Notes of an Anesthesioboist

Haunting Music

2012-01-27T21:16:00.013-05:00

Today in the hospital we were all surprised to hear strains from a harmonica playing "Somewhere Over the Rainbow," "Silver Bells," and other gentle favorites in the preoperative holding area. It was a patient playing in his stretcher - hospital gown, I.V., and all. Hearing soothing music played live in a setting in which such a gift is completely unexpected is indescribable. When he came out of surgery he played again. We could hear soft harmonica music from the area in the recovery room reserved for people who are going to be fast-tracked home. What a beautiful visitation for our not-so-hallowed halls. I have permission from "Harmony Hank," as I'll call this patient, to share this memento of those moments here. On rare occasions, magic does happen in the hospital!

***

There are some works of art that have captured my heart forever and will always be on my list of favorite or "most influential" works or "works I love most."

Then, among these, there are those I cannot, cannot, cannot imagine my life without. They have taken root inside me and are woven into my permanent intellectual and psychic fabric. I cannot shake them. They are part of me. They haunt me. They possess me like spirits inside.

Liszt's Piano Sonata in B minor, which I've recently been re-obsessed with in light of an announcement that Philippine concert pianist Cecile Licad will be performing it in Boston next month, and which I happened to look up TODAY only to learn that it premiered ON THIS DAY in 1857, is one of those latter works.

For me it will always be inextricably intertwined with Frederick Ashton's ballet Marguerite and Armand, and frankly if I didn't know better I would have thought, listening to the music, that Liszt had written it specifically for Alexandre Dumas fils' story The Lady of the Camellias, the subject of Ashton's ballet. I like to think Liszt did have this story in mind; the play premiered in Paris in 1852, Verdi's opera La Traviata opened in 1853, and Liszt composed the sonata in 1852 and 1853 and published it in 1854. Coincidence? Moreover he had been romantically involved with Marie Duplessis, the inspiration for the character of Marguerite Gautier, between 1845 and 1847. Surely the Lady of the Camellias was at least an indirect inspiration to the Sonata in B minor?

Ashton describes seeing the ballet unfold in his mind upon hearing the sonata on the radio. One might say that because he was a talented choreographer he was able to fit the ballet to the music, but once you see the ballet, you realize that it's also the other way around: the sonata follows the story EXACTLY. The best Youtube version I could find is between time index 42:55 and 1:12:30 of this Youtube upload of the documentary Nureyev: I Am a Dancer. Fonteyn and Nureyev, for whom the ballet was created by Ashton, will always be THE Marguerite and Armand, to my mind. Sylvie Guillem may have had more acrobatic technique, but she didn't have the soul for it. Tamara Rojo, though, who recently danced the role in London, may have been able to bring both qualities together - flawless technique and mature artistry. I'd love to see her Marguerite.

As for the sonata, my favorite recording of it is still Alfred Brendel's from 1981, but Andre Watts played a stunning version in Tokyo in 1988, and Evgeny Kissin's is amazing too. The piece epitomizes the Romantic period. It's almost PAINFULLY emotional and unapologetically melodramatic. But it also expresses what we mere mortals have no words to express, and sometimes we need that kind of intensity, especially in a world that holds the UN-emotional - rational and the scientific - so dear.

What is Death

2011-10-16T09:40:00.010-04:00

I've only had to declare death a couple of times. Once in a three-year-old and once in an adult. In each case the heart had stopped beating. Death was clear.

Brain death is tougher to cope with, both clinically and psychologically. I imagine it would make anyone want to say, at some point, "Are you sure? Are you really sure? How do you know? How can you be sure?" Some times when brainstem function is gone and seems clearly irretrievable, there remains a good, strong heartbeat. Strong. Vital signs vigorous.

At one point this month, as I often do around Halloween, I was watching an old episode of the T.V. Show Ghost Whisperer. I enjoy ghost stories. I think whether or not one believes in a soul that can live on after bodily death, ghost stories can be interesting and appealing because everyone can relate to the feeling of being haunted or wanting to haunt. Even the impulse to visit places we haven't seen in years is this kind of gravitation toward haunting. The place still haunts us, and we want to return to haunt it for bit.

In this episode the main character, who is able to see and speak to spirits, receives signs and visions from a man whose body is in a coma but whose soul longs to break free and move on. His family is reluctant to remove life support, so he remains tethered, unable either to wander as an earthbound spirit or cross into a realm of peace that lies beyond this world. Every time I walk into an ICU I think of this episode. Even if ghosts and spirits don't exist, how can we know whether some remote corner of a patient's consciousness feels this sense of being trapped, tethered to ventilators and tubes?

If a family makes a decision to release their loved one and permit the life-giving gift of organ donation, I think of how painful it must be to leave the bedside for the last time. I've heard the sobbing of parents and siblings as I've waited to bring a brain-dead person to the O.R. for organ removal. I've watched a woman tearfully thank the doctors and nurses on her way out of the ICU for the last time as she leaves her sister in our care. I've looked down at someone younger than myself, thinking, "Your life was just starting," and felt sick and sad. Yet the automatic drill sergeant in my mind kicks right in: Not now. No time for feelings now. You have a job to do. Make sure all the families waiting for new beginnings today have the best, most well-cared-for organs you can help this patient provide. But I feel sick, I want to say. I want to cry. No. No sick. No cry. You do what you have to do and cry later. So that's what I do.

Anyone who wonders why an anesthesiologist would be needed for organ donation by a brain-dead person clearly has no grasp of what an anesthesiologist's job is. An anesthesiologist's job is to keep a patient's organs well-perfused and well-oxygenated. Usually this is synonymous with keeping a patient alive under anesthesia. In this special case, it means keeping the patient's heart and lung functions stable so that the donated organs can continue to give life in another or several others. I won't lie and say this type of case feels just like any other, even like just another cardiac case. It doesn't. It's strange. The patient is dead in the ways that matter most to his or her loved ones but alive in ways that will matter to others. Dead but not completely dead. I am taking care of a living shell of someone. A body that is dying and that eventually will come to a full stop.

For the anesthesiologist that moment comes when surgeons cross-clamp the aorta (and, if the heart is being removed, cut the heart out). After that, we can just walk out of the room. For the transplant surgeons it's just the beginning; after about four hours of harvesting they must rendez-vous with the organs and recipients at their respective medical centers and keep operating for eight or ten more hours, this time to put the harvested organs into hopeful people who have been waiting for this new start. For us, though, it's time to turn off the machine and leave the patient behind: the only time we ever leave a patient unattended in the room. This always feels eerie and wrong, but after all, what is there to do, when there is no beating heart left, no circulation, no breathing? And at some point, there is an almost-palpable change in the energy in the room. The person does indeed become a shell, with none of the vibe given off by a living individual.

Afterward all sorts of thoughts swirl around. What if that had been my loved one? Or me? What would I have wanted done, or done differently? I had ice cream last week. I hugged the person I love most in the world last night. This person will never do either again. I want to see Florence again before I depart the universe. I want to make croissants from scratch. I want to hear my son play the Bach Double Violin concerto, which he's starting to work on. I want to laugh really hard at a play with my daughter. What else should be on my bucket list? The thoughts just keep coming, when there's time and space for them, and Mr. Mental Drill Sergeant no longer needs to keep me task-oriented.

Organ removal is even more humbling, I think, than cardiac surgery. It's a concrete reminder of our own fragility and our tenuous hold on life. Lately I've been researching my children's ancestry on their father's side as well as mine, and as I go back and back and back many generations, and see birth dates and death dates and marriages - all huge events when we go through them, but mere drops in the ocean of time when you see them listed over the years - I can't help but think of how paradoxical it is that we are so small and insignificant, yet so dear and so meaningful. I also realize that what we pass on in terms of ideas and good actions is so much more important that what we pass on chromosomally. Our lives are so brief, then death comes for us all. There's no avoiding it. This moment is all we have.

Time to go and make the most of it.

9/11

2011-09-11T01:14:00.000-04:00

images by Reuters, Doug Kanter, Shannon Stapleton, and Joe Raedle

Moving Beyond Mammy: Why I Strongly Disagree With Some Criticisms of The Help

2011-08-17T20:28:00.022-04:00

I read Kathryn Stockett's novel The Help two years ago, when it first became a literary sensation. I loved and was astounded by it; it quickly became one of my favorite books of all time, among novels like Harper Lee's To Kill a Mockingbird, Barbara Kingsolver's Prodigal Summer, Natalie Babbitt's Tuck Everlasting, Marilynne Robinson's Gilead, Mark Salzman's Lying Awake, and now also Sara Gruen's Water for Elephants. It was unexpectedly very personal for me. I grew up in a society where the privileged have help, the help wear uniforms and eat in the kitchen and call their employers their "masters," and in some families the kids are taught "not to get too friendly with the help." I was lucky, though, and had someone like Constantine (portrayed by Cicely Tyson in the photo above): a woman I bonded with who's like a second mom to me, who's now been in our family for forty years and whom I love with all my heart, and who I know loves me with all of hers. Because of her I learned that love transcends a lot of barriers people can try to erect in various situations.

My brief mention of The Help in a blog post from when I first read it in 2009 summarizes the major themes that made me like it so much: "story and story-telling, truth and lies, having a voice and keeping silence and secrets, writing and how it transforms both writer and reader, and the true meaning of dignity and of significance." It's also, one of my friends adds, about "the power you get over your own story when you break the secrets and silence." She and I read it as READERS, I might even venture to say students of literature - but not as scholars of history. For this reason, critics who have blasted both the book and the movie for (supposedly) failing to be true to the historical times in which the novel is set, and for not focusing on Black History and the sufferings endured by Blacks in the South in the 1960's, have irritated me profoundly. The book was not written to be a documentary about the Civil Rights Movement. It was written to be the story of the intertwining lives of three very different, complex, and compelling women. Novels are about CHARACTERS and novel writing is and should be entirely focused on who those characters are and how those identities drive what happens to them.

No one should presume to tell an author, "Your character should have done this" or "done that." Only the author knows her characters well enough to know why those characters do what they do; she then opens up their lives to us in moments, and we can get to know those characters, but not with the intimacy and authority to be able to dictate what their actions should have been. Any such criticisms are projections by readers, which may be out of keeping with the characters' identities and completely untrue to the world of the book. And that, right there, is the problem: people with an axe to grind couldn't accept a CREATED world, the world of the novel, but rather wanted it to be the world as THEY would have it or depict it.

I read the Open Statement to Fans of The Help by Ida E. Jones, National Director of the Association of Black Women Historians (ABWH) and a review by journalist and University of Georgia professor Valerie Boyd, who wrote Wrapped in Rainbows: the Life of Zora Neale Hurston. I sincerely respect the fact that they know much more than most of us about African American history, and I appreciated being educated on perspectives that might not have occurred or been familiar to me, but I couldn't agree with many of the statements they made. Some of them annoyed me because they missed the point, and because by being so ready to criticize the work - perhaps even before reading the book or seeing the film, like some of their commenters, and perhaps because it was not written by a Black woman? - these critics willfully obviated the possibility of appreciating its many gifts.

The ABWH statement asserts, "Portraying the most dangerous racists in the 1960's Mississippi as a group of attractive, well-dressed society women, while ignoring the reign of terror perpetuated by the Ku Klux Klan and the White Citizens Council, limits racial injustice to individual acts of meanness." What a short-sighted attitude. Stockett clearly did not set out to portray "the most dangerous" racists or write another Mississippi Burning. It's unfair to paint her as intentionally "ignoring" the more violent aspects of the 1960's simply because her novel is about the moments behind closed doors, about diaries and journaling, about words on pieces of paper. I thought that was the very beauty of her novel - that it's about these non-spotlighted things. Does EVERY author who chooses to write about Black women have to have a scene in her novel with a burning cross? Is that a requirement? I thought the special thing about this book WAS its focus on the tiniest moments - it's about the little things that aren't so little. The WHOLE POINT of it is that racism isn't just in KKK violence but ALSO, and perhaps even more insidiously, in the fake smiles of the well-dressed hypocrites and the not-so-hidden sneers of day-to-day interactions.

I also COMPLETELY disagree with the description of any of the characters as "asexual, loyal, contented caretakers of whites." There are no Mammies in Stockett's book - just real-seeming, complex women with courage and heart. Each African-American woman in the book had an identity and a personality. There aren't well-developed male characters, but I think it's because another big POINT of this book is the power and impact of WOMEN's relationships with each other - the focus was, rightly, on Skeeter, Abilene, and Minny.

