NO RESOLUTIONS!

In Boston it's New Year's Eve, but here in the Philippines where I'm on vacation, it's 8:50 a.m. on New Year's Day and I find myself thinking of highlights of the past year with tremendous gratitude. I refuse, you see, to make New Year's resolutions. Instead I want to make a gratitude list, and though each day I could probably list a dozen things for which I'm thankful, when looking back over the course of 2010 some amazing experiences stand out in my mind and make me sadder than usual to see a year pass, though deeply happy too for the blessings it brought.

New Year Gratitude List, 2011

2010 brought me...

10. Christmas with my parents and one of the best New Year's Eves I've had with my husband, kids, and favorite cousin - a beach party in beautiful Boracay.

9. The chance to meet a favorite composer.

8. A visit to relatives in Russia and the opportunity to learn more about this amazing country.

7. The chance to see friends I hadn't seen in YEARS, in New York and St. Petersburg, and to deepen friendships with those close by.

6. A relaxed afternoon in Bryant Park with my family, followed by an unforgettable meeting with one of my daughter's artistic role models.

5. A memorable trip to Maryknoll with one of my favorite cousins and the opportunity to talk to someone who has seen and experienced more than most in her 92 years.

4. The production of a life-changing concert which also brought new friendships and insights.

3. My daughter singing a very moving solo at a performance we worked hard to produce.

2. Moments with my husband I'll always treasure - watching floating lanterns over the beach on New Year's Eve, leaning toward each other on a train from Manhattan to Tarrytown whispering quietly about a special shared memory, and other seemingly small buy very meaningful moments.

1. The continued health and growth, physical and intellectual, of two beautiful, wonderful, compassionate, joyful children.

For these and so many other things, I am thankful. Now on to my bucket list... :)

Merry Christmas

"In the same region there were some shepherds staying out in the fields and keeping watch over their flock by night. And an angel of the Lord suddenly stood before them, and the glory of the Lord shone around them; and they were terribly frightened. But the angel said to them, 'Do not be afraid, for behold, I bring you good news of great joy which will be for all the people; for today in the City of David there has been for you a Savior, who is Christ the Lord. This will be a sign for you: you will find a baby wrapped in cloths and lying in a manger." Luke 2:8-12

The shepherds in Luke's gospel remind me of anesthesiologists. They made a living by keeping watch, protecting. Their work, if they did it well, looked easy enough (though it wasn't) and lacked glamour, and its proof was a preservation of stability, which of course looks the same as "nothing happening" even though in fact much energy is put into achieving that undisturbed state. They remained anonymous and, on the margins of Bethlehem life both geographically and socially, got little recognition for what could sometimes be a dangerous job. When dramatic things did happen, whether terrible or wonderful, like all people who avoid getting smug or arrogant about life, they paid attention and allowed themselves a fully engaged response - a quickened pulse, a widened gaze, a readiness to go where they were needed. They maintained a capacity for wonder and reverence for life despite a largely tedious existence. The people who walked in darkness have seen a great light.

This Christmas I am thinking of the shepherds and feeling a sense of camaraderie across the eons. Their not-so-secret message for me this year, I think, is a reminder to stay open to wonder, to run toward it every chance I get. I'd like to think if their ghosts could look my way across the thousands of years and miles that they'd give me a friendly nod as well, and permit me to rejoice with them in the thought that when Christ was born, the angel of the Lord invited to the baby Jesus' side not the rich and famous, or the prominent and "important," but the anonymous who kept watch at night and did their work in silence and solitude.

Christmas Treats

Anesthesioboist's Chocolate-covered Peanut Butter Balls

Melt 1 stick of butter.

Stir in 1/2 c packed brown sugar.

Add

-1 16oz. jar creamy peanut butter (about 1 1/2 c of PB - I use Peter Pan)

-1 1/2 to 2 c powdered sugar

-1 c graham cracker crumbs

-1/8 to 1/4 tsp salt

-1 to 2 tsp vanilla

and mix well.

Roll into 1-inch balls (about 50 of them) and chill.

Melt contents of a 12oz bag of semisweet chocolate chips with 2-4 Tb shortening.

Dip chilled balls into chocolate to coat, place on wax paper, and chill to set.

Let come to room temperature, then eat (they taste better at room temp).

Recommended non-edible treats of the season:

Books: Wishin' and Hopin' by Wally Lamb; The Christmas Miracle of Jonathan Toomey by Susan Wojciechowski; The Fourth Wise Man by Susan Summers; Two from Galilee by Marjorie Holmes; A Christmas Carol by Charles Dickens

Movies/TV: A Christmas Carol (George C. Scott or Jim Carrey as Scrooge); Elf; By the Light of the Silvery Moon; The Grinch Who Stole Christmas; A Charlie Brown Christmas; A Pinky and the Brain Christmas; Little Women; The Nutcracker (Baryshnikov's or the new one by the Royal Ballet)

Music: John Rutter/The Cambridge Singers, Boston Pops, Vince Guaraldi Trio, Carols from the Yard, Candlelight Carols by the choir of Boston's Trinity Church

Places to visit: New York City, Canterbury Shaker Village (NH), and of course, BOSTON!

On Guadalupe: An Old Favorite

Last year I wrote a post retelling the story of Our Lady of Guadalupe from the point of view of Juan Diego, the peasant who saw and spoke to her almost 500 years ago.

That's always been one of my favorite posts, so I'm reposting it today in honor of the anniversary of the first apparition, December 9, 1531.

