Timber

I was doing a spinal for a patient seated in front of me on an operating table. In front of her, facing me, her nurse was holding her steady; behind me, a tall, young nursing student stood observing.

Three minutes passed between the time I prepped the skin with sterile solution and the moment I injected anesthetic into my patient's spinal canal. "You're all done," I said cheerfully and withdrew needle and syringe out of her back in one motion. "We'll have you lie down in just a second."

All of a sudden the nurse's eyes widened and she said in a firm voice, "Sit down. Sit down right now. Right now, sit down, RIGHT NOW." She was gazing past me. I put my hands on the patient's shoulders and turned my head to glance over my shoulder in time to see the nursing student teetering on her feet trying to make her way to the nearest wall. With me now in charge of holding our patient, the nurse rushed around the operating table toward the student and arrived just in time to support her crumpling body before it hit the floor.

Vasovagal syncope is a very real concern and not uncommon in bystanders observing procedures that involve the insertion of sharp objects into patients. I once saw a tall adolescent male fall back unconscious because of an I.V. In a case that would fill any conscientious anesthesiologist with dread, the husband of a woman who was getting an epidural for labor fell, hit his head, and DIED of an intracranial hemorrhage. This page has an interesting comparison of legal cases brought against hospitals on behalf of people who have fainted while observing medical procedures.

I don't think it's fair to assign blame for fainting. People can't help their physiologic reactions, which can sometimes be unpredictable. Different people have different triggers. Some can't stand needles; others, blood or fractures or internal organs; my Achilles heel is the drainage of pus. Even just thinking about that can provoke that unpleasant, pre-vomit tickle in my throat. Needles commonly seem to be problematic for the toughest-looking individuals, so I try not to judge by appearances. But it can be tricky, this business of trying to be mindful of observers' needs when all we really want to do is put 100% of our focus on our patients.

I hope that student is okay.

Satisfaction

I have been neglecting this blog lately. Every time I stop by without writing something I feel a little guilty.

I haven't felt much like writing about medicine, or music, or my family, or food, or even books - all the things that I've loved writing about in the past. Yet there's been no dearth of activity in those arenas. My job is busy as ever. My music projects and those of my children occupy a lot of our energy and free time. I've recently read a terrific book (The 19th Wife by David Ebershoff). I'm still enjoying a rich culinary and family life. What's wrong with me?

I don't think it's depression rearing it's ugly head, because I'm feeling pretty darn happy, my marriage is great, I'm eating and sleeping just fine, and life is good.

There is one nagging question on the depression screens, though, that stands out in my mind - the one about loss of pleasure in activities in which one used to take pleasure. That one's bothering me. I still take pleasure in reading, writing, music, dance, family game night, great meals with great company, and all that. But I'm in a personal slump over my work.

It's more than just the difficulty of going back to work after a long break. Vacation was great, going back to work was hard, but usually after the initial plunge I get back into a rhythm and it's as if I never left. This time, though, the water still feels as icy now as on the first day back. I'm experiencing an inability to enjoy the aspects of my work that have, to date, made a life in medicine worthwhile for me.

In the past I've acknowledged that an anesthesiologist can't be in it for personal glory, ease of work, external affirmation, and the like. More often than not we get the opposite - complaints from people who don't like our decisions, lack of respect from people too ignorant about or indifferent to our duties and skills, hard decisions, tough clinical challenges, frustrating procedures, tiring days and nights, and little appreciation. The work, therefore, has to be its own reward, and for the most part, it has been. It's wonderful to relieve suffering, keep people safe, console them when they're afraid, be there for them when they need help and competence. Those have been the things that have given me satisfaction.

Since my return I've taken care of a couple of people with dangerous heart problems and seen them safely through surgery. I've helped women in labor get rid of their pain and be able to enjoy bringing their babies into the world. I've taken care of frightened children and tired elderly people. I've rescued epidurals and airways that others have had difficulty with. One airway, in fact, involved a patient perilously close to the edge whom two emergency physicians and one surgeon had tried to intubate without success. They were all at the bedside along with a couple of nurses and a couple of respiratory therapists when they handed me the equipment and let me do my thing. It turned out to be a classic "anesthesia save" of the type of difficult airway situation I've described so much already - one of my favorite ways of giving help with the work I do.