Many object to the fact that a Black male in the book is an abusive alcoholic. This, too, I find immature: the need for only positive portrayals when a given negative element is important to the story. Do people really think just because African Americans suffered for years, and continue to suffer in many ways still, that there were no wife-beaters among them, as there were among Caucasians, back in the 60's? Do all writers have to walk on egg shells and give terrible traits only to white people in their novels? This kind of reverse racism demonstrates some pretty stunted growth. The literature of my own culture suffers from similar post-colonial tensions. Poor us, it cries; look how the Spaniards raped and enslaved and colonized our people, and after them, the British and the Americans. We have to highlight how evil the white people were, and how long-suffering and noble we are. Give me a break. We have to tell the stories as the stories are - that's what writers DO.

At some point, the literature of a people has to move beyond the need to be perpetually and repeatedly social justice literature. Literature should ultimately be about story first and foremost - story and character. I don't think a story about any group is necessarily obligated to speak for "The Experience" of that group; a writer has to be true to the characters she creates, and those characters may NOT be at all representative in the way historical scholars would understand "representative," whatever that means. I thought the women in The Help were all worth "getting to know" for all their different strengths and faults - a sign of good writing and a story worth reading. In the end I always approach novels as being about the novel's characters, NOT about Black people in Mississippi or Native Americans in New Mexico or Haitians in Haiti. In this particular book, the message of having the courage to tell one's story, to use writing as a way of asserting voice, to paint oppressors of any kind as ultimately ridiculous, and to work together in friendship for justice despite danger, comprised such a valuable STORY that I find politicizing it really unnecessary and unhelpful. The characters are strong, courageous, humorous, imperfect, loyal to EACH OTHER, and different from one another. What's so Mammy about that?

There were many other points made in the aforementioned pieces and the comments they generated that inspired only incredulity and disagreement in me. Boyd's soap-boxy review The Help: a feel-good movie for white people can't even leave the anti-white venom out of its title. If a white person wrote something entitled "A Feel-Good Movie for Black People" there would be a public outcry. I am neither a white person nor a Black person and I certainly did NOT feel good about the pain I read about and saw on the screen, but like one African-American woman journalist who left a comment, I felt very good about the love I saw between women friends and the way the women "ultimately save themselves by telling their stories." Boyd's sweeping generalizations and judgments - that Black people would never confide in white people, that no white person would be remarkable enough to earn Black women's trust, that Skeeter was ONLY motivated by ambition as a writer and not by genuine compassion for the Black women working as domestics in her town, that this novel should have encapsulated the experiences of all maids working in Jackson in the 1960's AND been a portrayal of the larger Civil Rights Movement AND (unrealistically) shown a white woman breaking some kind of mold to confront her only circle of friends with their behavioral ugliness - reveal the bigoted stereotypes and narrow view of white people in her own mind. She's supposed to be this accomplished journalist and scholar - yet she can't rise above what one commenter aptly described as "petty grandstanding."

I honestly think a lot of people out there are just plain SORE that a white woman would DARE tell stories from Black women's point of view AND do such an amazing, vivid, compassionate job. Sour grapes, I say. They need to move beyond judging something for what they WANT it to depict and judge it instead by what the author actually set out to do - get into the small moments, the pouring of tea in kitchens and changing of diapers in the nursery, explore the daily moments and relationships in the lives of three characters: Skeeter, Abilene, and Minny. This is what novels do. They are not Civil Rights documentaries. Stockett didn't want to write a novel about the lynching of innocent, persecuted Black men; she wanted to write about courageous, funny, gifted, strong, inspiring women and their friendships, obstacles, trials and choices. I think her incredible writing and her portrayal of these characters has honored women of all races, and she should be praised and thanked for it.

But please don't be like the intellectually lazy commenters under Boyd's review who don't feel like thinking for themselves and have decided instead, based simply on her tirade or other negative hype, to hate The Help already and not bother to read the book or see the movie. Have a little cultural integrity and responsibility and experience the work for yourself, then decide. It deserves that much, if only because it has us all thinking and talking.

_______________________________________________________

Addendum 8/18/11: for an articulate, balanced, scholarly critical essay on what The Help could have done better, with a concrete and appropriate LITERARY example, check out this wonderful NPR piece by W. Ralph Eubanks: "Eudora Welty's Jackson: The Help in Context." He gracefully avoids undermining his own credibility by not lapsing into shrill, knee-jerk invective and thus successfully invites readers to open their minds and think critically - presumably the desired effect of any good critic.

8/29/11: Another thoughtful critical piece that makes an excellent point.

To Bare Or Not To Bare

2011-06-30T05:17:00.005-04:00

Topless sunbathing is widely accepted in France, where we've spent a lovely vacation visiting my husband's family. Our recent day trip to a beach on the northern coast sparked interesting conversations between my daughter and me and between my husband and me.

On one hand, I think the relative absence of Puritanical sexual repression in Europe, as compared to the United States, has provided some advantages. People are accustomed to seeing bare breasts on billboards and other media from a young age. Breasts therefore need not be objects of shock value or secret, horny fascination. Women are allowed to be comfortable with their own bodies - as they should be - and men allowed to be comfortable with women's bodies in multiple ways without having to be so obsessively titillated by the one aspect of them, their sexuality.

On the other hand, I value modesty. I think there's something to be said for being feminine and even sexy without needing to bare all, for keeping private parts private (and thus in some way sacred, and meant for reverent care) and preserving the meaning of intimacy. My husband pointed out, though, that two-piece bathing suits are already immodest; what's the big deal with doing away with the top piece? (He is, of course, half European.) My young daughter, on the cusp of womanhood, sounds torn between two cultures; she was a little shocked at how easily modesty was abandoned here in France, but also admired young women for their confidence in their bodies regardless of body type.

Not long after our trip to the beach I read the current National Geographic article about child brides in India and Yemen. So much in that article dredged up a lot of anger in me - at how girls and women are still seen around the world as possessions or goods for use, whose worth is directly associated with the integrity of their hymens, whose appearance or even presence is often blamed for what is really the uncontrolled lasciviousness and misogyny of the males around them. Are men all over the world really so incapable of controlling their basest tendencies? Really? Can't the rape just STOP already? What is WRONG with people?

In my mind the jury's still out on topless sunbathing. Where it's commonplace and culturally comfortable, there doesn't appear to be a down side, and there may even be many positives. Women's efforts at extreme modesty elsewhere don't seem to quell the animal frenzy that leads to their victimization by stupid, irresponsible, and worthless men. Perhaps if the whole world would just relax about the human body we could all just step back, appreciate it, and take good care of it.

Why I Hate Birth Plans

2011-06-11T20:47:00.008-04:00

Recently on a physicians' forum I came across a tragic story about a home birth gone bad. The doctors on the forum were mercilessly critical of the individuals involved, but I couldn't disagree with them. Their tone may have crossed the line from anger over the tragedy into disrespect or even cruelty, but I can't say I blame them entirely - there's a part of every conscientious physician that does get enraged over what's perceived to be preventable catastrophe, and sometimes venting the outrage in private (which this forum was supposed to be), among others who understand, can release some of the tension raised by the story.

There seems to be a wide chasm between expectant women who distrust or perhaps even hate doctors and doctors who see themselves as the protectors of human safety and life and who thus sometimes see such mothers-to-be as close-minded, willfully uninformed, and even selfish. From the physician's point of view, a) "natural" isn't synonymous with "safer;" b) pregnancy causes physiologic changes that can sometimes pose real dangers to mother and infant - DANGERS, not just inconveniences or discomfort; and c) a rigid "plan" for birth is nonsensical in light of the possibility of unplanned concerns necessitating prompt and sometimes life-saving intervention.

Don't get me wrong; I firmly believe in women's right to express PREFERENCES and to have those preferences respected as closely as possible when safety allows. Of COURSE I would never insist on placing an epidural in a woman who preferred to give birth without one. But I resent the kind of pseudo-feminist culture that creates guilt or a sense of "failure" in women who feel they would like an epidural to relieve childbirth pain. I've heard it so many times; a tearful woman saying "I'm a failure" because natural childbirth became medically assisted childbirth. No woman should ever feel BAD about bringing a new life into the world. That, and the social signals that engender it, I definitely resent.

And despite the title of this post, I don't actually hate birth plans. I had one myself. I scrapped it in the end and decided to just trust in the process, and take things a step at a time, and actually have face-to-face conversations with my caregivers, but I did draft one. A birth plan that is meant to clarify preferences is a good thing. A birth plan, written or spoken or just held in one's mind, that is meant to be a binding contract for a physician, come hell or high water, is stupid and ultimately, in my opinion, wrong. The priority should be the baby's and mother's SAFETY, not the parents' "birth experience." If the so-called birth "plan" interferes with safety, it has to go, and any parent who insists on adhering to it under such circumstances doesn't deserve to be a parent. What I hate about certain birth plans is the unspoken attitude or culture behind them that seems to declare that nothing is more important than the mother's "birth experience." This is irresponsible and wrong.

So when a screaming doula verbally abused an obstetrician colleague of mine recently for going to stimulate a baby who was cyanotic and was making no respiratory effort - and when I say screaming, I mean I was three doors down attending to someone else and I could hear her yelling at my colleague at the top of her lungs - I felt the same anger that the physicians on the forum were feeling over the home birth disaster. My colleague was doing her JOB, protecting the baby's life and ensuring the mother's safety, according to standards that have been carefully studied, and here was this medically untrained woman interfering with this physician's care and potentially threatening the life of the child by screaming at the doctor that clamping the cord and stimulating the baby were against the parents' wishes. The baby's safety didn't seem to matter; it was all about the parents' wishes. THAT kind of ignorant, selfish "care" is completely inexcusable, yet in certain circles is glorified and touted as advocacy of women's rights and empowerment of mothers. There's nothing empowering about medical ignorance, stubbornness, or selfish adherence to a dream of a birth experience contributing to a child's death.

Here's what I would want all expectant mothers to know about giving birth at our hospital. Pregnancy may be natural, but it can also be dangerous. If you show up at our door, we're going to bend over backward to protect you and your baby, but we're going to do so according to the high standards of safety to which we've been trained to adhere. Please tell us what you prefer, by all means - we do want to create as wonderful a birth experience for everyone as we can - but we also have to put safety above EVERYTHING. We would be bad doctors, and morally culpable people, if we did any less.

Anesthesia v. The Joint Commission, Part II

2011-06-02T21:02:00.004-04:00

Yesterday's post mentioned that the leaders of this country's most important anesthesia organizations had sent a letter protesting several inane mandates that were being imposed or about to be imposed on anesthesia providers by the JCAHO.

This letter, requesting written confirmation that we anesthesiologists and anesthetists could keep our current, safe practices rather than switching to the suggested idiotic, less safe practices, was sent last December.

Now...let the back-pedaling begin!

JCAHO's response arrived at the American Society of Anesthesiologists' desk just about a month ago, and our anesthesia group has been abuzz about it this week.

The highlights:

"Dear Anesthesia Providers:

...Your letter points out that if specially designed processes are followed to accomplish [the task of pre-labeling syringes], labeling a syringe first and later filling that syringe can be accomplished in a consistently safe manner. [REALLY?! YOU DON'T SAY...?! Is that why we've managed to do this for the last several DECADES?! Imagine that!]

...After discussions with the Joint Commission staff, it was decided that it is beyond the scope of this NPSG [National Patient Safety Goals] to detail all of the various safe and unsafe processes in which a syringe could be filled and labeled. The Joint Commission decided to leave the current NPSG as is, which requires all filled syringes to be labeled, and to remove from the FAQ the prohibition against prelabeling...

As a follow-up to the previous discussion, one exception does exist to the requirement that all syringes be labeled...As long as there is no break in the process, labeling is not required during the administration of spinal and epidural anesthetics and analgesics. [Why THANK you! But we already KNEW that, because to require something so USELESS and intrusive would be completely STUPID.]

...The issue of anesthesia professionals (or anyone for that matter) carrying a medication is left to the individual health care organization."

Thank you, JCAHO, for taking our concerns seriously and realizing the idiocy and lack of groundedness-in-reality of so many of your requirements. Keep up the good work. Maybe if you keep paying attention to what you described in your response as "a number of concerns" voiced by many medical practitioners from many different fields, you can make up for your deficiencies in clinical knowledge and practical imagination with responsiveness to those who actually live and work in the real world every single day.

[Photo source here.]