If You're in the Boston Area This Week...

Please come and see Missionaries in Concert, a production I've been involved with for a while. It's a powerful tribute to four U.S. church women who were murdered in El Salvador in 1980. The lyrics are based on the women's letters and journals, and the music by Elizabeth Swados is amazing.

Performances are at 8 p.m. and take place on

December 2 at B.C. High School,

December 3 at the Paulist Center in downtown Boston (Park Street),

and December 4 at the Church of St. Ignatius of Loyola (Boston College / Chestnut Hill).

The beautiful painting above is by artist George Bard and was commissioned especially for this New England premiere.

Vicarious Trauma

The subject of vicarious trauma has been on my mind lately.

It's always on the back burner anyway, because of my profession. Health care workers, social workers, clergy members, humanitarian aid providers, counselors, and other individuals who confront human suffering on a regular basis are at risk for it. Unlike countertransference (the redirection of a service provider's feelings or unresolved conflicts toward the person being served) and compassion fatigue or burnout (the blunting of empathy and increase in apathy and negative feelings in response to chronic exposure to others' suffering), vicarious trauma indicates a fundamental change involving the caregiver's physical, psychological, and spiritual health. It includes symptoms similar to, but less severe than, those of PTSD, such as hypervigilance, sleeplessness, an increased startle response, nightmares/flashbacks/other intrusions, and avoidance of potential triggers of these intrusive symptoms.

I can only speak from my experience as a physician but I would bet this applies to most professionals whose job involves witnessing or tending to the pain of others. I believe physicians have to strike a pretty precarious balance: feeling and showing enough empathy to provide care that is felt to be good care, with a personal connection, and maintaining enough separation of self to be able to function and provide care that is competent, prompt, and unencumbered by personal difficulties or emotional hang-ups. It's very easy, I think, on the one hand to be too distant, and to fail to connect on a human level for the sake of the work being done, and on the the other hand to get too personally involved, to over-identify with the sufferer - literally what the word patient means - and to be hampered in your caregiving because you have to run to the locker room and cry. A good doctor has to be able to cry, with or for others, but also to be able to postpone crying till later so that good work can be done. It does my patients absolutely no good if I am too busy sobbing for them to be able to hook up a syringe full of pressor and save them from their own shock. I also serve them ill, however, if I feel nothing for them whatsoever.

So to any patients or future patients out there: please don't judge physicians and nurses for staying calm while your life is falling apart or your loved one is in agony. As long as they are calm without being cold, caring without falling apart, and doing the right thing for your safety, they are serving you as best they can. When the time is right, and the work is done, they will allow time and space for that ache in their heart to remind them of you, and of why they strove to be there for you in the first place.

November 22, 1963: Mixed Messages from Trauma Room One

"The first thing [Dr. Robert McClelland] saw was the president's face, cyanotic - bluish-black, swollen, suffused with blood. The body was on a cart in the middle of the room, draped and surrounded by doctors and residents. Kennedy was completely motionless, a contrast to the commotion around him...Dr. M.T. Jenkins, an anesthesiologist, was near the head of the cart, administering oxygen...For nearly 15 minites, McClelland held the retractor as blood ran over its edges. As the other doctors labored on Kennedy's throat and chest or milled around the room, McClelland stood staring at the leader of the free world..." -from an article in D magazine, "The Day Kennedy Died" by Michael J. Mooney

Dr. McClelland has always consistently described a wound in the back of President Kennedy's head through which he observed a bit of cerebellar matter escape. The anesthesiologist, the famous M.T. "Pepper" Jenkins, agreed at first but later decided the tissue must have been cerebrum, not cerebellum - an important difference - and also later changed the location of the wound from occipital to parietal. Those who accept McClelland's version contend that we were not told the truth about Kennedy's assassination. His detractors point to evidence from the four-hour autopsy which indicates a different wound altogether - one that supports the official conclusion that President Kennedy was shot by a lone assassin from above and behind.

Whose version is closest to the truth?

Having been in a number of chaotic clinical scenes, especially those involving tons of personnel, I can understand how people's memories can be a little patchy, erroneous, even conflicting. But the differences in the above two physicians' recollections of what went on during the desperate attempts to resuscitate Kennedy are crucial to the story. Who's right?

Interesting historic note: the only female physician on the scene, Jackie H. Hunt, was - you guessed it - an anesthesiologist.

Halloween: Ghost Stories to "Get in the Spirit"

(Cupcakes from Whole Foods)

If you've read this blog around this time of year in years past, you'll know that I really, really don't like Halloween. At ALL.

This year I'm feeling a little less bah-humbug about it, though. Maybe it's all the Ghost Whisperer reruns I've been watching. Or maybe trying to focus on the creative aspects of Halloween (rather than the morbid and gory) is making it more positive for me.

Take food. All you have to do is browse through Halloween entries on Foodgawker.com to appreciate how creative people can be with culinary celebrations of Halloween. Inspired, I turned a quest to develop a moist, dense amaretto-laced cake into this Ghost Cake with white chocolate buttercream frosting. It was yummy.

Then there's music. NPR has this Halloween music mix and a list of "Tunes That Terrify" to get people in the mood, and a Halloween music puzzle that, I am horrified to admit, totally stumped me.

I don't like scary movies at all, but I've always enjoyed a good ghost story. In honor of New England author Mary Wilkins Freeman, who was born on Halloween in 1852, here's a list of spooky stories to enjoy on Halloween night or some dark, stormy night when you're curled up under a blanket and there's a fire crackling in the fireplace. Most of these are available online.