Even with fairly routine procedures we're not always entirely unappreciated. One of the psychiatrists in charge of ECTs, according to the nurses, has expressed how much she prefers the days when I'm on ECT duty, because of the tone I set, the atmosphere of calm in the room when I'm there, and the high level of care her patients receive. When I work with her in that setting, I do feel I've done good work, and that old sense of satisfaction returns.

You'd think with all this good work done, I'd be feeling pretty good about my job. The "Three Signs of a Miserable Job" as delineated by best-selling author Patrick Lencioni - anonymity, irrelevance, and the inability to asses one's own contribution to others or success - shouldn't be pertinent to my situation. But often I do feel like a replaceable cog in a big, impersonal machine, and I know this is true for many, perhaps most, workers. That's life, right? And we should just shut up and be grateful we have jobs? Fair enough.

I'll admit I'm sensitive. My satisfaction is often diminished by the sheer unpleasantness of the atmosphere in which I'm doing the work, or by workplace frustrations and politics, and amplified if the work occurs in a supportive or positive environment. This, of course, points once again to the recurring realization that I really need to have a thicker skin, that I shouldn't let external affirmation or its absence affect how I feel about myself or the work I do, and that I need to rely on my own inner sense of commitment, honor, and success to find satisfaction. I know all this. I know. I'm responsible for my own happiness. I know. I've told myself this over and over since I began in medicine.

But you know, sometimes, don't you just feel like saying, "Eh, screw it, I'm moving to Boracay?"

News From Haiti

Photo: Bas-Ravine in northern part of Cap-Haitien, © Rémi Kaupp, CC-BY-SA,Wikimedia Commons

Please check out Paul Levy's full post From Haiti: "Life Really Just Goes On," in which he posts a portion of the field diary of Dr. R. Malcolm Smith, Chief of Orthopaedic Trauma at Massachusetts General Hospital.

An excerpt ("rhabdo" is short for rhabdomyolysis, a dangerous condition that can develop after severe crush injuries):

"Discovered the only blood tests we can do is a crit and cross match. No facilities to do electrolytes. Problem with rhabdo patients so watching urine colour and volume pushing fluid and diagnosing acidosis clinically. No iv bicarb so took advice and sent someone to buy baking soda to give orally not sure. Can someone ask our renal guys about renal protection in this situation?

"Done 16 cases so far through 1 room in 3 days operating and 1 more to do tonight...Have about 60 waiting most with wounds and open fx.

"Had to operate for a short time with head lights when power cut this evening. Thank you Mary and LL Bean...C section just happened, our anaesthetist helped, baby looks fine. Life really just goes on. "

Haiti

Click photo above or here to make a donation. To create a similar post on your blog, click here. To see updates about the work being done by MSF/Doctors Without Borders, click here.

Traveling Again

Well, that went by fast.

We leave Manila at 10:30 pm on Tuesday the 12th.

We arrive in the United States at around 6:00 pm on Tuesday the 12th.

Funky, isn't it?

Clan Reunion

Remember when I posted a picture of my great-great-great-grandmother?

This, now, is her daughter-in-law, my great-great grandmother.

Yesterday my family and I attended a giant clan reunion of this woman's descendants.

With her first husband she had seven children. From this marriage came one enormous clan and three large sub-clans.

With her second husband she had three children, each of whom had between five and seven children. Thus three major clans came from this marriage. I belong to one of these.

Needless to say, when you gather this lady's hundreds upon hundreds of great-grandchildren, great-great-grandchildren, great-great-great-grandchildren, and yes, even a few great-great-great-great grandchildren, into a school gym, it's a sight to behold. Each major clan wore a particular color for ease of identification. This is a picture of SOME of my clan - the smallest branch of the family in attendance:

It was an incredible day. Half of the food vendors were from family businesses - almost all of the clans can boast of food talent. There was a sports tournament in the afternoon (my clan won volleyball, soccer, and tug-of-war!) and a light-hearted entertainment segment during which my daughter and I and some cousins performed in a hip-hop number set to Michael Jackson's song Black and White and some of the men in the family did a surprise number in hula skirts.