Anesthesia v. The Joint Commission

2011-06-01T19:20:00.010-04:00

The following was written by a colleague who wishes to remain anonymous but whose permission I have to reprint it here. I think it expresses what a lot of people are thinking but can only admit in private.

Dear JCAHO (Joint Commission on Accreditation of Healthcare Organizations, a.k.a. "Jay-Co" to clinicians talking about you or, most commonly, complaining about you):

Over the years I have dealt with your incessant nitpicking by reminding myself that the regulation of institutions responsible for human lives is, in principle, a GOOD THING. I believe in safeguards. I believe in holding organizations to high safety standards. I believe accountability is important.

But over the years I have also wondered how it is that the bureaucrats that come to survey our hospitals can be so unimaginably clueless about the practicalities of patient care. Yes, perhaps they have had clinical experience in the past, are highly qualified (according to you), and have an alphabet soup of degrees after their names that purportedly validate their authority. Yet why do they seem unable to belie the stereotype of the out-of-touch, small-minded bean counter who has absolutely no idea how the real world of caring for patients really works?

You've already received a missive about this from representatives of all the major anesthesia organizations in the U.S., but I feel that their diplomacy diminished the forcefulness their words could have had.

I've gritted my teeth and had to accept the locked anesthesia cart you mandated in the obstetric O.R. despite the fact that if a pregnant woman were hemorrhaging TO DEATH and needed a true STAT C-section, the delay caused by having to retrieve the key to open the cart might actually KILL her AND her baby.

I've rolled my eyes at the various little rules you add each year, with the determination and scrupulousness of people whose mission in life is to add at least ONE new rule each year come hell or high water, even if on occasion one of your commands might, for example, be to get rid of the very form you made us adopt the LAST time you came.

But I cannot, cannot, CANNOT wrap my mind around the completely ASININE prohibition against pre-labeling my medication syringes and against the transport of medicines on my person for the sake of patient safety / emergencies, and the criticism of anesthesia practitioners for not labeling the STERILE syringes of a spinal kit when there is absolutely no discontinuity in the opening of the kit, drawing up of the medication, and injection of the medication into a SHARP OBJECT STABBED INTO SOMEONE's BACK which needs to be done as swiftly as possible once the patient's cerebrospinal fluid is observed leaking out of his or her spinal canal.

You would rather, as I understand it, INTERRUPT a procedure for the sake of a literally USELESS step, CONTAMINATE a sterile kit with a nonsterile label, and risk the injurious complication of arachnoiditis from the ink on a labeling pen, than have a spinal anesthetic performed cleanly, efficiently, and above all, SAFELY.

You would rather I draw medication up into an UNLABELED syringe, leaving it unrecognizable for a few seconds or its contents potentially forgotten, than allow me the opportunity to SAFEGUARD the drawing-up process by making sure my label and my medication vial MATCH. Pre-labeling, by the way, is an EVIDENCE-BASED safety practice, unlike your nonsensical and over-intrusive prohibition.

Most egregiously, you would rather a patient CODE AND DIE during transport than have me carrying with me the very interventions that might save that patient's life. And for what? For the sake of making sure pharmaceuticals are locked away, locked away, locked away? Who is protected by this kind of imbecilic medical tyranny?

The above satirical cartoon sums up in a few seconds why you appear to be almost universally despised by the medical community. Arguably no one is more obsessed with patient safety than an anesthesiologist, and we certainly know intimately the day-to-day practices that safeguard it. Perhaps, then, YOU should take a few mandates from US. You might subsequently find your recommendations and regulations actually having some lasting positive impact and earning something with which you might be unfamiliar: respect.

Sincerely,

An anesthesiologist somewhere in the U.S. who cares deeply about patients and their safety.

How I Spent "Judgment Day" 2011

2011-05-21T22:20:00.008-04:00

If you knew, or thought you knew, when the world was going to end, would you change the way you live your life?

Would you spend your life savings and forego career plans? Would you take one last trip to see some places you'd always wanted to see?

I never believed in preacher Harold Camping's prediction that the Rapture would occur today. Even if Jesus himself hadn't said plainly that no one can know the day or the hour, Camping's calculations would still have held no merit, based as they were on a) a literal interpretation of the Bible and b) a calendar that failed to take Dionysus Exiguus into account. But I did follow some of the media coverage around this phenomenon with interest. It generated questions like, "What makes people willing to take such risky actions for the sake of one fallible man's ideas?" and "What would you change about your life if you knew it was ending - SOON?"

I was pleased to realize that the answer to the latter was "not much." I'd still go to work and do my job - but keep it part-time, or make it even MORE part-time. I'd still spend as much time enjoying my family's company as I could. And if today had really been our last day, I would have been truly happy to have spent it as we did today.

My husband and I had a long, relaxing lunch outdoors. The weather was perfect - sunny, breezy, dry, in the 70's. The food was delicious. Later in the day we went to a fair two towns over. I love small town fairs; they evoke simpler times, happy families, and friendly communities with something to celebrate. The best thing about this particular fair was the presence of a book tent, where my husband and I spent contented hours browsing through tables laden with used books while the kids enjoyed the games and rides outside. Back home I concocted some Thai-spiced burgers for a late dinner, and they were yummy. It was a day full of all the things I enjoy and the people I love most. If the world had actually ended, I would have counted myself blessed to have known such lovely moments.

Blog Anniversary - It Kinda Snuck Up On Me!

2011-05-16T15:53:00.006-04:00

I can't believe this blog has been around for four years!

I know it's been much quieter lately, but that's been working for me. Not that there's anything too extraordinary going on in the rest of my life right now - other than the usual extraordinariness of my ordinary life. One day I am running to the emergency room to help with a potential difficult airway, anesthetizing a patient for abdominal surgery, or putting epidurals in expectant moms; the next day I have a cake decorating class, or a post office errand, or a movie night with spouse and kids. Life's got stresses, life's got joys, and I'm finding that this kind of balanced, un-remarkable existence is just what the doctor ordered (so to speak!).

It seems fitting, then, that I should celebrate with...

Berry-Basil Guacamole. An ordinary treat with an extraordinary twist.

This is my latest obsession. I had some at my in-laws' and fell head-over-heels for it. I really enjoy this kind of food adventure: take something rather ordinary (mashed avocado), and make it a little special with the unexpected ingredient, a not-your-usual combination of flavors. The strawberry-basil combo is, I must admit, kinda old news; it's been done a lot, as a salad, an ice cream, and even a cupcake. But I still consider it somewhat special.

Let me know if you develop (or have) a good version. Mine is just what you see above: avocados, strawberries, fresh basil, a little diced cherry tomato and onion, and whatever sprinkling of seasoning and citrus juice happens to be on hand and palatable at the moment. Best with my other latest obsession: Tostitos brand Artisan Recipe roasted-garlic-and-black-bean whole grain tortilla chips.

Happy Berry-Basil Blogiversary!

On Advocating For Patients

2011-05-10T21:46:00.007-04:00

The following is based on an actual conversation from an evening on call. Some details have been changed.

Situation: Emergency surgery for a patient whose vital signs were unstable and whose mental status was deteriorating.

Doctor: "I have some quick questions before we enter the operating room, and I'll also need signed consent for the anesthesia."

Family Member #1: "Oh, I'm his health care proxy. I can sign that."

Doctor: "All right. Can you tell me about his medical history?"

Family Member #2: "You mean why we're here?"

Doctor: "No, I know that part, but I was hoping you could tell me about his major medical problems. Does..."

Family Member #1: "Oh, I don't know any of that. I'm just the health care proxy."

Questions:

What does the average person understand to be the role of a health care proxy?

What should that role consist of?

Can people really advocate for others whose situation they either are in denial about or don't understand fully?

Family Member #1: "My brother knows some of that stuff, though."

Doctor: "I was reading through some old records. He has high blood pressure?"

Family Member #2: "Oh, no, he doesn't have that."

Family Member #1: "No. Not that."

Doctor: glances at listed hypertension medication in the record

Family Member #1: "He's actually really healthy."

Doctor (puzzled, glancing once again at list of medical issues from previous hospitalizations): "Oh? I thought I saw..."

Family Member #2: "Yeah, he's healthy."

Pause.

Family Member #2: "He just has a little congestive heart failure and some emphysema."

Processing...

The physician ran down a list of specific questions, asking about recent hospitalizations, heart symptoms, frequency of inhaler use, mental status changes, and other medical information felt to be germane to the patient's care. In this situation, however, time was short - surgery needed to be performed as soon as possible. Not only was the information not readily available, but also the sources of information were largely unreliable. Such circumstances can have a significant impact on patient care. The doctor here is responsible for efficient and thorough information gathering and the performance of a proper focused physical exam, but time and available sources can be very limited in situations like these.

Plea: Please know your own medical history, and if advocating for another, know that person's issues as well as his or her medical management preferences. The best care is provided when clinicians have the best information available, especially during emergencies, and sometimes loved ones / proxies / advocates are our only source.

Another Pet Peeve: the Finger-Pointing

2011-04-20T20:21:00.005-04:00

People blame anesthesia personnel for EVERYTHING. You name it, they blame us for it. They call us by the umbrella name "Anesthesia" and if there's a problem, it's always "Anesthesia's" fault.

Got into the room late? Blame Anesthesia. (Even though the anesthetist's been sitting at the bedside for twenty minutes waiting for the surgeon or the nurses to be ready.)

Patient craving ice cream when she woke up? Must be Anesthesia's fault.

No more coffee in the break room? It's because of Anesthesia.

Think I'm exaggerating? Spend a day in any O.R. in the country and count how many times someone says, "It's because of Anesthesia."

Why? Because it's easy to point the finger at the people / work / department you understand the least. The practice of anesthesia is poorly understood by people outside the specialty, so it makes the perfect scapegoat for EVERYTHING.

I recently heard about a conversation that exemplifies exactly what I'm talking about. My chief was explaining to some of the O.R. nurses what happened to a patient who experienced a known but uncommon complication from one of the materials used by the surgeon during the procedure.

"Yeah," my chief said, "X event happened after the surgeon put in Substance Y for that part of Operation Z."

One of the nurses replied, "Really? How did you [anesthesia] guys cause that?!"

The attitude is so ingrained people can't even detect the nonsensical nature of their own illogical utterances. *Sigh*

The practice of anesthesia looks easy but if people were to try it for a day I think they'd come away pretty spent. When the endpoint is a smooth course, with "nothing unusual happening," the expertise, planning, and careful execution are easy to take for granted. For the record: we prevent or correct many more problems than we cause. When you hear someone say, "It's because of Anesthesia," think twice. You're probably not getting the whole picture.

Sometimes It's Easier Not to Write

2011-04-15T21:23:00.006-04:00

I've been neglecting this blog because I've had some recurrent feelings of annoyance lately, and I like to keep my unsolicited invective to a minimum. After all, when I see whiny complaints or bitter criticisms on other blogs sometimes all I want to do is roll my eyes and say, "Who died and made you queen?"

Still, I can't deny that I have some of those thoughts and feelings too. I got a lot of heat when I disclosed the behind-the-scenes frustration that sometimes gets vented "around the water cooler" about certain less conscientious members of the anesthesia and/or nursing staff at my workplace. Lately the same people have exhibited the same lack of professionalism, not around calling in "sick," but avoiding work while at work (disappearing between cases, not checking in with the person in charge before leaving, refusing to see a patient on rounds twenty minutes prior to the appointed departure time because "it's almost time to go," etc.). And the same loud, obnoxious people who have often pontificated about things they don't know enough to pontificate about have continued to be loud and obnoxious and under-informed.

Then there are the surgeons with narcissistic priorities. Some examples:

Dr. Narcissus: "Can you bring the patient to the recovery room without extubating him, please, so we can get the next case in faster?"
Our team: "No, that's not the safest way to conclude the anesthetic for this patient."
Dr. Narcissus: "What difference does it make, extubating there versus extubating in the O.R. with me having to wait around for turn-over?"
Us: "Extubation is safest in the controlled environment of the O.R. We'd still have to watch over and extubate the patient in recovery. It wouldn't save any time and we'd have less available anesthesia equipment outside the O.R."
Dr. Narcissus: "Bring it with you."
Us: "Huh? You don't seem to be understanding the relevant issues..."