The Man Who Found Out by Algernon Blackwood

Mrs. Zant and the Ghost by Wilkie Collins

The Signal-Man by Charles Dickens

The Captain of the Polestar by Arthur Conan Doyle

The Lost Ghost by Mary Wilkins Freeman

Of a Promise Broken by Lafcadio Hearn

Pigeons from Hell by Robert E. Howard

The Adventures of the German Student by Washington Irving

The Lovely House and The Haunting of Hill House by Shirley Jackson

The Monkey's Paw by W.W. Jacobs

The Whisperer in Darkness by H.P. Lovecraft

The Apparition and The Wolf by Guy de Maupassant

Four Ghost Stories and The Shadow in Moonlight by Mary Molesworth

By E. Nesbit: Man-size in Marble, John Charrington's Wedding, From the Dead, and The Power of Darkness

The Black Cat by Edgar Allan Poe

The Body-Snatcher by Robert Louise Stevenson

A Ghost Story by Mark Twain

By Edith Wharton: Afterward, The Eyes, Kerfol, The Lady Maid's Bell, and Pomegranate Seed

The Canterville Ghost by Oscar Wilde

Halloween gives us a chance not only to read about fascinating characters and other worlds but also to enter into some of those fictional worlds by becoming characters ourselves. That's one aspect of Halloween I like - the costumes. I enjoy seeing what my friends and family choose each year, and I have to admit I have a little escapist fun dressing up. How do people go about picking their costumes? Favorite books, shows? This year my daughter is pulling off a wonderful "Abby Sciuto" from the show NCIS. I saw some folks show up to a costume party as "rescued Chilean miners." I was boring and went to this costume party in an Indiana Jones hat, but I still had fun.

Finally, there's one more spirit-building treat I revisit each year: this addicting online pumpkin carving activity. Halloween. Love it, or hate it? Hope you can enjoy it this year, however you usually feel about it. HAPPY HALLOWEEN!

A 7-Word Game

I decided to write out this train of thought because it sort of came rushing at me in the last twenty minutes and I wanted to follow it through.

It began with me thinking about someone who left a comment on a website: what a loser.

Then I thought to myself, What do I mean by that? What's a loser? What makes that person, by your definition, a loser? What is your definition of a "loser?"

Pretty soon this led to these questions:

If you wanted to convey some idea of "who you are" to others by choosing words to define and then providing the definitions, which words would you choose, and what would your definitions be?

Would you choose the same words for other people to define (in order to get a better idea of them)?

I decided to do my own exercise and jot down some word definitions here just to see if I would learn something about myself. If you feel like trying this and sharing your results, I'd love to hear about it - drop me a line (or a comment)!

MY WORD LIST

FRIEND - a person you can trust with your truest self, whose company you cherish, and with whom you share a reciprocal commitment to regard the details of each other's lives as things that matter

JERK - someone who has suppressed or obliterated his or her capacity for respect

LOSER - someone with no interest in learning

MATURITY - freedom from needy-ness, from thinking that everything's "about" oneself, and probably also from highly reactive anger

FAITH - an individual's way of understanding, viewing, and responding to the world and to experience

LOVE - a deliberate, steadfast, and solidarity-driven pouring of energy into recognizing, upholding, protecting, or restoring another's dignity, well-being, and/or worth

SUCCESS - peace with oneself

Whew. I don't know why I got all philosophical tonight but I had to get it out.

How Will You Celebrate Ether Day 2010?

c. 1846 Daguerrotype by Southworth & Hawes of a re-enactment of Ether Day

Happy Ether Day once again, everyone!

Every year on this day I repost my original Ether Day post.

I'm also going to celebrate with a bowl of mussels, a glass of wine, and perhaps a slice of cake tonight. Someday I will have a cake like this one in the shape of an anesthesia machine (see this video of how it was made). Way to go, Charm City Cakes!

Sick II

One of my facebook updates this week on my private account was that I

"have a love-hate relationship with interleukin-6. Yes, macrophages and T cells, I know you are doing your job, but how many proinflammatory cytokines does it really take to fight this thing? What's that? Be grateful you guys are even working? Oh, all right. I'll shut up and eat my soup now."

Yes, I've been sick this week. It started brewing shortly before my overnight call on Monday, during which I worked till about 3 a.m., then tossed and turned till 5 a.m. unable to breathe due to nasal congestion, then got woken up by my beeper at 7 a.m. Rested Tuesday, then tried to go to work Wednesday morning but asked to be replaced by a moonlighter and went home. Called in sick Thursday. Was allowed to stay home Friday because of low case volume. This is rare for me. I almost NEVER take sick days.

The culture of medicine has bred me to think of them as a weakness. It has also hardened me somewhat to any intrusion of personal problems into professional life in general. I can't let exhaustion, home stress, or personal worries make me fail to do my job, on time, competently, with focus. It's just not acceptable. Not being "on our game" for any reason is sub-standard because patients' wellbeing is at stake. I find I get mentally impatient with people who make excuses - most of which sound lame to me - for not getting their job done. Medicine doesn't care if I'm planning a wedding or if I stayed up late taking care of my sick child. The job has to get done, and get done well. No excuses. I find myself thinking very harshly critical thoughts when people outside of medicine approach their work with softer standards.

