood, and krites, judge.

Already the surgeon had asked the O.R. team to set up new instruments in an empty O.R. for an exploratory procedure to rule out post-op hemorrhage.  I followed suit, quickly setting up anesthesia equipment and drugs for possible emergency surgery.

Back at the bedside, the blood test had come back.  "Postop crit's a little lower than pre-op," the surgeon remarked.

I glanced at the numbers.  "Not by much.  After the amount of I.V. fluid he's had, that's basically an unchanged blood count."

"I still think he's bleeding from somewhere.  Are you ready to go?" he asked, looking as if he might wheel the bed to the O.R. himself.

"I'm ready," I said.  "But shouldn't we consider other possible causes - "

"He's actively bleeding.  There's no time."

I wasn't convinced, but we went to the O.R., and I anesthetized the patient for the second time that day.  I was able to bring the patient's blood pressure up some, with drugs, and get his heart rate down as well.  His oxygen saturation was perfect.  His exhaled carbon dioxide was right on the mark.  

"You fixed him," the surgeon said good-naturedly, just to lighten the mood a little.

"I wish!" I said, still busy with all the little tasks that added up to the kind of borrowed stability he was observing on the monitors - a cc of this in the I.V., a cc of that, ventilator adjustments, fluid status checks.

A nurse anesthetist named Mike came in to take my place at the helm but asked me to stay close by.  

"I don't think this is a bleed," I said to him. "I have a feeling it's cardiac."

Just then the surgeon announced, "Well, there's no blood in the abdomen.  It's gotta be in the stomach.  Guys, let's get endoscopy in here to scope out the stomach."

"He's not going to find any blood in there either," I said privately to Mike.

"How do you know?"

"I think something else is wrong.   Just a hunch."

"Patient's kinda young to have heart problems."

"Maybe.  But it's not out of the question.  We can't just write it off.  The EKG on the monitor's a little different from earlier."

The surgeon overheard and glanced over at the monitor.  "I don't see any ischemia," he said.  "Is the blood here yet?  Let's hang a unit of blood."

"Matt," I began, trying to open a discussion with the surgeon, "his crit's not that low.  We might want to hold off on a transfusion if - "

"He's actively bleeding!" the surgeon insisted.

"I just think we should consider a cardiac possibility - left ventricular failure, post-op myocardial infarction..."

"He's bleeding.  Hang the blood."

Quoting the latest critical care studies about conservative blood transfusion practices would have been futile. I whispered to the nurse anesthetist, "Go ahead and hang it, but go easy.  Volume resuscitation's gonna help the low blood pressure, but we don't wanna to go too fast."

The endoscopists arrived to perform the internal examination.  They passed a camera into the patient's mouth... throat... esophagus... stomach.  We could tell where we "were" by looking at the walls of tissue in the cavity the camera happened to be occupying.   Little dots, the papillae, on the tongue.  Smooth, pink mucosa in the throat and esophagus.  Characteristic rugae on the inner surface of the stomach.  No blood.  

Mike, the nurse anesthetist, looked at me and gave me a secret finger-point and thumbs-up.  "You were right," he whispered. "No bleeding."

"Get a post-op EKG and send enzymes when you get to recovery," I said.  "Still hard to say exactly what this is."  The vital signs were stable, more or less. The surgeons were closing. I left the room to meet with another anesthetist.  

Later I got a call from Mike.  "Hey, I just heard the upshot."

"And?"

"Pericardial effusion."  A collection of fluid in the sac containing the heart, limiting its ability to contract effectively. No wonder the blood pressure had been low and the heart had been beating so fast in an attempt to compensate.

"How did you know?" Mike asked.

"I'm not sure.  It just wasn't behaving like a hemorrhage."

"The surgeon couldn't see it as anything else."

"He must be flippin'.  Did he admit the guy to the ICU?"

"They're still talking about whether to watch it or drain it."

The patient was actually doing pretty well, all things considered, and was alert and in good spirits.

"I wish I had insisted on more of a discussion before going back to the O.R.  I didn't think it was a bleed from the very beginning."

"You did try to tell him. He wouldn't have listened anyway. He never does when he gets like that.  It's his way and what he sees and what he wants.  Everyone else is wrong.  What can you do?"