Me: "I did something a little different for the anesthetic based on some studies in the British Journal of Anesthesia."
Dr. Contemptuus (looking at patient in recovery room and not understanding that he's actually doing better than expected): "Well, I don't think the patient read that study."
Me: "His pain score is already less than expected considering you cut him open from stem to stern."
Dr. Contemptuus: (shrugs)
Patient: (chatting comfortably with family, laughing, and telling jokes)

Me (through the nurse-in-charge): "I'm sorry, tell Dr. P I have to delay his case because I have a hemorrhaging pregnant woman who needs an immediate C-section to attend to."
Dr. Puerilus: "I'm going to call the administration." He proceeds to do so AND to call my chief at home to LIE and say I asked him to come immediately to help with the C-section (only because the surgeon actually wanted to avoid the delay of his own, NON-emergency case).
Chief (to me, on the phone): "Hey, Dr. P said you really need me there. I'm on my way."
Me: "I don't. I never said that. In fact, I never actually spoke to him because I had to run up to O.B."
Chief: "Oh. You mean he made that up?"
Me: "Yup."
Pencil-pushing administrative nurse calling me to ask about delay of Dr. P's case: "I guess I shouldn't be distracting you with this while -"
Me: "While our patient's about to bleed to death and lose her child? NO, I guess you shouldn't."
Pencil pusher: "Well, he's just wondering when-"
Me: "We'll be able to start Dr. P's case once THIS LIFE-THREATENING EMERGENCY is stable."

CLICK.

It's not the clinical medicine that's the most stressful part of this job, though that can be demanding enough. It's the short-sighted PEOPLE.

I've cut back my hours and elected to spend more time enjoying life with my family. Life requires balance, and medicine tips the scales pretty forcefully. So we try as a family to keep the equilibrium. I recently took my daughter to her first Shakespeare play (The Merchant of Venice, with F. Murray Abraham as Shylock), a feminist theater festival highlighting women's rights abuses across cultures, and a wonderful performance of The Fantasticks in New York. My husband and I have had lunch a couple of times, been to the movies, spent some lovely quiet time talking. My son and I have had some time to ourselves. I wouldn't trade any of this to make more money; it's just not worth it. My family's love keeps me going and helps me remember why I need to keep looking past the little frustrations at work and focus on taking really good care of patients and those who love them.

Life in Medicine: A Reality Check

2011-04-05T10:16:00.005-04:00

This was posted on a discussion forum for physicians. It's a draft of an e-mail from an anesthesiologist to a medical school applicant who has not been accepted to medical school and has subsequently written to him/her for advice. I've changed the name of the student in question to just "Student."

Many physicians on the forum commented, "I'll sign it too" or "Put it up for all of us to sign" or "You could almost certainly get every doc [here] to sign this" or "It's the truth. She should know the whole story."

The e-mail draft is reposted here by kind permission of its author. I think it's extremely thought-provoking and worth reflecting on, especially by any students contemplating applying or reapplying to medical school.

[Student],

Sorry to hear things didn't go as well as you would have liked this cycle. It is a difficult process and I too had a tough time getting into school. That being said the road is long, hard, filled with debt and financial uncertainty. The federal government and a series of large multi-billion dollar companies provide their CEO's 10's of million dollar bonuses on taking payments and distributing a small fraction of them for your services. This is typically deemed as "efficiency in medicine" but Ii can't exactly see any efficiency out of a $22.2 million dollar bonus to the CEO of AETNA. Everyone says "I can work hard" or "I can get through it", but when it comes down to it you get 8 years into it and you start to see for the first time and question why nurses are running the show at the majority of hospitals, why the lawyers are so "involved" at work, and how no one with an MD after their name ever gets educated about expense, cost, and reimbursement.

The interesting thing about medicine is that by the time you see what it really is you are already committed to it. The paperwork, insurance, and contract negotiations don't show up until you are already in your 30's. Insurance companies establish a team of individuals dedicated to finding reasons not to reimburse your services, fortunately residency and academic medicine protects you from a lot of this, but that soon changes. By this point most people find themselves >$100k in debt and feel that there isn't any other job they are qualified to do which provides some significant barriers to exiting. As a physician you are expected to be the first one in the door, the last one out it, and the ultimate individual responsible yet a body of administrators / insurance companies tell you what drugs you can and can't give as well as what studies you can perform.

To this a lot of people say "but I want to be a doctor and help people" but which type of people do you want to help? When some entitled patient walks in your door and complains about a $20 copay do you want to help them? Is your time not worth $20 after a decade of your life, $200k in medical school, $50-100k into college, and 3-7years of earning less than a first year nurse (out of a 2 year school) while you were in residency? How about when you are anesthetizing a 60yr old HIV positive heroine addict with no veins who thrashes when you attempt to put an IV in? Most people want to run away from that one, but someone has to help her and you happen to be the person on call.

Truth be told, [Student], there are lots of great jobs out there. Jobs where you can come out of college and earn a decent living with less sacrifice of your time, effort, and finances. Dental school is an excellent option. Dentists make anywhere from 150-300k/yr as a 3 day/wk General Practicioner (+/-call). The training involved is 4 years of dental school and 1 year of residency. Endontists make $500-700k/yr working 4 days a wk with 4 years of dental school and 2 years of residency (no call). Now why do they make more pulling/drilling teeth than you do prolonguing lives? You can thank the federal government for medicaid/medicare and the hippocratic oath for your moral imperative. There is nothing like a patient walking into the ER with a tattoo on their arm (tattoos are expensive ranging from $300-800 typically) complaining that they want a prescription for motrin because they can't pay for a bottle at the store (medicaid covers prescriptions written even for diapers). A dentist seeing the same financial complaint for a dental extraction would tell the patient to reschedule.

For a physician to make anywhere near 300k they would have to enter a top-competitve residency at a minimum of 4 years length with what is typically a significant call burden. The only specialties avoiding this are radiation oncology, dermatology, and radiology which have a lessened call burden. The time sacrifice also has social implications as a woman, most people don't like hearing this, but most physicians don't have more than 2 kids. By the time they have time to have children they are typically approaching advanced maternal age (AMA is age 35, residency typically ends at age 30 if no breaks were taken) and the risks start to outweigh the benefits.

Now do I hate medicine? No, actually I am fairly satisfied with my job. I get to take people who just met me then poison them with drugs to slip them into a coma so that they don't feel the lacerations, saws, and needles that we poke into them to raise their overall quality of life. Not only do i spare them the trauma of the experience, I off set my poisons with other drugs to keep the patient alive, well resuscitated, and from going off the physiological deep end. The job itself is amazing, unfortunately it is surrounded with lawyers, politicians, and white haired physicians pronouncing a "follow what i've said not what i've done" mantra while lining their pockets. This is then wrapped around the recent scandals of states equating an anesthesiologist to a CRNA, because 4.5 years of school is just as good as 12. I am actually quite fortunate to have no debt outside of what I plan on marrying into, but have friends with easily $500-600k in debt with the juice running (rates are currently 6.8% on loans). If i could spend all day in the OR and not have to hear administrators tell me about "hospital compliance training" or "annual compensation reviews" or "drug shortages" it would be heaven.

[Student], from what I know about you there were top grades at a good school but your boards were a little weak. You should look at this as a blessing and really review why you are drawn into this and investigate alternatives if you find those reasons wanting. One universal constant in medicine is that people applying to medical school and subsequent people applying to residency don't know a thing about what they are getting into. The only exceptions possibly family of a physician who is open about the experience. Be careful of blind leaps.

Celebrate Poetry Month!

2011-04-01T18:17:00.002-04:00

It's National Poetry Month. I'd like to open the celebration with my favorite recitation. Ladies and Gentlemen, "Litany" by Billy Collins, recited by a three-year-old boy.

Poetry Month Challenge: learn a poem (or two, or three) by heart and recite it (them) to someone you love. If on Facebook: upload a favorite poem or stanza each day as part of a Poetry Month album. Celebrate the mystery, beauty, and power of well-wrought language!

Of Gods and Men

2011-03-26T14:54:00.019-04:00

Fifteen years ago today, seven French Trappist monks were abducted from their monastery, Notre-Dame de l'Atlas, in Tibhirine, Algeria. An Islamist group, the GIA (Groupe Islamique Armé), claimed responsibility for the kidnappings and demanded that several GIA members be released from prison in exchange for the monk's release.

Two months later the monks' heads were found on a roadside; their decapitated bodies have never been found. The circumstances of their deaths remain unclear. While the GIA had earlier claimed that the monks had been executed, there is a troubling alternate theory that the monks were killed by gunfire from Algerian army helicopters during a botched raid and that their bodies were then decapitated to implicate the GIA in a shameful cover-up.

Xavier Beauvois's film Des hommes et des dieux (Of Gods and Men), which won the Grand Prix at the 2010 Cannes Film Festival and which I finally had the chance to see (after much anticipation!) this week, focuses not on the monks' deaths but on their lives. (See the American trailer here and the slightly different European trailer here.) I think it ranks with Roland Joffé's The Mission (1986), John Dulgan's Romero (1989), and Franco Zeffirelli's miniseries Jesus of Nazareth (1977) as one of the most beautiful faith-infused films ever made.

Its pace is slow, deliberate - like the Gregorian chant that marks the rhythm of the monks lives - and this is one of the film's virtues. No high-speed chases here, no breathy love scenes - how refreshing! The beauty and dignity of a few individuals' humble lives instead calls viewers to slow down, to pay attention, to focus, to notice, to cherish the ordinary and discover in it the extraordinary. One cannot appreciate this film without entering into the monastic spirit of contemplation portrayed in it.

Between scenes in which the monks go to chapel to sing the liturgical hours - vespers, compline, lauds, terce - we catch glimpses of their daily lives, lives imbued with a sense of the sacred even during the most humble tasks. One brother mops the floor and tends the garden; another, a physician by training, sees villagers in the monastery clinic; the abbott, Christian, played by Lambert Wilson (known in the U.S. for his role as The Merovingean in The Matrix), studies the Koran, visits with villagers, and tries to do right by his community. The peaceable and mutually supportive nature of the monks' relationship with the Muslim villagers is made clear in several scenes.

There are touching moments scattered throughout the film like small wildflowers in an open field. A young girl from the village and the old doctor monk have a frank conversation about being in love, dispelling the stereotype of the inexperienced or repressed celibate who knows little of such matters. The abbott opens the door to the cell of a monk who has fallen asleep snoring over his book and folds the sleeping monk's glasses for him. The monks gather with each other after a stressful moment while the doctor sutures one of them and the oldest gently rubs the youngest on the shoulders, trying to de-stress him in a paternal gesture of protectiveness.

The monks are saintly but imperfect. While washing some dishes one of them says to the other, "F- you!" after taking a humorously-uttered statement the wrong way. The brothers sometimes overhear each other's prayers in their cells, and some of their prayers are wracked with doubt and fear. The abbott makes an executive decision without input from the others, and they call him on it. Later the community comes together on more than one occasion to discuss whether they should leave Algeria, and the villagers they have come to love, in light of the rising violence and danger in the region. There are no easy answers for them, and each day brings tests of faith, small and large, with which to wrestle. In one of the most powerful moments in the film, the abbott, Christian, finds himself face to face with terrorists who have invaded the monastery. His exemplary courage, calm, and respectfulness under pressure were inspiring beyond words.

Like a meditative chant that lingers in the mind and keeps coming back hours and days later, Of Gods and Men is a film that permeates and stays with you. It's like that gentle whisper in which the prophet Elijah finds the presence of God outside the cave in Mt. Horeb. The Divine is not in the clamor of the tempestuous, earth-shattering wind, or in the earthquake, or in the fire, but rather in the stillness, in the quiet voice found in peace and silence.

Some reviews:

NPR (1) and NPR (2)

Click here to read Christan de Chergé's testament, written over a year before his death.

Click here for an interview with Henri Quinson, who left Wall Street to enter a Trappist monastery in rural France and who was the monastic advisor for Of Gods and Men.

March 24, 1980 - REMEMBER

2011-03-24T10:29:00.006-04:00

OSCAR ROMERO was assassinated 31 years ago today for speaking out against human rights violations in his country. He is a saint, de facto if not de jure (yet).

Photo source.

"The common good will not be attained by excluding people."

"Peace is not the product of terror or fear. Peace is not the silence of cemeteries. Peace is not the silent result of violent repression. Peace is the generous, tranquil contribution of all to the good of all. Peace is dynamism. Peace is generosity."

Click here to read an article about President Obama's visit to Romero's tomb this year.

Start at 2:25 below to skip the potty-mouth part and get to the truth-telling (From the Sojourner article Jon Stewart: How Oscar Romero Got Disappeared by Right Wingers...for the Second Time):

The Daily Show
Tags: Daily Show Full Episodes,Political Humor & Satire Blog,The Daily Show on Facebook

On Suffering

2011-03-14T16:16:00.016-04:00

Here's something that has never made sense to me regarding suffering: asking, "Why?"