But this week my body just couldn't function. On top of the nasal congestion, my least favorite symptom of a respiratory infection, I had a violent, productive cough that hurt my chest and kept my husband up at night, occasional chills, muscle aches, nausea, and fatigue. I was in bed for three days. The worst part of it was missing my family's hugs. "Air hugs" from my adorable children and the fear of infecting my loving spouse, who hugged me anyway, carefully, despite my illness, were poor substitutes for the tight bear-hugs we enjoy giving each other.

So I've been thinking to myself - because I've had time to do nothing but think and watch reruns this week - how lonely many patients must feel in the hospital, suffering with unpleasant symptoms for days, with only occasional visits and brief touches for human contact. I remember feeling a little lonely even when I was in the hospital for a happy reason - childbirth. Illness is more isolating, and the truth is so few people want to be around suffering for too long. I wonder if I've been forgetting to be present enough to people when I visit them on rounds. Sometimes unexpected time away from work, not because of vacation, is a good thing. Having the tables turned has provided a reminder, a chance to reflect a little on things I shouldn't be forgetting about. Like compassion for the sick.

Friendship and Female Physicians II

Over a year ago I wrote a post about the challenges of making friends as a female physician. I cross-posted it on Mothers in Medicine, and the comment boards on both blogs were pretty interesting.

One of my best friends in med school was an O.B. nurse. Though she has moved almost all the way across the country and I haven't seen her since I was in school, we're still in touch and expect to be seeing each other at last in a couple of months.

By some coincidence one of my best friends now is also an O.B. nurse. I'll call her Ziva (yes, I watch a lot of NCIS). Ziva is from Israel. She is smart and funny, a lover of books and movies and good music and good food, talented and competent, and above all a great and generous person I would entrust with my children's lives. Ziva and I can talk about just about anything - silly "girl stuff," deep intellectual stuff, spiritual questions, moral/ethical dilemmas, work stress, kids, comic moments from day-to-day life, worries about tough problems, faults and failings, embarrassing secrets, cultural differences, things that inspire us or bring us joy.

For some reason, her colleagues are very uncomfortable with our friendship and underhandedly persecute her for it with snide comments and not-so-veiled criticisms. One time I arrived to provide a spinal for a C-section. Ziva was already in the room counting instruments, and one of the other nurses said, "Oh, are you happy now - your friend's here." Another time she happened to mention that she and I had recently discussed the mechanics of intubation, and in front of all the other nurses one of her other colleagues made some critical remark about her being friends with me. When Ziva called her on it, saying "What's wrong with that? T. is SO nice! She's totally adorable," the other nurse said, "I have no desire to be friends with T. I have my OWN friends." Ziva found this nurse's comments and the tone in which she said them disrespectful and hurtful. Many of the other nurses can barely conceal the clouds of disapproval and resentment that darken their looks when Ziva and I greet each other cheerfully at the nurses' station.

"They feel threatened," my husband said.

"But if I were a single, tall, good-looking MALE doctor it would be FINE for a nurse to be close to me, right? Isn't that totally self-demeaning of these women? Sure, it's ok to befriend a man in a position of authority, but it's somehow wrong if it's a woman?" I was totally frustrated and irritated that the culture in this workplace wouldn't tolerate a genuine close friendship between a female doctor and a nurse.

Ziva and I do not flaunt our relationship in professional situations. I feel I am just as business-like with Ziva while delivering patient care as I am with any other team member, and conversely, just as nice with the other team members as I am with her and with the patients and with any colleague. But there's a lot going on here. Gender issues. Cultural issues. Xenophobia, or, even worse, maybe some anti-Semitism. And perhaps status issues. Maybe they think nurses and doctors can't or shouldn't be friends (unless, of course, it's a dating situation between a male doctor and a female nurse). Or maybe they feel Ziva's smarter and more highly trained and better educated than they are and they just can't stand it.

I am feeling exasperated and a little angry. This type of collective attitude is completely stupid and unnecessary. I don't know that there's much I can do about it. I'm certainly not going to change this blessed friendship for the sake of a few small-minded harpies who aren't comfortable enough in their own skin to show some tolerance, respect, and support.

The Story of My Life

I haven't been writing as much lately. This is because

a) I am a creative-project monogamist. I am completely consumed by a concert I'm producing this fall and all my productive energy seems to want to go there. Thus blogging and other writing are suffering.

b) Work has been busy. Just this week I'm on overnight call in the hospital three times. I'm tired.

c) Work dynamics have been exasperating lately, and I don't want to vent too much negative stuff here that would blacken the atmosphere. I get annoyed at over-critical people; surely my complaints would come across as similarly annoying and judgmental or over-critical, and I just don't feel like going there right now. Maybe on the next post...or the one after that...but not right now.

In the meantime, here's an amusing clip - one that's gone viral in our anesthesia community - that just about sums it up:

Story. Of. My life.

My New Favorite Blog

"Autistic people are just as capable of love as anyone else. Loving other people isn't restricted to those who can speak fluently, read each others' faces, and remember not to talk about feral cats for half an hour while trying to make a new friend. We may not copy the emotions of other people, but we have just as much compassionate as anyone else. What tends to be different is how we express it. Neurotypicals will often attempt to sympathize with the person; autistics (at least, the ones that are like me; we I've said, we're diverse) will often try to fix the problem that made them upset in the first place. I don't see that either approach is superior to the other..."

-Lisa Daxer, an autistic biomedical engineering major at Wright State University.