I sighed.  I tried to picture myself trying to get this particular surgeon to listen to another opinion, to consider not getting fixated on one possible cause of the observed problem.  He was a good guy, but Mike was right:  he would not have been receptive.  It had been his operation, and it was his right to make the final judgment on whether it was necessary to go back and re-examine what he had done.

My instincts had been on the mark that time, but I told myself they could easily have been wrong.  There could very well have been a hemorrhage, one that surgery could have corrected and stabilized, in which case going back to the O.R. quickly was the best thing the surgeon could have done for his patient.  I can't really fault a physician for being too cautious; only for being too cavalier.

And yet.  Part of me wished there had been time for a real discussion to take place, and the inclination to listen on the surgeon's part.  I had been in a similar position with this surgeon before. I once diagnosed an intraoperative occurrence as a common and easily treatable respiratory event and tried to reassure him, in my capacity as a consultant and airway expert, that it would be safe to proceed, but he had insisted on reversing the anesthetic, waking the patient up, and sending the patient to a specialist, who subsequently assessed the incident as the common and easily treatable respiratory event I had previously identified.

"Better safe than sorry," the surgeon had said to me after that.  Well, okay, sure.  I'm an anesthesiologist, after all - a physician obsessed with safety.  That's practically our mantra whenever we set up for any given case. 

But shouldn't all our years of hard work and training allow us to have some trust in our own discernment?  Sure, everyone's terrified of making a bad judgment call.  Making the wrong call.  Making a mistake.  Those cost lives in medicine, and engineering, and aviation, and a whole host of professions.  But we've spent so much time and energy learning how to gather information, put it together, analyze it, and interpret it.  Shouldn't we be practicing with those intellectual skills, instead of making decisions mainly out of fear? Defensive medicine is understandable in this society; but it's costly, not only in monetary terms but also in other, less tangible ways.  We sell ourselves short by failing to implement our hard-earned clinical judgment.

I am still figuring out how to advocate effectively for patients in these types of situations and conversations without committing an error myself, missing valuable input from colleagues, or escalating tensions.  I'm sure I don't always say the right things in the right way, or make perfect decisions.  The process is not as simple as people might imagine.  But I'm learning, and I suppose it's going to be a lifelong series of lessons.

Monday, April 20, 2009

Ironing Out the Teamwork Kinks


Sometimes it's hard to be the newbie and the one in charge.  I'm still learning.  

One of my colleagues was working with a nurse anesthetist and asked me to help with a patient whose airway was very obviously going to be difficult beyond belief.

We were right about that, unfortunately.  I won't go into all the details, but we spent a long, tense time trying to intubate this patient, and we needed to demonstrate some high-performance teamwork.  

In the middle of this very tough and very important process two things happened.  When I asked someone on the team to have a particular medication hooked up and ready to administer to the patient, the person refused, saying only that he "didn't want to" do that.  Later I also found out that the same person had temporarily shut off a device without letting anyone know.  Neither action resulted in negative consequences for the patient, but I was unhappy with each of them and knew I would have to talk to the individual about his actions afterward.

When we were wrapping up and the situation had stabilized, the clinician in question noticed I had grown pretty silent and asked if I was upset with him.  Yes, I wanted to say.  I'm totally upset.  But instead I took a breath, put a hand lightly on his elbow, and said, "I'm not upset with you.  But I think there were things that should have gone differently."

He understood immediately and said, "Ok. I'll come find you after so we can talk."

He got the patient settled in the recovery room, than came to join me in the anesthesia office, where I was chatting with another colleague.

"So, what were you unhappy with?"  he asked.

"Well, the main thing is that we were operating without an important piece of equipment for several minutes."

"I know.  I'm sorry - I shouldn't have shut it off."

"It's not that so much as not communicating that to the rest of us.  We were assuming something was there that just wasn't."

"I'll never do that again."

"No, you can do it if you have a reason, but  I want to suggest that we all get into a habit of announcing our actions and echoing people's announcements when they make them, so the speaker knows the communication has been received successfully, and everyone on the team is on the same page.  That's really important, especially in a hard situation like that.  But even in ordinary situations.  Like when the surgeons ask for the table to be lowered, we should demonstrate that we're paying attention by answering either 'Table going down," or 'Standby, please, for table down' if we need a second to move stuff out of the way. Closed-loop communication should happen everywhere, not just cardiac cases."