Every time I attend one of these mega-reunions, I am astonished at the contribution one woman can make to the world simply by raising children. Yesterday we numbered in the hundreds, and we could all trace our existence back to this ONE woman! It was a staggering and inspiring thought.

Our children's lives are changed with things as simple as the way we prepare and share our food with each other, the welcome we give to friends, the conversations we have (or fail to have), the respect (or lack thereof) we give to their gifts, rights, boundaries, individual needs, thoughts, feelings, and passions in life. Even the smallest moment can unexpectedly have a huge impact. It was a great reminder with which to begin the new year.

I Think I'll Try A New Year Meme This Year

I was inspired by Beth's blog Life. Not Terribly Ordinary. to bring you this. A few years ago Hilda who writes Dominican Oboist did this too, and I've been wanting to try it. Be tagged. (What can I say? I'm in vacation mode.)

1. What did you do in 2009 that you've never done before?

Spoke publicly in front of 100-200 people. Briefly. For someone who abhors public speaking, this is a big deal.

2. Did you keep your new year's resolutions, and will you make more for next year?

I make it a point never to make new year's resolutions. One day at a time is more my speed...

3. Did anyone close to you give birth? My friend R.

4. Did anyone close to you die?

My grandmother's 102-year-old sister, who a few months prior to her death had attended my daughter's debut as Annie in her school musical.

5. What countries did you visit? France, England, the Philippines.

6. What would you like to have in 2010 that you lacked in 2009? Goals.

7. What dates from 2009 will remain etched upon your memory, and why?

January 20: Inauguration

May 7: my daughter's opening night as Annie

August 29: Ted Kennedy's funeral

8. What was your biggest achievement of the year?

Supporting my daughter through some minor middle school dramas (at least, I hope she felt supported).

9. What was your biggest failure?

Inability to inspire enthusiasm and support for the project mentioned in #15 in certain individuals in positions of authority. Still despondent about that.

10. Did you suffer illness or injury? No.

11. What was the best thing you bought?

The Sibelius music notation program.

12. Whose behavior merited celebration? For the most part, my children's.

13. Whose behavior made you appalled and depressed? Tiger Woods'.

14. Where did most of your money go? Mortgage company and Amazon.com

15. What did you get really excited about?

Getting a composer's permission to produce one of her works in honor of an anniversary that holds deep personal meaning and interest for me.

16. What song will always remind you of 2009? Tomorrow from Annie.

17. Compared to this time last year, are you...

-happier or sadder? About the same, pretty happy.

-thinner or fatter? About the same - and my electronic medical record concurs.

-richer or poorer? Um, probably about the same too...

18. What do you wish you'd done more of? Exercising, sleeping, and writing.

19. What do you wish you'd done less of? Getting impatient.

20. How did you spend Christmas?

Enjoying the company of friends and family over delicious food.

21. Did you fall in love in 2009? Every day.

22. What was your favorite TV program? Glee.

23. Do you hate anyone now that you didn't hate this time last year?

We're not supposed to hate, right? But if you replaced that strong word with the euphemistic "strongly dislike," or the with the more precise, "find extremely annoying and sometimes downright odious," the answer would be yes.

24. What was the best book you read?

The Help by Kathryn Stockett. In 2nd place would be The 19th Wife by David Ebershoff.

25. What was your greatest musical discovery? Mezzo-soprano Susan Graham.

26. What did you want and get? An iPod Touch.

27. What did you want and not get? A Kitchenaid mixer.

28. What was your favorite film of this year?

Disney's version of A Christmas Carol.

29. What did you do on your birthday, and how old are you?

Watched my daughter perform, and late-30's.

30. What one thing would have made your year immeasurably more satisfying? A summer-long sabbatical.

31. How would you describe your personal fashion concept in 2009? Nonexistent.

32. What kept you sane? My husband.

33. What celebrity/public figure did you fancy the most? Capt. Sully Sullenberger

34. What political issue stirred you the most?

"Stirred," as in "exasperated" or as in "inspired?" If the former, then HCR. If the latter, then perhaps the causes for justice and freedom of various kinds in places like China, Iran, Honduras, North Korea, the Congo, etc.