Listen to her interview on NPR here and check out her wonderful blog, Reports from a Resident Alien.

Continuing Medical Education

[Photo source: http://commons.wikimedia.org/wiki/File:Medical_history_-_district_doctor_table_cca_1925_.jpg]

There are some lessons we learn and keep re-learning in medicine. For me some of these recurring lessons are

• Listen to your "gut."
• Pay attention to the clues.
• Listen to your team.
• Don't be afraid to call for help.

and

• Stick to your guns when advocating for your patient.

I encountered a young patient recently, just at the cusp of adolescence and adulthood, who had undergone a procedure related to a sports injury. Other people had been responsible for his care during surgery; I was coming on duty for the night and was part of the team watching over him in the recovery room.

Someone came to me and said, "His t-waves are flipped on the monitor. Do you want to do anything?"

T-waves are a particular portion of the tracing generated on a heart monitor or EKG by the electrical activity of the heart. Normally they look like a small hump. Sometimes the hump is inverted and the wave resembles more of a "u." This is often a concerning sign with many possible causes, but in children and adolescents in can be normal in certain areas of the EKG.

I went to the patient's bedside. He was resting comfortably and his vital signs were good. But I had a nagging feeling inside.

Listen to your gut.

"Let's do a 12-lead," I said to the recovery room nurse.

A 12-lead is short-hand for a complete EKG. It's unusual for one to be done on someone this age - who looks for heart problems in healthy, athletic kids? - but I wanted to see for myself what the complete picture looked like.

I took a stethoscope and listened to the patient's chest. His lungs were clear but he had a loud murmur. I looked on the preop evaluation. The physical exam was noted as normal. He hadn't had any medical issues at all according to his history. He wasn't aware of being told of a murmur before.

Pay attention to the clues.

While the EKG was being done I called a hospitalist and a cardiologist for consultation. My kid started feeling nauseated and threw up a little. The cardiologist wasn't able to call me back because of a snafu with the phone system. The hospitalist was tied up right at that moment but agreed to see my patient shortly. The ICU folks next door were tied up too.

Meanwhile my young patient, whom I shall call Joey, was getting increasingly pale and lethargic. His vitals were still strong, and he complained of no chest pain or tightness. But when the EKG printed out this is what it showed:

I thought this was a significantly concerning EKG. I ordered cardiac enzymes to be drawn and sent to the lab. I tried to page the cardiologist again but was still unable to reach him. I really wanted an echocardiogram to see what that heart muscle was doing and suspected it was abnormally thick. I wanted to give Joey drugs that are normally considered "cardioprotective" but I also wanted to keep his blood pressure up to preserve his heart's blood supply. Meanwhile, he was beginning to look sicker and sicker.

"Dr. T, everyone you've called hasn't really responded so far," the recovery room nurse said to me. "He looks a lot worse than he did when we first started. Why not call a rapid response team to the bedside?"

Listen to your team. Don't be afraid to call for help.

"Sure," I said. The nurse called the emergency team to the recovery room. I heard the overhead page summoning my reinforcements. Part of me felt like an idiot, and the other part really wanted some input on what to do with this non-child, non-adult with a grossly abnormal EKG but no chest pain and no prior history or abnormality. If there was something wrong with his heart, which I strongly suspected, he needed to have an echocardiogram right away and perhaps some more invasive procedure, preferably at a more advanced center where things could get done faster and there were lots of pairs of hands at the ready.

The hospitalist arrived in a matter of seconds along with the critical care doc, IV access team, respiratory therapist, and a couple of other responders. I showed her the EKG. She was somehow able to get in touch with the cardiologist directly and handed me the phone. I explained the situation.

The cardiologist said, in a tone which I can politely describe as skeptical, "Do you REALLY think this young KID is having a HEART attack?"

Stick to your guns when advocating for your patient.

"I really think, having been with him for the last half hour, that he is having some kind of serious cardiac issue. Something is wrong. His clinical picture is deteriorating before my eyes. I need some input on the next step."

"You said he had some ST elevations on the EKG? In which leads?"

I started to explain the grand mess that was the EKG, but then the hospitalist took the phone back. "Do you want me to fax it to you so you can see it?"

We faxed the EKG to the cardiologist. He called us back and had us send Joey to the nearest tertiary care center.

Joey's going to be fine. He has a condition that sometimes predisposes to sudden death - the kind that makes athletes drop dead on the field or on the court - but he can get help for it and do reasonably well. It's funny - I know just how to handle his condition on the O.R. table, under anesthesia, but the acute diagnostic management definitely pushed me out of my comfort zone.

Throughout this entire incident my beeper was going off non-stop for other things - OB wanted an epidural, there was an O.R. case to start that I had to postpone, I needed to speak to Joey's parents who were completely blind-sided by it all. But we ultimately kept our focus on Joey and were able to get him the help he needed. I learned so much from his recovery room course - things I had learned before, but which are always good to learn again.

• Listen to your "gut."
• Pay attention to the clues.
• Listen to your team.
• Don't be afraid to call for help.

and

• Stick to your guns when advocating for your patient.

Cupcake Disaster

Ready?

(Cue stabbing music from the Psycho soundtrack.)

I don't know what happened. They just EXPLODED in the oven.

"I think it was the baking soda," said my son. "That's what makes science experiment volcanoes explode."

He just might be right. I was laughing too hard to answer him.

"How can you laugh at something like this?" he asked. "It was a total fail!"

"Because it's funny!" I squawked, and laughed all the harder.