If the earth were uninhabited, its tectonic plates would move all the same. Earthquakes and tsunamis would happen all over the desolate world, hurting no one. We suffer because we live on a planet on which the shifting and fracturing of the upper mantle are a natural and inevitable occurrence. We suffer because accidents and illnesses happen. We suffer because stupidity, self-interest, insanity, or power-lust cause people to harm one another or themselves. We suffer, finally, because we cherish those who feel the effects of these natural occurrences, accidents, and evils, and because love makes loss almost unbearable.

We happen to live here and we have the capacity to care, about ourselves and/or others. Of course we suffer. That capacity to care is also what enables us to experience wonder and joy.

I suppose it's only natural that we seek to avoid suffering. That is, it's understandable to want to avoid it. But I also believe we are morally obligated not to turn a blind eye to it, and the reason I'm bringing this up is a Facebook thread I read yesterday that really, really bothered me. These are the statements that I found irritating:

Person A: "I have not been able to bring myself to look at images from Japan yet."

Person B: "There are some of us who can truly feel deep compassion without the visuals."

Person C: "I refuse to. I don't need to be traumatised by that flood of images (can we call it disaster-porn?) in order to pray for the people of Japan."

Person H: "I think I used up my year's quota of natural disaster media coverage in the Queensland floods."

Person L: "I am in tragedy overload and cannot bear to watch it. It's not entertainment and it turns my stomach when people talk about it as if it is."

I understand some of the points made in the above statements (and others I didn't bother to quote), but what turns my stomach is the image of a bunch of safe, comfortable Americans / British people / Europeans WHINING from their comfy homes about how "tough" it is to look at others' pain and suffering. THEY WON'T EVEN LOOK, they REFUSE TO SEE the faces of their brothers and sisters suffering across the world - and thus, to my mind, in a way deny or refuse to affirm the reality of that suffering. It made me think of a kid plugging her ears and willfully refusing to hear the sobbing of another kid - I don't see you; I don't hear you; therefore I won't see or hear or feel your pain or have to take any responsibility for it.

I understand that sensationalism is negative and disrespectful in itself, but I felt like saying (and please consider that I was feeling very upset about the posts at the time), "Y'all are a bunch of wusses. Suck it up and LOOK! It's not happening to YOU! The >10,000 people who suffered and died under the debris deserve better than to have a bunch of comfy foreigners hiding their eyes and 'praying for them.' Solidarity is the highest form of compassion, and sometimes allowing ourselves to experience a little secondary trauma is the right thing to do. So many people spend their energy avoiding the REALITY of suffering that they can't even confront it vicariously. SAD."

I did not stick my nose into the discussion for reasons too complicated to elaborate here, but I was so deeply bothered by the way the majority of respondents felt justified in their insistence on looking away. It's so easy to claim, I feel for people anyway even if I don't know exactly what they've been through. I can pray for them without having to understand the details of their their pain. I guess I feel it's disingenuous. Don't we have an obligation to do more than "feel for" others? Shouldn't we seek to know and understand in order for our compassion - from the root, to suffer with - to have integrity? How can we feel we have the right to just erase someone else's misery from our minds by refusing to see it? Isn't that selfish, and cowardly?

I'm not saying my point of view is necessarily right. I'm still working it out, and trying to figure out why I had such a strong reaction to this thread. Someone there shared a lovely blog post that offered a beautiful alternative to disaster-porn mentality, and I appreciated that, but I also knew that it didn't convey the experience of those who witnessed or were directly affected by the disasters, and I still couldn't shake the bothered feeling I had when I thought about people willfully refusing to see their suffering.

I'm venting it here because I am trying to make sense of my own jumbled thoughts and feelings. I suppose it's normal when the unthinkable happens to wrestle with all sorts of ideas and emotions. There are never any simple answers when it comes to human suffering, are there?

Diaries at the Morgan

2011-02-23T21:44:00.012-05:00

Christine Nelson , Drue Heinz Curator of Literary and Historical Manuscripts at The Morgan Library and Museum, has done a lovely job with the current exhibit, The Diary: Three Centuries of Private Lives. From the exhibit's companion blog:

"Where does a diary end and, say, a sketchbook or scrapbook begin? And what do we call a string of digital updates in which we reveal a little bit each day (or each hour, or each week) about what's on our minds? Or a public blog that tracks our periodic observations? All these forms of self-documentation have something in common with the traditional diary, with its focus on what I thought, felt, read, ate, spent, observed, or did today (and the next day, and the next)."

I've been wanting to see this exhibit since the day Prof. Michael Leddy mentioned it on his wonderful blog Orange Crate Art. I had the chance to go to the Pierpont Morgan Library with my kids today, and it was everything I'd hoped. The exhibit is housed in one room, sparsely adorned with only selected quotations from a few of the diaries displayed on the walls. The diaries themselves are presented neatly in cases with informative captions highlighting interesting facts about the authors or the writings themselves.

The diaries are presented in groupings such as "war diaries," "spiritual diaries," encrypted diaries, and diaries about works in progress, etc. with each diary open to a page of interest that gives the viewer just enough of a voyeuristic glimpse into the author's mind to be both intriguing and satisfying. John Steinbeck wrote famously on May 31, 1938, "Here is the diary of a book and it will be interesting to see how it all works out." The book was The Grapes of Wrath. We also saw the musings of Hawthorne as he was working out The Scarlet Letter, E.B. White on The Trumpet of the Swan, and diary drafts of Kingsley Amis's poems.

There were also observations of an American teenage actress in London (discussing how the British boys couldn't hold a candle to the ones back home), a chess diary by Ruskin, and diaries by Pepys (of course!), Thoreau, Einstein, Charles Seliger (whose penmanship strains the eye), Tennessee Williams (whose penmanship, by contrast, is large and loopy and a little multidirectional), John Tudor (from the period of the American Revolution), Bob Dylan (from much later!), Arthur Sullivan, and Sir Walter Scott. Charlotte Brontë's need to vent her frustration into a diary became kindling for her fiction writing, and I couldn't help smiling at one acerbic comment about "another who seems a rosy sugarplum but I know her to be colored chalk."

I was especially taken by the very first volumes we encountered when we entered the room: a small notebook dating from the Renaissance with erasable pages coated with gesso, and the 19th-century hand-sewn diaries of Elizabeth Eastman Morgan, who lived in Western Massachusetts and wrote about her household chores (sausage- and candle-making, butter-churning, pickling, spinning wool, etc.) and the signs that marked the change of seasons (the peeping of frogs in April, the appearance of whortleberries in August). Her diary is featured in the companion online exhibit and podcasts, which are captivating in and of themselves and well worth an afternoon of browsing, especially for people who are unable to visit the Morgan before May 22 this year.

A special bonus was the chance to see Pierpont Morgan's restored 1906 library . Walking into the East Room reminded my kids and me of the scene in Disney's Beauty and the Beast when the Beast gives Belle the gift of a library, and she opens her eyes and sees a vast collection of books lining the walls from floor to ceiling. On display in the library's beautifully appointed rooms are some gorgeous illuminated manuscripts, a 15th-century block book, exquisitely detailed Babylonian cylinder seals, and music scores by Chopin, Liszt, and Mozart. The library website also offers, incidentally, a Music Manuscripts Online project, providing access to digitized versions of more than forty music manuscripts from the Morgan's holdings.

This was a wonderful exhibit. We bloggers are diarists of a sort, and collections like these churn up those delicious questions about why we do what we do and how we tell the stories of our lives. It's a lot of fun to see how some illustrious people have done just that over the centuries, setting down fragments of their minds for themselves and readers to see and contemplate again and again.

Reflections on Happy Coupledom

2011-02-14T01:15:00.003-05:00

This Van Eyck portrait, traditionally known as the Arnolfini Wedding, is sometimes held up as an early (1434) example of marriage being portrayed in art as an actual partnership rather than a mere contract or event. If that's so, I wish the man didn't look so miserable! Some people call this "The Shotgun Wedding," but more likely the style of the woman's dress, not pregnancy, accounts for the exaggerated size of her abdomen in the painting.

I love the convex mirror painted on the wall behind the couple and occupying such a central focal point in the overall composition. The mirror is decorated with ten scenes from the life of Christ and shows the presence of witnesses in the room - the minister and perhaps the artist.

When I think of the institution of marriage as it has evolved in Europe and the Americas over the centuries, with some even feeling today that it is obsolete, all I can think is how thankful I feel for my almost-fifteen years of happy marriage. I look at other happily married couples and have two other thoughts: 1) It's so great to see people who are so comfortable, truly comfortable, with themselves and each other and 2) I hope my kids are lucky enough to find healthy relationships like these.

I know that luck or blessing or whatever you want to call it is only part of the favorable set-up. There's also diligence, and patience, and good character, and the capacity to see and want and choose good character in others.

As my children get older and begin to be interested in more grown-up experiences and relationships, I often wonder: how can we guide our children to make choices that will bring them relationships like these, the kind that will give them peace, joy, and lasting love?

Modeling a healthy and mutually respectful relationship is crucial, and I'm contented that my children seem to see marriage as a beautiful and valuable bond, one to welcome if a compatible partner and the desire to build a life with that partner transpire. We also tell them that being in love is important but that love is not enough; common values and the commitment to support each other through shared victories and problems, to build a life side by side with hard work, are essential and go beyond the bonds of friendship and romantic love into a more sacred love, the intimate love of family. The kind of love that is an active process and a daily decision, not merely a feeling or an experience.

Over the years I've nurtured both indirect and direct ways of trying to pass on some guidance and wisdom, as much as I have, to my kids. When we watch movies together, for instance, I always make a point to comment on the relationships in them - what makes them work or not work, why certain ones look promising and other don't, who's a jerk and who isn't. Two films we've watched on DVD recently stand out in my mind as having moments that exemplify relationships with promise: Little Women and Amazing Grace. In both, we saw couples who were able to see and appreciate the truth about one another and were not afraid to confront each other honestly with that truth, even if it was hard. Along the same lines, both films showed couples who were at ease talking and opening up to each other, listening well, and valuing each other's thoughts.

If I were to add one more characteristic to look for in an intimate partner besides those already mentioned - respect, diligence, thoughtfulness, patience, integrity, supportiveness, appreciation, and the ability to talk and listen comfortably and truthfully - I would advise my children also to seek partners who are happy with and in themselves. This kind of happiness requires self-knowledge, security, a healthy spirit, humility, and responsibility and can be found in individuals who don't look to others to provide happiness for them and don't blame others when happiness eludes them.

I think my kids are getting the idea, and I'm glad. I'm also glad, though, to see that when a Facebook questionnaire asked my teenage daughter, "Is it possible to be single and happy?" her answer was, "Of course. I am."

This, I think, already sets her on the right track.

Black Swan

2011-01-24T20:02:00.009-05:00

Photo: Polina Semionova as the Black Swan conspiring with the evil Von Rothbart to seduce Prince Siegfried

I finally got around to seeing the much-hyped Aronofsky film Black Swan today. I want to see it again. I just don't know if my nerves can take it.

It was about as creepy as I expected it to be from the trailer. The sex scenes, which I wasn't too thrilled about sitting through, were also about as explicit and gratuitous as I expected (quite). The dancing was predictably strong from Natalie Portman's double (ABT's Sarah Lane) and, to a trained dancer's eye, noticeably flawed but nonetheless respectable from Portman herself. Portman's acting, though, was spot on. She deserved her Golden Globe.

First, a quick review. Black Swan is about a young dancer who desperately wants the lead role in Swan Lake, one of the most demanding roles in the classical dance repertoire. The ballerina must be able to play Odette, an innocent young girl transformed by the wicked magician Von Rothbart into the Swan Queen - the epitome of purity, vulnerability, fragility, sweetness, and helplessness - and Odile, her alter-ego and doppelganger, Von Rothbart's daughter, who embodies cunning, uninhibited sexuality, confidence, invincibility, and heartlessness. The sworn love of Prince Siegfried would have broken Von Rothbart's spell over Odette, but because Siegfried is seduced by Odile into promising his love to her instead, his original vow to Odette is nullified, and Odette's only escape from the imprisonment of being the Swan Queen is to leap to her death.