35. Whom did you miss? My friends "lawprof" and "speducatorlvc."

36. Who was the best new person you met? My colleague and now ex-colleague Iz.

37. Tell us a valuable life lesson you learned in 2009.

Focus on what really matters. And very, very few things really, really matter.

38. Quote a song lyric that sums up your year.

"'Cause I'd get a thousand hugs

From ten thousand lightning bugs

As they tried to teach my how to dance

A fox trot above my head

A sock hop beneath my bed

A disco ball that's just hanging by a thread

I'd like to make myself believe

That planet earth turns slowly

It's hard to say I'd rather stay

Awake when I'm asleep

'Cause everything is never as it seems." From Fireflies by Owl City

Pictures from Market Day

The Boston-Manila Connection: a historical tidbit

When I read Jose Rizal's classic Noli Me Tangere I was surprised to see mention of ice cream - in fact, a cameo by an ice cream vendor, or sorbetero - in a story set (and written) in colonial times, and in the tropics.

This week I learned that chilled desserts were indeed possible in nineteenth-century Manila thanks to The Ice King. The Ice King was Frederic Tudor, whose Tudor Ice Company harvested ice from Walden Pond in Concord, Fresh Pond in Cambridge (a stone's throw from my home in the U.S.), and Spy Pond in Arlington, Massachusetts and exported it to such faraway ports as Havana, Kingston, Rio de Janeiro, Calcutta, Singapore, and yes, Manila.

The year the business started, 1806, 130 tons of ice were exported; by its peak in the 1850's, the number was 146,000 tons. At the height of the ice trade each shipment amounted to about 180 tons which would melt down by 50% by the time it reached the Far East and to as low as 40 tons on arrival in India, three to four months after leaving Boston Harbor. The business was profitable nonetheless.

I love the names of some of the ships involved in the ice trade: Arabella, Coringa, Harmonia, White Swallow. The record time of 81 days for the return trip from Calcutta to Boston was made by the Witch of the Waves (the average run was 102.5 days).

I won't be able to eat ice cream now without thinking that some of my ancestors in the Philippines might have chilled their beverages with frozen chunks of the pond located a few minutes from my current American home. Cool. (Pun intended.)

Welcoming 2010 with a Book Meme

On our way out of Boston I was pleased to note that The Help by Kathryn Stockett, my favorite book after To Kill a Mockingbird (which is in a class by itself), was being prominently displayed at the book shop at Logan Airport's international terminal.

I'm in the middle of another really good book during this winter vacation, so I thought I'd start off the year with a post about books. I got this from Señor Enrique who writes the blog Wish You Were Here:

Please share

• One book that changed your life.
• One book you have read more than once.
• One book you would want on a desert island.
• One book that made you laugh.
• One book that made you cry.
• One book you wish had been written.
• One book you wish had never been written.
• One book you are currently reading.
• One book you have been meaning to read.

I'm not tagging anyone - I just feel like doing this, and anyone who feels like it too can join me. Or not.

Here are my answers:

One book that changed your life. Tuck Everlasting by Natalie Babbitt.

One book you have read more than once. The Memoirs of Sherlock Holmes by Sir Arthur Conan Doyle.

One book you would want on a desert island. I'm with Señor Enrique on this. Some kind of survival manual. Besides that, the complete works of Charles M. Schulz.

One book that made you laugh. The Sweet Life in Paris by David Lebovitz.

One book that made you cry. The Queen's Fool by Philippa Gregory. Don't ask me why. It's not a sad book.

One book you wish had been written. The Autobiography of Jesus Christ.

One book you wish had never been written. Anything that has bolstered racism, the oppression of women, the abuse of children, or totalitarianism.

One book you are currently reading. The 19th Wife by David Ebershoff. Really absorbing, and I'm sad that I'll be finishing it here because it means I won't have it to read on the plane on the way back to the U.S.

One book you have been meaning to read. The Physick Book of Deliverance Dane by Katherine Howe.