Margot Fonteyn was right: "The one important thing I have learned over the years is the difference between taking one's work seriously and taking one's self seriously. The first is imperative and the second is disastrous."

There are some recipes that continue to elude me. Chocolate chip cookies like the ones sold in David's Cookies shops in New York before they all closed. Perfect parmesan-truffle fries. Great pan de sal and salsa monja, two favorites from home. And dark chocolate-raspberry cupcakes like the ones I had at a friend's wedding.

But I won't give up. Better luck next time!

Humanities and Medicine: All the Rage

There's been considerable buzz on the web the last few days - on the New York Times website, on Facebook, and on a physicians' forum called Sermo, at least - over a New York Times article from last Thursday entitled, "Getting Into Med School Without Hard Sciences."

The article describes the Humanities and Medicine Program at Mount Sinai Medical School, a program which each year admits into the medical school 35 undergraduates who major in the humanities or social sciences and can maintain a 3.5 GPA. Dr. Nathan Kase, who founded the program, said, "The default pathway is: Well, how did they do on the MCAT? How did they do on organic chemistry?...That excludes a lot of kids, but it also diminishes; it makes science into an obstacle rather than something that is an insight into the biology of human disease."

Students in the program, who apply during their sophomore or junior years of college, can forego taking the MCAT or physics, organic chemistry, and biology during college but do have a "boot camp" in those subjects at Mount Sinai prior to beginning their medical studies. A study published in the Journal of the AAMC entitled "Challenging Traditional Premedical Requirements as Predictors of Success in Medical School" has reopened the sometimes vitriolic debate over whether the traditional requirements should be revised or whether they are even necessary.

This discussion is not new; essayist Lewis Thomas, while defending the vital importance and inherent wonder of scientific learning, wrote about the need for more well-rounded physicians and published an essay entitled "Humanities and Science" in his popular work Late Night Thoughts On Listening to Mahler's Ninth Symphony. Many medical schools around the nation have included "humanities and medicine" curricula as part of their med students' training.

Most physicians who were science majors have of course come out in passionate defense of tradition, with some showing embarrassingly arrogant contempt for their counterparts in the humanities. They have called the Mount Sinai program an example of the "dumbing down" of American education, which I find patently offensive as a former English major who chose one of the most science-oriented specialties in medicine (but also, to my mind, one of the most artful).

I value what I learned in biochemistry about molecular pathways and receptors and in physics about pressure gradients and flow, but I also know that my training in the humanities contributed to my intellectual skill set in ways my science classes could not. I can think critically, listen to and interpret stories, write a narrative, learn foreign linggo, diagnose conditions based on various clues and signs, analyze situations, and make critical decisions because of the riches I gleaned from strong training in both the sciences and the humanities.

I still remember a surgeon who once answered a patient who was surprised she hadn't read a particular Shakespeare play, "Well, I spent my time reading things that would actually be useful to you for this operation." I find this attitude to a sound literary education small-minded and cheap. People without imagination so often focus on what is considered visibly "useful" without considering the intangible good done by less pragmatic knowledge. I was taught by some of the best teachers in the world that understanding a character or a line of poetry is not fluff compared to deriving an equation but rather a crucial component in the working of the mind and its interaction with the world.

During my training I was once asked in front of a patient to recite some respiratory physiology equation which, to my patient's approval, I was able to do easily at the time. But I wanted to say to the attending physician, "Ask me, too, what this patient's story is. I can tell you because I listened. I can tell you because I can put together and recreate a good narrative. And in the end it will help me take better care of this patient than knowing that equation." Good patient care is and, for me, always has been about story and relationship as well as facts and figures. We have to be able to do well working with both.

I find the habit of many physicians of looking down at the humanities and humanities students completely obnoxious, but of course, I am biased. I happen to think I'm a better doctor for having been well-educated one, with multiple aspects of the mind trained and challenged - not just the ones that can distinguish between an ester and an amide.

I Am Not Always Nice

I relieved a CRNA for his lunch break. He gave me a very good report on the patient before leaving the room. A few seconds after his departure I looked over the drape to check on the surgeons' progress, because I noticed one of the drugs we were using at regular intervals was starting to wear off.

(Surgeon #1 is generally well-liked among the nurses, anesthetists, and anesthesiologists for his competence and humor.

Surgeon #2 is almost unanimously disliked for his arrogance, rudeness, and inferior skill in comparison with Surgeon #1.)

Me: "How much longer do you think you might be?"

Surgeon #2 (muttering): "Why are these people always chomping at the bit?"

Me: "Why do you assume that I'm asking because I'm 'chomping at the bit?' "

Surgeon #2: "Well, that other guy asked the same thing a while ago."

Me: "Has it not occurred to you, after all your years of experience, that questions about the duration of surgery have nothing to do with being in a hurry to finish surgery but rather have everything to do with planning and executing a safe anesthetic for your patient, and making sure the TIMING of the drugs we give coordinates with what you're doing? Some of us actually try to put some THOUGHT into our moment-to-moment management of patients. When we ask you how long you have, it's almost always for the sake of pharmacologic timing, so we can be sure to provide the drugs you NEED for the procedure to go on, not because we give a flying fig how long you're going to take."

Silence.

Surgeon #1: "About twenty more minutes."

Me: "THANK you."

Don't mess with me.

Martha, Martha

Yesterday I was in full-out St. Martha mode trying to cater my husband's pontoon boat sunset cruise.