Audiences have been willing to watch this drama unfold over and over again for more than a century. I think it's because we recognize the two sides, light and dark, in ourselves. We empathize with Odette's sorrow and love; it breaks our heart. But with Odile we enjoy being impervious to such weakness; we relish being able to live freely, skirt danger, gratify our passions. In Black Swan, Portman's character, Nina, is seen as perfect for the "white swan," Odette, but her director is frustrated by the inhibitions - which he clearly feels are sexual - that prevent her from embracing the role of the "black swan," Odile.

The fascinating visual and thematic elements in Black Swan are some of the same themes that make the ballet Swan Lake itself such a crowd-pleaser year in, year out, generation after generation: the struggle between good and evil, light and darkness, and the close-to-home truth that sometimes that struggle is within, with darkness that lurks in every soul. We all have the Black Swan inside us, and sometimes, evil wins over good. That's just reality.

And there's that - reality. What is reality? Can we lose our grip on it, as Nina does progressively throughout the film? Where is the border between creative imagination and the psychotic unraveling that took a hold of Nina and intensified with every passing scene in Black Swan? For artists especially, there's this question: can you create a character or a world with such verisimilitude that you recreate reality, and what price can you, do you, pay for that? Anyone who's over-identified with another, or been involved in an artistic production that dredges up darkness, knows how dangerous that darkness can be when we get close to it, when life and art intertwine and reflect or imitate each other. The darkness can hurt. It might even be able to kill.

As can the quest for perfection. There's a clear message in the ballet Swan Lake that transformation involves, must involve, suffering and sacrifice. It's hard to separate that message out from the real-world process of becoming a dancer. Like the shoes in the familiar beating-of-the-pointe-shoes ritual glimpsed through this movie, dancers have their bodies and spirits smashed time and again against a variety of very hard surfaces - the demand for perfect technique, the absolute requirement to have perfect (read: thinnest) bodies, relentless competition to be the best.

The physical mirror dancers have to gaze into each day is as ruthless as the obsession with body image it engenders, and like other symbols for the search for self and identity - masks, portraits, faces - mirrors figure prominently in this film, as do (predictably) black and white color schemes and decor. There's also plenty of mutilating behavior - directed at self and others - reflecting the merciless hurting of the body and mind to which some dancers subject themselves. Art promotes plenty of obsession in general, but dance in particular seems to foment it to an extreme degree - not just over the art itself, either - and Black Swan holds up a magnifying glass that chillingly exaggerates and distorts this tendency into a dangerous current that sweeps its hapless protagonist into a transformation that threatens ultimately to destroy her.

While many bloggers and reviewers found this film cliché-ridden, I found it compelling as well as disturbing. Very dark, but definitely worth seeing. One of its best (and, I think, unsung) features, which I noticed from the very first moment, is its film score by Clint Mansell. It opens with the famously lugubrious oboe passage that open's Tchaikovsky's Swan Lake - already I was sucked in - but in subsequent scenes Mansell takes Tchaikovsky's ballet and reworks it into a suspenseful soundtrack that retains just enough recognizability to make it spine-tingling and spooky. If you know the ballet score well, you know you're hearing bits of Swan Lake, but it's the scary version - it's very effective. I think this impressed me almost more than anything else about this film. I guess a ballet-loving oboe student WOULD notice something like that, right?

Bottom line: I was expecting a psychological thriller with some decent ballet and some disturbing unanswered questions, and I wasn't disappointed.

I Am an Oboe Too

2011-01-23T10:31:00.006-05:00

Anna McNonymous, who blogs at Dangerous to French Fries, wrote a post about why she would be an oboe if she could be a musical instrument.

All I can say is, ME TOO, ANNA! Thanks for that great reminder of my oboe self, and how after several months of hiatus because of The Big Project, I simply MUST go back to it again.

Some characteristics of my oboe self?

-I need lots of TLC. Lots.

-I don't like the cold.

-I may not crack under pressure, but one day you'll find a little crack in me and you'll be like, "How did THAT happen?" But then take me to the right place and I'll be able to sing again. Go figure.

-I need to be handled JUST RIGHT if you want me to produce good work.

-I have nice parts. Er, ORCHESTRAL parts, you know?
-I've done a lot of ballet.

-I'm capable of ugliness that makes you groan with exasperation or throw up your hands in despair, and heart-stopping beauty that makes you sigh and feel glad that we met.

-I'm picky and particular and hard-on-myself and obsessive and critical and...oh, wait. That's the OBOIST.

Someday I want to play something with this glorious pianist (and composer). But I don't think I'll ever be competent enough!

Snow Day

2011-01-12T17:39:00.012-05:00

Addendum 6/14/11:

It has come to my attention that there are readers out there who are unwilling or unable to read the post below as an occasion of BLOWING OFF STEAM on a particular day about a particular set of individuals at a particular practice. Really? No one at work EVER did anything to annoy you? You never mouthed off just to VENT about a particular frustrating occurrence - even those of you who might be on, for example, a forum "designed to act as an outlet for blowing off steam?"

Please consider that in the comments section under this post I do take to heart the admonitions of readers who point out that my views might be biased or unfair or objectionable, and I do reflect and admit that I have some growing to do; that I do realize my mouthing off about two or three people was probably not fair to the dozens who don't come under the same category; that I try to describe to a reader the advanced training and clinical abilities of CRNAs; and finally, that this was actually discussed among physicians and CRNAs in our practice, and the views of both sides - the objections of CRNAs to being lumped together and criticized unfairly, and the objections of physicians to subpar work ethic from some CRNAs who, despite considering themselves MD equivalents did not demonstrate an MD-equivalent commitment to actually SHOWING UP - were laid out on the table. Each side asked the other to shape up on the particular problem being pointed out. Nevertheless, my chief and I persisted in the opinion that we did not feel we were "allowed" to call in sick, ever (though we sometimes do actually get sick enough to require it), and that we were held to a (perhaps unreasonably) higher standard than most professions have to meet.

While I can see why it would be tempting to demonize me for expressing how I felt on this particular day, I would ask that people consider that I was venting, that I was not alone in feeling this way, that some CRNAs in my practice actually agreed with me, and that some of the points raised (especially in the comments) might be worth discussing or even be of some value despite how grating they may sound.

_________________________________________________________

Boston had another blizzard today. I was really worried about this one. It was supposed to snow hard, about three inches an hour from 3 a.m. to 12 p.m. with poor visibility, impassable roads, etc. I've driven home in snow like that, and I find it terrifying. Your car won't do what you want it to, and worse, OTHER PEOPLE can't be counted on to be either careful or able to control THEIR vehicles or even able to SEE you.

I texted my chief to see if there was any chance the O.R. would close and cases would be cancelled for non-call personnel, but it was business as usual.

So I went back to the hospital to spend the night last night before the snow started. My husband and I had been planning a quiet evening together, but all he could do was wave sadly at me from the window as my car pulled away.

My chief, worried that the bridges connecting his area to the hospitals would be closed, drove to the hospital at 2 a.m. and set up an air mattress in the anesthesia office.

My other colleagues left their homes at least an hour earlier than usual to brave the blizzard and arrive at work on time.

100% of the doctors in our practice made sure they reported for duty at the appointed time, literally come hell or high water.

How many of the nurses and nurse anesthetists did the same?

To be fair, one of the nurses had the honor and dedication to trudge through the snow from her house in order to make it. I don't mean to imply that there aren't dedicated, hard-working nurses. But several of the nurses called in "sick" and only ONE of the nurse anesthetists who were scheduled to work this morning actually bothered to come. What was their excuse? Too much snow.

It has become common for nurses to seek to be recognized as equal to physicians in much of the work that they do (even publishing articles to that effect in newspapers and journals). But on days like this, it's IMPOSSIBLE for the docs to gather around the water cooler without noticing and commenting on the vast difference in work ethic between M.D.'s and non-M.D.'s. It's just not possible to get through med school and residency making excuses for not showing up and meeting your duties to patients, just because conditions are inconvenient. Nor do we get to feel entitled to extra pay or time off for the extra time and effort spent getting to work hours and hours early due to a snow storm.

Moreover, with our verbal Socratic oath I believe most of us take an attitudinal, internal oath to be there for our patients whether or not we feel like it, have had enough breaks during the day, etc. Why else be a physician, if you don't have this kind of commitment to taking care of your patients?

So it grates. I hate to admit it, but it grates when what you think of as the practice of medicine, not only a duty but also a calling to be there to heal others, gets generically lumped in with the practice of other "health care providers." There is a difference, generally speaking, not only in training but also in the overall attitude to the work. Doctors don't take snow days.

NO RESOLUTIONS!

2010-12-31T19:49:00.008-05:00

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

2010-12-25T05:00:00.010-05:00

"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

2010-12-21T11:42:00.001-05:00

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

2010-12-09T22:41:00.004-05:00

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...

2010-12-01T10:49:00.003-05:00

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

2010-11-28T13:06:00.004-05:00

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

2010-11-22T20:20:00.004-05:00

"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"

2010-10-30T17:57:00.011-04:00

(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

2010-10-20T22:55:00.006-04:00

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?

2010-10-16T12:06:00.012-04:00

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 Ethe r 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

2010-10-01T20:12:00.005-04:00

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

2010-09-17T01:15:00.005-04:00

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

2010-09-11T10:18:00.006-04:00

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

2010-08-24T11:46:00.005-04:00

"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

2010-08-21T11:39:00.016-04:00

[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

2010-08-09T19:28:00.003-04:00

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

2010-08-02T15:40:00.002-04:00

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

2010-07-26T17:49:00.008-04:00

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

2010-07-25T11:19:00.008-04:00

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

2010-07-18T14:35:00.008-04:00

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

2010-07-12T08:49:00.010-04:00

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

2010-07-03T03:42:00.031-04:00

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

Rest From Work

2010-06-24T12:34:00.006-04:00

I'm taking a break from early morning starts.

I'm taking a break from difficult airways and back-to-back epidural placements.

I'm taking a break from preop evaluations that make me grimace, or mentally roll my eyes, or make we want to go back home, curl up under one of Ramona's quilts, and take a nap.

I'm taking a break from surgeons who repeatedly have multiple add-ons to their schedules.

I'm taking a break from nurses who think room air is adequate oxygen for desaturating patients, who announce in loud voices that if they were "anesthesia" they'd throw their bodies across the door rather than allow a particular complicated patient to be brought to the operating room, who question my not giving a certain drug without thinking that I might be trying to protect the patient from that drug's potentially deleterious effects, and who in general either aren't comfortable with acute crises or who think they know more than the rest of us do about how to handle them.

I'm taking a break from A-lines and those who might forego using them to monitor the induction of anesthesia in really, really sick patients.

I'm taking a break from the 2 a.m. pages that I get because someone else didn't put in the right orders for a patient.

All those moments are in the past and across the ocean now. Now I am in a time and space of healing and rest. I'll eat food from the garden and listen to music from my son's violin, the chorus of frogs at the pond, the birds and sheep in the meadows. Now I'll inhale the scent of honeysuckle, lavender, and roses all around me, and just be.

V.I.P.'s

2010-06-11T21:04:00.006-04:00

People often seem to think that members of the medical world are excessively preoccupied with, defined according to, and ruled by a status-oriented system. That may have been an accurate perception a generation ago, but I've seen enough surgeons sweeping O.R. floors, attending physicians socializing with interns, and doctors having deep conversations with custodians to believe that "medical people" have matured a little past the old caste systems that governed the hallowed halls of medicine. Not a lot, perhaps - but a little.

I've been busy over the last couple of weeks - overwhelmingly busy, in fact - immersing myself in another world which is full of joy and fulfillment for me but which also surprised me by what it had in common with medicine.

People highly trained and skilled in a discipline that demands total commitment, superb knowledge, hard work, talent, and long hours.
Shop talk, engaged-in with relish and even pride, that can often leave outsiders feeling out-of-the-loop or even condescended-to.
Excessive preoccupation with who's "important" - the seasoned, perhaps famous professional, the experienced teacher, the uber-talented whiz kid - and where everyone fits into a silently understood hierarchy.

You'd think I was talking about doctors, but I'm actually referring to musicians.

I'm producing a concert that means more to me than pretty much any other creative project I've undertaken, and I've just held some auditions for both the principal and ensemble roles. In the process I've been gently chided for being over-friendly with "V.I.P.'s" (for example, faculty members at music colleges) and surprised by things like a singer's discomfort over the possibility of running into one of his students at our audition. I guess I just don't understand why there's so much lack of humility in these circumstances. So what if your student goes to the same audition you go to? How wonderful that you prepared him well enough to be ready for that!