"Gotcha."

"The other thing is that I was trained to have my drugs drawn up, ready to go, and if possible, hooked up, in line, in case of acute need during a situation like the one we just had.  There's no reason not to be prepared like that, especially if as you said this particular procedure is something you haven't done on your own before."

"I know, I guess I just get nervous they'll accidentally get injected."

"I can understand that, but that's what stopcocks are for.  It's worse to lose precious seconds fumbling for syringes while a patient's crumping."

"Ok."

"But the communication is the main thing.  We can't afford to lose crucial moments or data.  I'm guilty too - I gave a small dose of esmolol during a busy moment but just made a note of it without verbally announcing it, whereas I should have said, 'thirty of esmolol going in now.'  So I think we need to make a group effort on the team communication thing."

He didn't get defensive and he certainly wasn't indifferent; in fact, I know already from working with him before that he cares very much about doing the right thing for his patients.  Yet I didn't expect the conversation to go as smoothly as it did. I expected it to be much more uncomfortable, but it went surprisingly well.  Was it because he was receptive and cared about the clinical work as much as I did? Because I avoided getting upset and putting a lot of attitude in my tone of voice?  Because we sat face to face and tried to listen to each other?  

It's tough being the new one, the "young" one, the female one, and have to engage in touchy conversations with older male clinicians who've been at this job much longer but with (as this guy describes it) less rigorous training.  I was expecting more awkwardness.  It was a testament to this man's maturity and good professional intentions that he was willing to hear my criticism and agree to work on specific things that would ultimately help the whole team function better.

After that I went to the colleague I was helping originally to ask if there was some way I could have been of better use to him - to take some of my own medicine - but he refused to be critical.  I know I could have been more efficient, less clumsy, anticipated his needs better, but all he would say was, "No, you helped a lot."

Oh well.  I wish my colleague had given me more feedback. I know there was plenty of room for improvement in my own team participation.  I guess I'll just have to keep practicing and trying to learn from each day as it comes.  

Saturday, April 18, 2009

Least Favorite Part of the Job and Lame Attempt to Cheer Myself Up


Is it the balls of mucus I occasionally suck out of people's throats?

Frustrating days spent being torn in a million different directions, then being kept late at work due to scheduling snafus?

Snide surgeons and nurses?

Difficult patients?

No.

Those aren't the worst aspects of my job.

Saturday call, hands down, is my least favorite part of being an anesthesiologist.

I despise it.

I start getting queasy over it the day before.  I am reluctant to go to bed on Friday night before a Saturday call because I know that instead of waking up feeling rested, hopeful, and cheery over having a couple of days off, I'll wake up facing the gloomy prospect of having to drive away from home and be shut up in the hospital for twenty-four hours away from sunlight, family, favorite books, and good food, with possibly a wasted Sunday spent recovering and catching up frantically on errands after that.

So I'm trying to cheer myself up by planning (among other, more important things) my Blogiversary, coming up in less than a month.  

If you haven't voted already on my poll for how to celebrate (see sidebar on the right), please do.  So far my suggestions are running a pretty close race.  I have 
  • 7 votes to do an interview (5 to do one like the one on last year's first blogiversary post plus 2 "Other" votes which included a self-interview and an audio interview); 
  • 6 votes for a "best-of-Notes-of-an-Anesthesioboist" blog carnival/post compendium; and 
  • 5 votes for a book give-away.

Maybe I'll combine all three - link to my favorite posts in "Year 2," have people send me interview questions, then throw the questioners' names in a hat and pick one out for a book give-away.  But one kind of book?  Food, medical, or literary?  Hmm....Suggestions? 

Well, there's time enough, I suppose, to figure this out.  Please feel free to start sending me interview questions whenever they occur to you.  They don't have to be profound!  A few people were concerned about that last year and really you can ask me something totally fluffy like my favorite color of cupcake frosting or something like that, if you want.

Ok, enough procrastinating.  I gotta go do rounds before another O.R. case or epidural comes my way.