"What's a pontoon boat?" I had to ask him.

I saw a picture and decided it was a rectangular ring of benches on a floating platform covered by a canopy. I had to figure out what kind of food would be satisfying enough for the "light supper" his invitation mentioned but portable enough to eat on such a vessel.

"Finger foods," said a CRNA at work.

"Sandwiches," said another. "And watermelon slices."

My final menu consisted of the following (which, I realize, aren't at all coordinated with one another as a menu, but everything got eaten, so I guess no one minded):

Cherub tomatoes and carrot sticks with buttermilk ranch dip

Organic corn chips with chunky guacamole

Cucumber tea sandwiches with butter and dill

Cocktail meatballs with a sweet grape-jelly-and-chili-garlic sauce

Mediterranean pasta salad

Fresh strawberries and watermelon slices

Assorted cupcakes from Yum Bunnies Cakery

I was busy. I mean, running around, organizing, shopping, slicing, cooking, trying-to-make-everything-look-and-taste-good busy. Work has been like this too recently - difficult airways, busy obstetric service, M&M (not the chocolate kind), running, running, running. It's definitely been a very "Martha" couple of weeks.

The "Martha" I keep mentioning was a woman who, according to the Gospel of Luke, welcomed Jesus into her home, which she shared with her sister Mary and her brother Lazarus. The story goes like this (Luke 10:38-42):

As Jesus and his disciples were on their way, he came to a village where a woman named Martha opened her home to him. She had a sister called Mary, who sat at the Lord's feet listening to what he said. But Martha was distracted by all the preparations that had to be made. She came to him and asked, "Lord, don't you care that my sister has left me to do the work by myself? Tell her to help me!"

"Martha, Martha," the Lord answered, "you are worried and upset about many things, but only one thing is needed. Mary has chosen what is better, and it will not be taken away from her."

Does anyone find this just a little annoying? Does anyone else think the Son of the Most High could have used a little Sensitivity Training here?! You think turning water to wine was hard? Let's see you try to put a nice spread out for people you care about, at short notice, with no miracle-making powers, when you also care about food quality and presentation, etc.!

I jest, but there's truth in the spirit of what I'm saying. For the Marthas of the world, this New Testament story irritates. We work hard because we care about our welcome, we Marthas. We worry about the details because how you approach even the smallest thing is how you approach everything. All our fussing and fretting comes from a place of love. It's so unfair. Not only did Jesus fail to appreciate Martha's efforts and admonish Mary to help out a little more but he also actually praised the seemingly neglectful sister instead. What gives?

I can understand the need to emphasize contemplation and an interior life in the midst of day-to-day busy-ness, especially nowadays. People can't seem to slow down and just think, or watch sunsets, or listen to the hum of cicadas. A life of action without reflection can quickly drain the spirit, while a contemplative life without some kind of action remains hollow and unrealized. I get that. And I also understand putting priorities in perspective: it makes no sense to have every doily perfectly placed if one has missed out on a wonderful teaching moment or spiritual experience. I get that too. But work done out of love - not out of pride - is such a treasure in itself; couldn't Jesus have given Martha a little credit?

We had our share of "Mary" moments on the sunset cruise out of Cape Ann Marina in Gloucester. The weather was perfect, the water smooth, and the company warm and friendly. My husband put his arm around me as we looked out over the water and breathed in the sea air. Quiet moments nourish and refresh and can sometimes open up the world in new ways - there's no question about that. But as the feast of St. Martha approaches (July 29), I had to give a shout-out to her and all the Marthas of the world, whose nourishment, generously provided, makes a difference.

The 7-Link Challenge

Today I thought I'd participate in Problogger's 7-Link Challenge as described by Lisa on her blog Anali's First Amendment. Here are the rules:

"The idea is to publish a post that is a list of 7 links to posts that you and others have written that respond tothe following 7 categories. Your links should be to

• Your first post.
• A post you enjoyed writing the most.
• A post which had a great discussion.
• A post on someone else's blog that you wish you'd written.
• Your most helpful post.
• A post with a title that you are proud of.
• A post that you wish more people had read.

You might like to add a few explanations to different links."

Harder than it sounds! But here they are:

• My first post.
• A post I really enjoyed writing. Perverse as that may seem. I enjoyed this rather gentler one too.
• A post which had a great discussion. Discussed further here where it was cross-posted.
• A post on someone else's blog I wish I'd written. Plus this classic one from Shuna. And almost anything from this blog or this blog. And Michelle Au's cartoons. And...I could go on and on! So many great people / writers / bloggers out there!
• My most helpful post. Or so it would seem, from what I hear from other people.
• A post with a title I'm proud of. Well, "proud of" may be overstating it a little; "amused by," maybe? I liked this one too.
• A post I wish more people had read. It's hard to convey everything you want to, though, when something is meaningful on a deeply personal level - as in this other recent post and this less recent one.

It's been fun walking down memory lane on this hot Sunday afternoon!

Photo above: View from a window in the abbey of Mont-St.-Michel through which the monks would haul a sled loaded with supplies from below. Here's what the sled ramp looked like from the outside:

If I Were a Physician in France

On my way onto the plane for my recent flight home from France I picked up a copy of Le Figaro thinking I might enjoy the article about actress Sophie Marceau, who was on the cover of EVERYTHING while we were in France in celebration of her turning 40. I did enjoy catching up on Marceau - I still remembering watching La Boum in my high school French class - but I couldn't help but notice a two-page spread showing a large group of physicians in their white coats standing on the staircase at the Université Paris Descartes - a staircase I remember descending last year after my visit to the Musée d'Histoire de la Médecine.