As for the "V.I.P." thing, well - I have a number of reasons for disliking the whole notion. The first is my background: a grew up in a society in which the line between haves and have-nots was and is as stark as can be. I was born into the side that held the power, material comfort, educational advantages, and prestige, and I saw people lord it over those who didn't, and I hated that and hate it still.

Another reason is my profession: I don't believe in V.I.P.'s on my operating table because I'm going to take care of the disheveled, impoverished vagabond with the same standard and attention as I would take care of the queen of England, the president of the United States, or any Hollywood celebrity. Illness and death remind us all that no one human being is, in the end, intrinsically more powerful than any other; we just allow or prevent the exertion of power by various means. I also use trousers as a reminder: we all put them on one leg at a time; no one's that special.

A third reason is my faith, meaning my view of the world and the human person. The teacher I've chosen to learn my life lessons from taught that I should love each person. Period. That even the so-called least in society are worth the world. End of story. And because that picture of human worth includes me, then I need not look askance at others - either for their faults or disadvantages or for their talents and successes. It just so happens that the concert I'm producing is concerned, at its core, with this very idea, so I was doubly surprised that people would show interest in it but still feel preoccupied with who should be in a place of honor and who lower or higher.

I don't pretend to be immune to insecurities about being good enough, fitting in, or doing well. On the contrary, I've often struggled with such insecurities both in medicine and in my other endeavors. Learning humility has been a journey not about acquiring some kind of false modesty, the kind that leads people to deny their gifts or abilities, but rather about learning to see and affirm intrinsic goodness and good work in others and myself.

Several evenings ago my daughter and I attended a master class given by two amazingly talented, intelligent, artistically generous New York songwriters. We learned so much, not only because the feedback they gave singers and composers was so insightful, incisive, and well-articulated, but also because they offered their wisdom with such genuine humility - with kindness, humor, respect, a clear intention to affirm others' good work and effort, and self-effacing wonder in the achievements of others. I am convinced now that the most effective teachers are those who have the inner security in themselves that comes from genuine humility: the openness to recognizing the goodness of others, and to letting their light shine while sharing one's own light generously with them.

The Michelangelo Code

2010-05-28T22:12:00.009-04:00

Ian Suk and Rafael Tamargo see a pons and medulla / brainstem in God's throat in Michelangelo's Sistine Chapel fresco The Separation of Light from Darkness. I see it now too. [Hat tip to Dr. Douglas Field's article in Huffington Post for highlighting Suk's and Tamargo's Neurosurgery paper on the subject.]

In 1990 Dr. Frank Meshberger also observed in a paper published in JAMA that the stuff around God in Michelangelos' God Creating Adam looks like a brain in cross-section.

I guess all those hours secretly dissecting cadavers - an activity strictly forbidden by the Catholic Church at the time - really did have an impact on Michelangelo's art. I wonder if hours spent reveling in great art has an impact on our practice of medicine? I think it does, at least in subtle ways.

***

Addendum: This was my son's comment as he looked over my shoulder at the above fresco. "Is that supposed to be God?"

"That's how Michelangelo painted God on the ceiling of the Sistine Chapel," I replied.

He paused for a moment, thinking, then said, "I think God should be painted as a circle. No beginning, no end."

That's probably the best idea I've heard yet to express any concept I might have of God / a divine presence or energy in the universe. That, and the name given by God to Moses in the Hebrew Bible: I AM. No Patriarch-in-the-Sky for me.

Le Roi Est Mort, Vive Le Roi; or, is God dead? Or alive? And What Does That Mean, Anyway?

2010-05-27T17:02:00.008-04:00

A week ago Craig Venter announced the creation of the first synthetic cell: an organism with a fully synthetic genome. That is, he and his team took more than 1000 preassembled units of DNA, constructed from them the full genetic code of the organism Mycoplasma mycoides, and transplanted this prefab genome into the emptied-out cell of the organism Mycoides capricolum. The latter's protein-building molecular machinery recognized the DNA and "booted up" the cell. In short, it came alive.

Some have gleefully touted this the beginning of the end of religion. One commenter at OnPointRadio wrote,

"Science has accomplished what was inevitable and finally robbed religion of the argument that life is more than mere chemical processes...that it is some mystical, magical thing for which only 'god' can account...Hopefully this puts religion one step closer to obsolescence...humanity will never be rid of this human scourge that is responsible for so much intolerance, division, war and strife, but little by little, science is removing religious dogma regarding the monopoly 'god' has on life...At long last, religion's final tenuous argument about the mystical nature of life dissolves..."

Art Caplan, who directs the Center for Bioethics at UPenn, said on the On Point radio episode about Venter's achievement,

"To make non-living parts come to life I think is a major achievement. Not only does it open the door toward, as you've been discussing, some of the design of the microbial world to serve our purposes but it also philosophically pushes the notion that some sort of vital force or special force is necessary to understand life itself. I think this achievement kind of refutes that and basically says it is possible to understand what makes life tick in a more reductionist, mechanistic way...

...When you start to be able to figure out your million base pairs and order them up the right way, and then transfer them into a dead husk of another microbe's cell, and have the thing fire up and do everything that a bacteria's supposed to do, you have in a sense brought to an end maybe 3000 years of debate among philosophers and biologists about what is life. You're basically saying it's something that's under the control of a set of coded instructions. If you have the right chemistry around it, you can make things come to life. That's a pretty amazing demonstration and a pretty important moment in the history of science. So in that sense, understanding life, understanding how it works, seeing that you can even create it and manipulate it - I don't want to push that into the background. That's major...[It] puts you on the road that says we will be able to pull apart the ingredients of life, artificially synthesize the whole thing someday, and that there's no mysterious force out there, no ineffability."

I agree with science writer John Horgan, however: the mystery of life's origins is not solved by this laudable experiment. I also don't think that simply being able to figure something out, down to its molecular mechanisms, or even recreate it, proves the non-existence of the divine or the mystical. Everyone has beliefs about what Reality is and little "proofs" to defend those beliefs, but most of the "proofs" I've heard from both rationalists and believers strike me as dissatisfying or incomplete. I have no well-formed concept of God, nor do I deny the possibility of us all being merely biological machines whose consciousness passes into oblivion when the machines stop working. But I have experienced the ineffable and the inexplicable. Thoughts and ideas themselves, attractions and aversions, enjoyment and creativity, to me would remain somewhat inexplicable, greater than the sum of their parts, even if one could parse out every molecular mechanism behind them.

The more important question, I think, is not whether Venter's achievement and synthetic genomics prove or disprove matters of faith (which are inherently un-provable anyway) but whether we have to worry about the Frankenstein phenomenon: lab experiments spinning monstrously out of control. Time and time again we get ahead of ourselves ethically and morally: we start doing and making things without having responsible conversations to prepare for the issues that inevitably arise with technological advancement. According to Venter his latest achievement breaks that mold, and bioethical discussions occurred before the experiment was carried out. I hope thoughtful reflection - so easily and arrogantly dismissed as unnecessary or unfashionable - becomes the norm rather than the exception in an era in which science is galloping ever-faster as politicians, lawyers, and religious leaders try to keep up.

A Spouse's Silent Sorrows

2010-05-24T21:08:00.006-04:00

I have given anesthesia for a lot of breast surgery. I don't think I'll ever get used to the fog of pain and sorrow surrounding a double mastectomy.

All surgery is invasive in some way. Amputations, in particular, have a horror all their own; the idea that destroying someone - cutting off a body part, violating a coherent whole - should be necessary in order to save a life is almost too horrible to bear. When that kind of mutilation reaches the most private and intimate parts of people's bodies and lives, the very air around patients and their loved ones can be heavy with unspoken suffering.

As a woman I cannot imagine the grief of such a dramatic physical loss. I remember having bouts of depression when I was recovering from an elbow fracture years ago. Anxiety, too - I was afraid I would lose the ability to use my arm and hand effectively. Certainly that kind of functional loss would have been devastating. But there's something about mastectomy that makes the loss seem so utterly cruel, the devastation completely personal. Maybe I'm wrong, but I imagine the tears I would shed at having to face a mastectomy would be much more agonized and primal than those I shed worrying about my arm.

I wonder if anyone ever talks about the grief of husbands and partners. I think about that every time I see a patient supported by a spouse or partner who clearly loves her deeply and truly. I still remember the husband of a beautiful young woman who replied, after she said, "I love you" right before we wheeled her into the operating room for her mastectomy, "I am in love with you." More recently there was another kind, compassionate husband who kissed his wife and said affectionately, "Bye, Babe. Love you," then looked forlornly at us as we wheeled the bed away from him to take her to the O.R. He looked as if he didn't know what to do, as if he were about to cry.

In that one moment a thousand thoughts seemed to be emanating from his lost look: There goes the woman I love. I'm so sad for her. I have so many memories of her. The nights we held each other, the children she nursed, the decades of flirting with each other in the kitchen. How can I not feel her pain when it's my pain too? Is it wrong that I feel it's my loss too? I love her so much. How could this be happening? I miss her already. I miss what we had. I'm scared of what's coming. My heart hurts. I just wanna scream and cry. It's not fair.

I'm guessing, of course. But that's what his face seemed to say. Some men or women might feel people would criticize them for grieving the loss of their beloved partner's breasts. I think when there is real love between two people - sexual love, physical love, spiritual love, and committed love that inspires them to work on a lasting relationship every single day - then such grief is completely understandable and natural and inevitable and right. When you love someone body and soul, then Body and Soul are inextricably intertwined in the forging and deepening of the relationship. A loving partner would be saddened not because he or she thinks breasts are the end-all and be-all of female sexuality, or that a woman's worth is related to her body parts, but rather because such surgery strikes so visibly and painfully at the heart of a lot of shared stories, intimate moments, mutual devotion, and cherished physicality. Such raw, heavy grief hurts all the more because it is often unspeakable.

One time I was discussing a painful experience with someone, with my husband listening, and while I was describing the regret I felt I started crying a little. I looked up and saw my husband's face full of love and support for me, his eyes a little wet as he felt in part the pain I was feeling. So often the beauty of compassion between partners is overlooked or forgotten, but when it exists the connection between the two can be felt by everyone in the room. This is what I see when I meet supportive husbands, boyfriends, and lovers of women who must have mastectomies. I wish I could tell them their profound grief hasn't gone unnoticed, unwelcome; that the love to which it bears witness matters tremendously and has touched those of us who are taking care of the women they love.

Oboe Feast Day

2010-05-23T12:38:00.009-04:00

The music director at my church says the sound of the oboe is supposed to represent the Holy Spirit - perhaps one reason he invited a wonderful oboist to play for Pentecost liturgy today.

My favorite piece for oboe, Ralph Vaughan Williams' Concerto for Oboe and Strings, contains several moments that sound Spirit-filled to me (the opening of the third movement, for example), so I'm posting it today, played by the incomparable Celia Nicklin.

As I listen I'm trying to reflect today on the symbols of the Spirit - wind and fire - and think of the things that "set me on fire" or "catch my breath":

the people I love
music
dance
the written word
learning languages
teaching
learning
working with others to create something special
the desire to combat injustice

The concerto:

You can also listen right on Youtube through these links: first movement, 2nd movement, 3rd movement.

Language Matters

2010-05-20T16:39:00.001-04:00

Happy Eliza Doolittle Day!

This NPR article says it all for me.

Blog Anniversary #3: Let the Games Begin!

2010-05-16T01:40:00.003-04:00

It's my three-year Blog Anniversary!

This year, I thought I'd take my inspiration from the wedding tradition of wearing

something old,

something new,

something borrowed, and

something blue,

but recreate it to reflect this blog - so we'll have

something literary,

something culinary,

something medical, and

something musical.

(I skipped "faith-related" because we had a pretty high dose of that during the recent High Holy Days.)

SOMETHING LITERARY

This is from a Facebook meme I found amusing. If you feel like it, share your version. Also works with movie titles and song titles.

"You Are What You Read": fill in answers to the following using book titles only (name the author in parentheses).