Thursday, April 16, 2009

They Don't Screen For It On Med School Applications


I had coffee with a good friend yesterday who is grieving over the death of his life-partner.  He told me how painful it was to be told of his loved one's death while he was driving to the hospital on the freeway.  He had told the doctor at the beginning of the conversation where he was and what he was doing, but the doctor just blurted it out anyway.

Apparently that was neither the first nor the last time this doctor had shown such lack of sensitivity. When one operation got delayed by several hours, my friend (whose partner was getting progressively weak and dehydrated) was met not with an apology but with, "Well, if you want to trust the care you get at a community hospital, you can go there."  This doctor didn't soften until my friend finally broke down in sobs in front of him at the hospital after his partner died.  Then I think the ice finally cracked a little.

I see this a lot in medicine.  I think it boils down to this:  being "Calvary-ready" or not.  People are either ready, willing, and able to be close to human suffering - to look at a weeping man, woman, or child in the eye, talk to people in distress, touch their wounds, embrace broken bodies and wounded souls, without recoiling - or they're not, and they have to build up layers of arrogance, insensitivity, and cynicism in order to function.  You're either afraid of it or willing to confront it face-to-face.  There's no check-box for that on medical school applications.  Everyone claims to be well-suited to deal with people's blood and tears.  Everyone says they want to help people who are in pain.  But some people really don't even want to be in the same room as a suffering person.

My friend was Calvary-ready.  He was in a committed relationship with his life-partner for thirty-five years - a little less than my entire lifetime.  Most of his adult life.  In the end he absolutely refused to consider letting an institution care for his loved one and learned how to do all the work himself - trache tube changes, machine adjustments, every nursing task down to the grittiest, most menial one.  For those who cannot accept a definition of marriage that includes the kind of relationship these men had:  if this isn't a model of enduring, faithful, Christ-like,unselfish, sacramental love that Christians want all married couples to grow toward, I don't know what is.

Tuesday, April 14, 2009

Surgeons v. Anesthesiologists: Why the Tensions?


I often get frustrated when patients attribute to their surgeons more concern for their overall medical well-being and perioperative safety than I have observed. Don't misunderstand - I think surgeons do care about their patients, but I also think they can be fairly goal-oriented and single-minded about operating, sometimes when an operation should be delayed in favor of managing pressing medical issues.

To be fair, I have worked with many wonderful surgeons, especially at St. Boonie's, who deeply care about their patients and open-mindedly listen to anesthesiologists if the latter bring up safety concerns that mean possible cancellation of scheduled operations. Frustrating for all, and potentially costly, but ultimately the right course of action for the patients in question. (That's not to say that some anesthesiologists don't go overboard with the gate-keeping and perhaps apply their standards too conservatively; I've seen that too.)

I've also had surgeons physically help me every step of the way when I've encountered difficult airways, with the helpful, team-spirited attitude, "If we haven't got the airway, we haven't got anything." The chief of surgery at St. Boonie's is like that; Caroline Walsh is like that; one of the young surgeons at New Hospital has been like that. One of the neurosurgeons at New even advocated for my monitoring needs during assisted ventilation of a patient in the recovery room, which I thought exceptionally in-tune and helpful of him.

On the whole, though, what I typically see is a lot of exasperation from surgeons whenever a medical condition precludes speedy progress to the O.R. - perhaps because in many hospital systems, these conditions can easily remain undiscovered or unevaluated until right before the scheduled procedure. I always wonder: didn't they look through the chart themselves and see that the lab value was egregiously abnormal, or examine the patient and hear the lung crackles practically from across the room? Surely they, too, did a history and physical, as we're all expected to do?

The usual pattern I see is this:

-An anesthesiologist reviews a patient's history/chart, does a physical exam, and spots a concern - unevaluated cardiac disease, new heart rhythm problem, wheezing on auscultation of the lungs, a potassium value that is acutely too high or too low, or some such potential danger.

-No one else in charge of the patient's care seems to have noticed the problem, thought it significant as a safety risk for anesthesia and/or surgery, or done anything about it prior to surgery.