It was the central image for an article about physicians writing a letter of protest to Sarkozy regarding French health minister Roselyne Bachelot's healthcare reform bill. Whether it's in the U.S. or Europe, it seems, health care reform must provoke controversy! The article discussed the doctors' objections to the allocation of decision-making power exclusively to hospital chief administrators (CEO's / CFO's), to cuts in staffing and services, and to decisions about patient care being made based on financial rather than medical criteria. Their battle cry, "Let's Save The Public Hospital," pointed to the increased economic burden that the current bill implied for teaching hospitals carrying the brunt of high-acuity, high-volume patient care.

Physicians weren't the only professionals openly protesting Bachelot's bill. Nurse anesthetists blocked train tracks at the Gare Montparnasse last May to protest the bill's failure to recognize their specialty (France currently has 7500 nurse anesthetists).

Though I am much less familiar with the French system than the American, the article made me think about how my life might be quite different, both as a physician and as a patient, if I were living in France, as I have often fantasized.

If I were a physician in France I'd be making less. Primary care physicians in France get $32 for consultation ($37 if it's a house call), whereas Americans under Medicare get $92 for the first visit and $125 for a "moderately complex consultation." French Anesthesiologists make from 4000-7000 euros a month, according to one website.

But...

As a physician in France I wouldn't have crippling student loans to pay back (the government would have paid for my education), and my malpractice costs would be significantly lower. I'd also be able to make decisions as I please without being muzzled by an insurance company - though as an anesthesiologist in the U.S. I can already do that; it's usually primary care physicians in American who have to deal with the frustrations of having to adjust medical decisions based on insurance company restrictions.

In France I would, however, have had to have been in a science / medical track for most of my scholastic career, starting in high school, and would probably never have been able to do what I did in the U.S. - major in literature, then switch to medicine after university. I'd have had to do a lot of demanding oral exams - not just the few I got through here in the States. I'd have had my exam results posted publicly and my class rank determine my specialty choice (which does occur to some degree in the U.S., but less stringently).

As a patient in France, I'd be entitled to health care, but I'd perhaps be paying higher taxes, waiting longer to see specialists, and maybe even having to travel out of my home area for access to certain services, such as a labor and delivery ward. In either country, the system is tiered, with people able to pay for additional private insurance getting access to more services.

I don't think there's any perfect training system, practice situation, or place to be a patient, but as both a physician and a patient I'd probably want for myself the flexibility of an American education system coupled with the universal access enjoyed by the French. I dream of living in some idyllic little French village without worrying about whether I can get care when I need it; then I watch shows like BostonMed, and the familiarity of the American system wins me over all over again. The problem neither country seems to be able to solve is the high cost of universal health care; Assurance Maladie, the French state health insurer, has been "in the red" for decades. I'm interested in seeing what both countries come up with in the coming years.

Vacation Highlights and France Top 10 Lists

This trip to France has been completely wonderful - relaxing, educational, filled with breathtaking experiences and good times spent with family and friends. We really couldn't have asked for a better vacation, and with just a few more days to go I am already starting to get sad about leaving. Some highlights:

Peaceful country life:

Stumbling upon some charming towns while driving around Normandy:

The old mill in Vernon

Picturesque spot in Cocherel

Giverny:

Mont-Saint-Michel and the Musée des Manuscrits du Mont-Saint-Michel in Avranches (a.k.a. the "Scriptorial"):

And of course, Paris:

***

I am a list-maker, and I couldn't resist creating a few France-related Top 10 Lists. Here they are:

Top 10 Favorite Experiences in Paris

10. Going to the top of the Arc de Triomphe.

9. Walking through the area around the Place Vendôme (and drooling over the chocolatiers' windows...).

8. The green spaces: Jardin du Luxembourg, Jardin des Tuileries, Place des Vosges, and many others

7. Visiting the Musée Cluny and the area around the École de Médécine.

6. Sunset cruise on the Seine on a friend's barge.

5. Enjoying the street performers in Montmartre on summer evenings.

4. Browsing the bouquinistes on the Quai de la Tournelle and Quai St.-Michel after Mass at Nôtre Dame; we also like the the bandes dessinées shops in the Marais

3. Walking the Quartier Latin.

2. Visiting the Musée d'Orsay (even when my favorite Caillebotte painting is out on loan, as it was this year).

1. Hanging out on the Champ de Mars (in front of the Eiffel Tower) at night when the sun doesn't set till 9:30 p.m.

Top 10 Experiences in France Over the Years

10. Shopping for groceries at Carrefour (the United States just doesn't make food this good)

9. Giverny

8. Rouen

7. 2007 pilgrimage in honor of St. René Goupil

6. The Loire Valley / chateau country

5. Our afternoon in Dieppe

4. Paris, of course - especially off-peak

3. Chartres

2. Mont-Saint-Michel

1. Relaxing in my husband's family's place in the country

Top 10 Things We Have Yet To Do As a Family in France

10. Versailles

9. The lovely villages in the south of France featured in the film A Good Year

8. Marseille

7. Caen, Omaha Beach, Bayeux

6. Ski trip to the Alps

5. Brittany coast

4. Reims

3. Some pilgrimage sites: Taizé, Aubazine, Lourdes

2. Honfleur

1. Spending the night IN Mont-Saint-Michel