-The anesthesiologist delays surgery until the patient's condition is "optimized" or the problem corrected (unless the surgical procedure is an emergency).

-The surgeon gets mad, because he or she wants to help the patient by getting the main job done - the tumor excised, the lung biopsy sent to pathology, the hernia repaired.

If it were up to some surgeons, I suspect they'd go ahead and operate on a patient with a potassium of 2.8 or a loud murmur that could be undiagnosed aortic stenosis. The patients would be none the wiser. Most patients don't realize that if they didn't have an anesthesiologist watching their back, they'd be brought into the O.R. by their surgeons despite some increased risk that could be detected and reduced by a preop evaluation specifically geared toward assessment of anesthetic and surgical risk. (Not that ALL risky conditions are easily detected or successfully addressed; but the anesthesiologists at least try very hard not to miss them.)

The GOOD surgeons understand that the practice of surgery is still the practice of medicine, and that patients need to be seen as more than specimens to be sliced and diced. The GOOD surgeons engage in teamwork with the anesthesiologists and don’t resent it when we bring up concerns they may or may not have considered. The GOOD surgeons don't act on exasperation at the prospect of a civilized discussion regarding the safety of a given procedure for a particular patient, will listen to a competent anesthesia consultant when concern is warranted, and won't personally resent the ensuing delay, postponement, cancellation, or what-have-you.

A good surgeon will also respect an anesthestist’s or anesthesiologist’s instructions inside the O.R. when safety is at issue. Rarely have I seen this to be a problem. Usually when I ask the surgeon to stop operating for a minute, for example because I want to assess a patient’s EKG without them tugging on organs or causing interference with EKG wires, the surgeon will graciously stop. The command is not personal; the patient’s safety is at issue; and no surgeon wants a patient coding on the table.

But I did encounter one surgeon whose behavior I consider among the most appalling I’ve seen. I'll call her Dr. Myrtha Banshee.

I was working with a pleasant and competent nurse anesthetist the day Dr. Banshee's patient, a school-age child named Elly, came to New Hospital for surgery. I spoke to Elly and her family prior to surgery and gave them my usual pediatric anesthesia spiel. Dr. Banshee arrived, already irritable (which, according to the nursing staff, was fairly typical). Elly was living with and being raised by relatives but asked to see her mother before we went to the O.R. Her mother was invited in to give her a kiss. Because of this brief delay, we arrived in the O.R. four minutes past the scheduled surgery time - not bad, reallly, considering the way most hospital schedules go.

Dr. Banshee was displeased. She was in a hurry because her secretary had scheduled her office hours half an hour after the scheduled time for this procedure. This surprised me; the procedure usually took about an hour if you factored in the anesthetic and wake-up time.

Dr. Banshee had asked the nurse anesthetist if the patient could remain on the transport stretcher for the surgical procedure and he had initially said yes. I said I wanted Elly on the proper O.R. table, and we moved her off the stretcher onto it. Banshee asked loudly, "Why is the patient on the O.R. table instead of the stretcher?"

"Dr. T. just asked me to move her," replied the nurse anesthetist.

"Why?" she asked, turning to me, her resentment emanating from her like black smoke billowing from a smoldering fire.

"Because," I answered, as matter-of-factly but emphatically as I could, "if this kid CODES and DIES, I don't want to be performing CPR on a stretcher."

That silenced her for a second, but then she muttered, "Everyone ELSE is willing to do it on the stretcher."

"Well, good for them," I said. "For me it's easier to provide a safe anesthetic on the O.R. table." She couldn't argue with that, but according to the nurse anesthetist she had some choice words for me after I left the room and spent the rest of the case irate and complaining.

Before leaving the room I helped the nurse anesthetist with the induction of the anesthetic. We had agreed that I would place the I.V. once he had given the child enough anesthetic gas to get him to a deep state of unconsciousness.

Kids take several minutes to get anesthetized enough to be ready for the application of painful stimulus. For surgeons the wait can be frustrating, I'm sure. But touch a kid the wrong way before she's ready, and a dreaded pediatric anesthesia complication can occur: laryngospasm. A spasm of the vocal cords that closes off the airway, making mask ventilation difficult if not impossible. Kid's oxygen saturation goes down precipitously; kid turns blue; lack of oxygen causes the heart rate to fall; you've got a code on your hands...unless you can break the laryngospasm and intubate the kid in time. No one wants laryngospasm.

Myrtha Banshee was already infuriated by our "delay" getting into the O.R. "That mother doesn't even have custody," she hissed. "She had no right to be allowed to talk to the patient right before surgery." I thought this a heartless attitude; I was surprised to learn later that Dr. Banshee is a mother herself. But on top of this so-called delay, she had to wait for the patient to "go under." That proved too much for her patience. The nurse anesthetist warned her, "She's still a little light," but she paid no attention and inserted an instrument into one of the child's orifices. The child flinched, of course - even with the mind unaware, the body reacts if a certain level of anesthesia hasn't been reached. I got an I.V. in quickly and administered medication to deepen the anesthetic. The nurse anesthetist intubated the child without incident, and the surgery proceeded.

I left the room feeling angry and having lost every shred of respect for that surgeon.

About half an hour later I went back to the room to check on things, and the nurse anesthetist whispered in my ear, "She punctured an artery. We've lost about a hundred cc's." And this was the case she wanted to do on the transport stretcher?! Myrtha Banshee got control of the bleeder and finished the surgery, complaining the entire time about the scheduling and the way the O.R. was being run.

That night, the call person had to bring this kid back to the O.R. to manage a known and not-uncommon complication of the original surgery. I couldn't help feeling resentful all over again when I heard about it.

I can deal with most surgeons, even the crabby ones. I see them as members of the same team who ultimately want what I want: a patient well-cared for. This surgeon never wanted the same thing and was never on the same team. When surgeons or other anesthesiologists experience trouble or a complication, my usual reaction is sympathy, and it certainly doesn't make me think less of them; this surgeon, however, inspires nothing but incredulity at behaviors and attitudes I simply cannot respect.

I hope I don't have to work with that kind of surgeon too often.

Saturday, April 11, 2009

The Empty Tomb: Moving Toward an Easter Poem


I am not, strictly speaking, an atheist.

Nor is it entirely without reservations that I engage in a believer's practice.

I love story and ritual.  For this reason the liturgical traditions of Catholicism are beautiful to me, and valuable.  For this reason I will cherish its presence in my life and the life of my family.  We are nourished and connected by its ancient rhythms and sense of the sacred among us.

But I also consider it a wonder and a responsibility that we have developed the ability to think critically, explore different ideas, interpret and appreciate the world around us.  We humans are thinkers as well as feelers and do-ers. We have a duty to learn what we can, nurture and maintain a capacity for curiosity and wonder, and remain engaged in unswervingly rigorous analysis of what we observe and think we know.

My problem with the attitudes of august atheists like Dawkins, Hitchens, Harris, and McEwan is that they share with certain fundamentalist Christians the propensity toward annoying condescension.  You can almost hear this subtext:  "It's a shame those poor people aren't like us, isn't it?"  I have a problem with people who think to themselves, "He's a believer?!  But he seems so intelligent!" There's nothing more arrogant than absolute certainty, nothing more inferior than feeling superior.  On both sides there are a number of arguments that strike me as a little hollow.  No one, to my mind, has really earned the right to feel he or she is closest to the truth.

I once described myself as "A theist who's skeptical about the miraculous; an atheist who prays; a believing nonbeliever who talks to saints."  I'm sure this is a description that would drive a lot of people crazy.  Does it suggest a mind and heart too wishy-washy, or just open to real possibility? I'm not even sure it matters.  

If that description's bothersome, wait till you read what's next:  a few elements of my Christian credo.

I think Christ is gone.  The texts say so too:  "He is not here; he is risen."  Aslan has left Narnia. It's up to us now.  The world is our job; we have no one but ourselves to blame for its flaws, and it's what we have to work with.  Period.

I also think Christ is here.  Calvary is walked every day.  Faces crowned with suffering weep and bleed, hearts break, people are nailed against their will to terror beyond imagining.  Christ is here, living among us.  Christ is here, reaching toward the wounded, working to help.

That about sums up my "belief."  Christ absent and present, wounded and healing, God dead and living. The contradictions don't frighten me, and the fluid definitions keep me growing and honest, and, I hope, humble.  We need mystery; it keeps us going.

***

I wrote the poem below over a decade ago. It still expresses my understanding of the mystery of resurrection, not necessarily as an event or supernatural occurrence (though the poem can certainly be read that way), but as a process open to all who are open to it.  I think it explains my "faith" better than these other ramblings ever could.


The Labor

In Nazareth my father taught me how
to measure wood and sand it till it shone.
From him I learned to work with all my might;
to play with all my heart’s delight; to teach –
he was so good at that; to laugh with joy;
and best of all, to love and help my ima.
The gifts she gave were priceless pearls: a jar
of water in the shop; some honey cakes
(the special kind); a story by the hearth
at night; a vision of the evening sky.
The laying-on of hands began with her;
she taught me how to heal. When I was small
she washed my wounds and scrapes and held me till
my tears were gone. And when I was a man,
my calluses as hard as nails -
when Nazareth became Jerusalem -
an eon since I'd shed those tears - I knew
I'd have to learn again the things I thought
I'd come to know.  And in the end it was
not I who touched the ailing and the dying;
they touched me, and all the wounded world
reached toward me and filled my outstretched arms
until I was a mother holding all
that life inside – a vessel, but a child
as well, enclosed inside unfathomable
darkness, darker than the deepest earth,
no mother near nor father listening close.
My healing hands were pinned against my will,
or should I say connected at long last
unto my will, my dearest wish: a laying-
on of hands that could deliver all
my children safe and sound. And there I was
to meet them as they came, emerging from
the empty darkness leaving all their shrouds
behind. And lo, they were like little children
dancing in the morning sun and laying
on each other’s cheeks their healthy, hearty, happy hands.

Thursday, April 9, 2009

Love and Wonder in a Carcass


I got out of work unexpectedly early today and went for a walk with my husband around our peaceful neighborhood. The weather was sunny and cool - glorious, really. It's about time we started seeing days like this in New England.

Just as we were coming back around the block toward our house, my husband spotted something on a neighbor's lawn. It was a tiny skull of some sort attached to a vertebral column with some ribs still connected to it. The remains of a small animal picked clean of all its flesh, its dry bones curled almost into a fetal position.

I immediately went to get my camera and find my son, who was watching some of the neighborhood boys shoot hoops in a nearby driveway.

"Where are we going, Mommy?"

"I want to show you something. It's a mystery. The skull and spinal column of a small animal. I'd like your opinion on what it might be."

At this, my son acquired more of a spring in his step as he followed me to the grassy area where I had seen the bones.

"Cool."

He put his baseball cards in his pocket and knelt on the sidewalk to look at the specimen. "It could be a chipmunk," he suggested.

"That's not a bad idea," I said. "It's certainly about the right size. Shape of the head seems right too."

"Or maybe a bird?"

"Possible.  I don't know enough about the skeletal anatomy of birds versus mammals to be sure, come to think of it, though I'm thinkin' mammal."

We looked at the skull from different angles, and I noticed in the concave hollow of the base of the skull a very similar architecture to what I remembered about the base of the human skull. There was even a recognizable foramen magnum leading like a secret portal to the vertebral column.

"Hey, look at that," I whispered to myself.

"What?" my son asked.

"Our skulls are not that different on the inside from this little animal's. They're engineered so similarly.  Amazing."

I said I would go back to our house to find my anatomy book. As I got to the door I heard one of the neighborhood boys ask my son why his mom had brought him down the road, then heard my son explain about the "cool" animal bones and invite them all to look. I had a brief mental picture of a group of neighborhood boys gazing intently at the little skeleton on the grass, and I smiled at the possibility.

"Honey, have you seen my Netter?" I called as I entered the house.

"I think it's at the bottom of a whole pile of your medical books upstairs."

I rummaged through various piles of books and finally found it - an old friend from medical school, still with me after all these years. I went back outside to where the boys were shooting hoops and called my son over. I turned to the page showing the inside of the base of the skull.  "See? Remember how the animal's skull had these depressions in the bone, just like this, like someone scooped out part of the inside of a bowl? Our skulls are the same." By this time three or four other boys had gathered around to look. I was delighted with their curiosity.

I was pleased to hear, too, that they had been debating the identity of the animal. A boy my son's age had suggested a mouse. "There are some mice on B Street, so maybe there are some over there too." I agreed it was a reasonable suggestion. Another, older boy proudly put forward his hypothesis: "It's probably a baby squirrel eaten by a crow. They fall out of the trees a lot." This sounded eminently plausible to me as well.

I closed the book and started for home again. "I'll see you there for dinner," I said to my son.  

My time with him had cast a glow inside me. It was as if the afternoon sunlight had managed to get through even there, to places unseen, and turn what was dark into gold. The little hollow of a dead creature's bone held our closeness like a cup. A tiny chalice pouring out wonder. A passage through death and mystery to blessed life.


Wednesday, April 8, 2009

Singular Intimacies


Lately in my trolling through blogs during quiet moments on call I've begun to realize how much people enjoy - actually enjoy - learning about medicine.  Whether it's through the NOVA reunion Doctors' Diaries on PBS; shows like Trauma: Life in the E.R. or the much less realistic House; or books about life in medicine, there seems to be a lot about the world we inhabit that appeals to people - which still takes me by surprise.  I guess I can understand it, though.  It must be like my enjoyment of shows like Law and Order: Criminal Intent - the appeal of an inside look at an unfamiliar existence in which people try to solve mysteries of one kind or another.

If I had to recommend ONE book written for a general audience by a physician, it would have to be Singular Intimacies:  Becoming a Doctor at Bellevue by Danielle Ofri.  This excerpt alone illustrates why:  Dr. Ofri produces some of most stunning writing you'll find by a physician - or by any author.

There are many excellent doctor-authors out there.  Most write engagingly and incisively about their work.  Once in a while, though, you find the work of someone who goes beyond journalistic skill to art that inspires wonder and awe:  the work of a true writer whose prose moves and takes one's breath away.  This is the kind of writing Dr. Ofri offers her readers.

Singular Intimacies, issued in reprint just this month, chronicles her years moving up the ranks at New York's busy Bellevue Hospital.  She begins her journey in a foyer "jammed with white coats and saris, kafiyas and dashikis.  Spanish, Tagalog, Bengali, and English elbowed for air space as did the smells of coffee, curry, and homelessness."  Can't you just feel the jostling and detect those whiffs of New York?  

Richard Selzer writes of Singular Intimacies, "This book should be required reading by anyone contemplating a life in medicine."  Oliver Sacks affirms, "Danielle Ofri is a finely gifted writer, a born storyteller as well as a born physician."  Jerome Groopman says, "Her vivid and moving prose enriches the mind and turns the heart."  Amen.

I'll give you another example of what they're talking about - a perfectly constructed sentence about a final conversation with a memorable patient, "The arc of our words shimmered in the air and her history settled softly into mine."  Beautiful.

In addition to being a mom and working on the faculty at Bellevue, where she encourages students to use writing/story-telling as an active part of their medical practice, Danielle Ofri edits the Bellevue Literary Review and plays the cello.  Her writings and commentaries have a strong presence on the Web.  To enjoy more of her work, check out the pieces below:



Tuesday, April 7, 2009

Should be a Facebook Quiz: What Medical Specialty Are You?

Thanks to FreshMD, who works in a refugee clinic and writes a wonderful blog, I decided to take the University of Virginia Medical Specialty Aptitude Test while waiting to see if the surgeons are doing an appy tonight or not.

The results? Drum roll, please...

Anesthesiology is, indeed, one of the top 5 things I should have considered as a medical student embarking on choosing a specialty. It came in at #2 behind dermatology, of all things - a specialty I never really felt attracted to.

I remember when I took a similar test in medical school offered by GlaxoWellcome, I was SHOCKED to see that my top result was anesthesiology; at the time I thought I was headed for a career in pediatrics. I didn't know enough about anesthesia going into medical school to even have the specialty on my radar screen.

I guess the people who design these things know what they're doing...or maybe it's the power of suggestion?

The one other specialty I could see myself practicing would be neonatology which, as one of the neonatologists I know once said, is in many ways a cousin of anesthesiology. But that wasn't on the UVA test.