Describe yourself: A Moveable Feast (Ernest Hemingway)

How do you feel: A Separate Peace (John Knowles)

Describe where you currently live: A Tale of Two Cities (Charles Dickens)

If you could go anywhere, where would you go: Dancing in Petersburg (Mathilde Kshchessinska); or, The Most Beautiful Villages of France (Dominique Reperant)

Your favorite form of transportation: A Room with a View (E.M. Forster)

Your best friend is: Iron and Silk (Mark Salzman)

You and your friends are: The Complete Peanuts (Charles Shultz)

What's the weather like: Clear Light of Day (Anita Desai)

You fear: The Sound and the Fury (William Faulkner)

What is the best advice you have to give: Don't Sweat the Small Stuff (Richard Carlson)

Thought for the day: French Women Don't Get Fat (Mireille Guiliano); and, Their Eyes Were Watching God (Zora Neale Hurston)

How I would like to die: The Sweet Life in Paris (David Lebovitz)

My soul's present condition: The Secret Scripture (Sebastian Barry)

SOMETHING CULINARY

Anesthesioboist's Almost-Flourless Chocolate Cake:

Preheat oven to 375F.
Line a 9-inch baking pan with buttered parchment paper.
Melt together 6 oz semisweet chocolate, 4 oz bittersweet chocolate, and 1 c butter.
Stir in 1 c sugar and let cool slightly.
Beat in 5 eggs one at a time.
Stir in 5 tsp flour.
Optional: also stir in 1 1/4 tsp baking powder / 2 1/2 tsp vanilla / pinch of salt / liqueur of choice. I didn't use any of these the first time I made this and it turned out fine.
Pour batter into prepared pan and bake 30-35 min or till set but with center still a little wiggly. Don't overbake!
Turn over onto plate and dust with powdered sugar. Serve with chocolate sauce and/or cinnamon cream and/or fresh raspberries.

SOMETHING MEDICAL

Guess the diagnosis:

Boy with a Drawing

(though in fact the painting is more of an association rather than a portrait of someone with the diagnosis in question)

Lincoln

Mona Lisa (I don't buy it)

SOMETHING MUSICAL

First, I give you a little background oboe music by Stravinksy, written when he was 25 and, I guess, in a sweeter/more lyrical mood than his later work expresses.

I also give you this tongue-in-cheek quote from one of the best oboe-related articles I've read recently, entitled "The Supreme Court Could Use An Oboist." Written by ex-oboist Meghan Daum (though, as she points out, "once an oboist, always an oboist"), the article explains why Judge Diane P. Wood would have made a great nominee to the Supreme Court (hat tip to Elaine Fine for the link to the article in the L.A. TImes from which it came).

"...Speaking for myself and so many others in the oboe community, I don't think it's an overstatement to suggest that even if Wood had no judicial experience at all, even if she'd never even gone to law school - heck, even if she were a fifth-grader squawking out 'Ode to Joy' on a plastic Bundy - she'd still probably be more qualified for the Supreme Court bench than anyone else in the pool. Why? Because oboists may vary talent, discipline, ethnicity, gender and taste in unfashionable clothes, but we all have one thing in common: We're just about the most judgmental people on the face of the Earth. Ergo, one of us should sit on the highest court in the nation."

LOL.

Hope you've enjoyed this little "blog party" I put together for Blogiversary 3. Thanks for being here!

Blogiversary Weekend

2010-05-14T20:44:00.003-04:00

My 3rd Blog Anniversary is this Sunday!

I haven't decided yet how I'm going to celebrate, but maybe I'll have an idea by then. :)

A Music Competition Unlike Any Other

2010-05-13T22:17:00.008-04:00

One of my friends recently told me about the film Meetings with Remarkable Men, (supposedly) about the life of G.I. Gurdjieff (about whom I know absolutely nothing), and I was so blown away by the opening scene, in which men playing ancient wind instruments or doing some overtone singing (!) participate in a contest to make the giant rocks around a particular valley "ring." The contest itself is riveting, and the handing out of the award (seen in Part 2) is, in my opinion, worth the wait.

This movie was musically fascinating. It had me thinking playfully that maybe I had a past life in Central Asia somewhere. That would account for my attraction to Russia, old reed instruments, and the music and cuisine of the region, wouldn't it? :)

Happy Birthday...

2010-05-07T11:10:00.015-04:00

Original cast of the ballet Sleeping Beauty at the Mariinsky Theatre, St. Petersburg, 1890, with Carlotta Brianza as Aurora, Marie Petipa (daughter of choreographer Marius Petipa) as the Lilac Fairy, Enrico Cecchetti as Carabosse, and Pavel Gerdt as the Prince.

Happy Birthday Tchaikovsky! (And Brahms, and Robert Browning - I don't mean to short-change them, but I'm in a Russian ballet state-of-mind at the moment).

Every year on May 7 I think of Tchaikovsky and what a huge part of my life his ballet music has been. Every time I see a gentle snow falling outside my window I hear his snow scene from Nutcracker in my mind, and not even Mussorgsky's Night on Bald Mountain can conjure up dancing goblins for me as well as Tchaikovsky's Carabosse music from the Prologue of Sleeping Beauty. There are also those exquisitely beautiful adagios filled with pathos, or longing, or even in some cases an almost prayerful reverence - I'm thinking of any number of pas de deux from Swan Lake or Nutcracker or Sleeping Beauty - that have the power to break hearts open and spill intense emotions a lot of people throughout the centuries have seemed to want to work hard to suppress. Tchaikovsky bares them all - he wears his heart on his sleeve and consequently has at times been criticized for being maudlin or even "vulgar." Perhaps this is why I have a soft spot for him: his music gives us permission to feel great joy and sorrow and love and awe in a world where there can often be distrust or disdain for such non-rational experiences.

Tchaikovsky met with a mysterious and tragic end after a deeply troubled life. I wish he could have known what joy he would bring to generations of people through his work and foreseen that over 100 years after his death there would still be people like me who would think of him with gratitude on his birthday.

When I was growing up I did a LOT of ballet - at least two hours a day. I wanted to be a ballerina and even took special classes in New York with a prominent teacher there. I read about ballet history, watched ballet videos daily and learned all the major parts, took master classes from Margot Fonteyn and Melissa Hayden, and had the chance to meet Rudolf Nureyev, Cynthia Gregory, and Robert Joffrey.

I gave up that dream when my skinny pre-adolescent figure ballooned in high school and I realized I couldn't sustain a 1000-calorie-a-day life forever, but dance has always been a huge part of who I am. Now I can enjoy it stress-free, and I've been getting back in touch with its history, especially after visiting the Mariinsky Theatre in St. Petersburg. I didn't realize until this year that Mathilde Kschessinska had been Nicholas Romanov's mistress, or had tried to sabotage Olga Proebrajenska by releasing chickens onstage during one of her solos, or that Marius Petipa and Ekaterina Vazem had aired out their resentments so publicly, or that Anna Pavlova had reduced Tamara Karsavina to tears over a "wardrobe malfunction." Colorful stuff!

Ballet has evolved into something truly athletic - high legs, gravity-defying leaps, eye-widening spins by both men and women - but it wasn't always so. Dancers from the early 20th century may seem technically less capable to us now - a perception which, incidentally, isn't necessarily accurate - but they had an artistry and elegance that has become increasingly hard to find. Fonteyn, Kolpakova, and Alonso might look old-fashioned to viewers with today's sensibilities, but there was something special about dancers of their generation that I could watch over and over again. They and the later 20th-century greats - Plisetskaya, Gregory, Kain - bridged the gap between the late Romantic Period / turn of the century, dominated by Russian ballerinas like Pavlova and Karsavina, and the stars of the 1990's / early 21st century: Sylvie Guillem, Alessandra Ferri, Darcey Bussell, Polina Semionova, Alina Cojocaru, Vishneva and Lopatkina.

Technique can dazzle but without depth and soul it's a hollow Fabergé egg with no treasure inside. There comes a point when getting your foot up by your ear is no more than a cheap thrill - a trick that comes from being born with flexible hamstrings rather than from the kind of artistic maturity and musicality that makes a true Odette or Aurora or Giselle. I'll take Cynthia Gregory's Rose Adagio from Sleeping Beauty over ANY young Mariinsky dancer's today, much as I admire the latter.

Post-Cold War Generation

2010-05-05T16:41:00.007-04:00

Photos from the train to St. Petersburg: my son and a sweet, bright young Russian boy bonding over hand-held electronic games...

...and, of course, chess. I would never have dreamed such a moment possible when I was their age: Russia v. the U.S. engaged in a peaceful game. No language needed.

Ok, people: these single-digit-age kids can do it. Now can we all just get along?

(This, by the way, was probably one of my favorite moments of the entire trip.)

Door Number Three

2010-05-01T21:09:00.011-04:00

Our community has been hit by a sudden, painful tragedy: a freak accident that claimed a child's life. On what should have been an ordinary day - kids playing outside after school, others walking home from after-school activities, parents preparing the evening meal - one family in our neighborhood suffered an unbearable loss. We're all shaken and deeply saddened.

At work I face stress and anxiety-provoking situations all the time, yet people tell me I meet them with calm and grace under pressure. My home life is a different story altogether. As a mom I have a tendency to harbor deep anxieties over my children's well-being that I keep in check only with a lot of mental self-persuasion.

Right before we left for this trip to Russia I confided in a friend, "I worry that something bad will happen to one of us, and it'll be all my fault for dragging the family to Russia in the first place. I'll blame myself forever knowing they could all have been safe and intact but for my wanting to go." Just two weeks earlier two metro stations in Moscow had been attacked by suicide bombers.

"First of all," she answered, "nothing bad is going to happen to any of you. And secondly, what are you going to do, spend the rest of your life locked up in your house? Go live your life!"

So off we went. We rode the metro in Moscow - the relatives with whom we were staying, in fact, live right at one of the ones that was bombed. We rode a high-speed train to St. Petersburg - one of these had suffered a so-called "mechanical failure" (read: terrorist bomb) last fall. We flew in airspace that had been shut down for a week because of a volcano's threatening spew.

My friend was right: we can't let our lives be ruled by dread. But that's something I have to keep reminding myself. It only takes a moment to ruin a life, a number of lives; the current tragedy in our community is an agonizing reminder of that. What parents wouldn't give everything they had to rewind to the moments before such a loss, and somehow change things so that they could have that precious, unique, irreplaceable child back?

Years ago, when my first child was just an infant, I made a "dread list" as a way of exorcizing some of my demons, and I must admit it did help. Writing down my worries didn't dispel them entirely but it helped me let go of dwelling on them and constantly revisiting them. I won't say the words "carbon monoxide" don't cross my mind every time I wave goodbye as one of my kids goes for a sleep-over, or "roller coaster disaster" when we're at the county fair, but I don't mention my dark thoughts to them or prevent them from enjoying these normal treats of American childhood.

Change, too, makes me anxious, especially change of my own making. I worry that the decisions I make will be harmful in some way to my kids - as if I had control over everything that might happen to them - and if I allow myself to, I can fret about such decisions almost pathologically. The thoughts go something like this: Door #1 means we stay as is, Door #2 means we choose something else because of me. If we go through Door #2 and something bad happens to one of us, I will forever blame myself for not choosing Door #1 instead. If I pick Door #1 and meet with adversity, I'll wish we had chosen Door #2. What if I pick the wrong door?

This, of course, is a senseless, useless mental game, one that I banish from my thoughts when I have to make life decisions that affect my family, because if I didn't, it would drive me absolutely bananas. But the very fact that I have to banish it at all means that the tendency to entertain it is there, lurking like an imp holding out a temptation. People who tend to be plagued with "what-ifs" understand me, I think. And they would understand that the "what-ifs" I have to work so hard to suppress are nothing compared to the "if-only's" I am trying so hard to avoid.

If only I hadn't been there, gone there, stood there, done that. If only she had waited a second longer. If only he had taken the other road instead of this one. If only we had been able to do things differently. If only.

It's only human to want to avoid loss. It's small consolation that our capacity for experiencing loss is a corollary to our ability to hold things dear. Because we are human, we can recognize beauty, value things or people, experience wonder and joy in our relationships; but also because we are human, irrevocable separation from those we love hurts like hell. It is hell.

But I tell myself: we can't live in fear of what lies behind Door #1 or #2 or #3, or along this road or that road. We can't control everything that gets flung across our paths or berate ourselves for not being able to avoid the unexpected, the cruel adversities and unspeakable sorrows. We can only do what we can do: create life stories that bear witness to the best in us. We can't do more.

But my heart aches anyway. For my son's schoolmate and his family and friends. For the families I've met over the years at work who have wept the tears this family is weeping. For the loss of children, the sorrows and suffering of children, of families. If only.

Russia's Real Treasures

2010-04-26T07:42:00.015-04:00

Years ago there was a master puppeteer from Russia who would perform in Harvard Square. Every time he set up his marionettes on the corner of Brattle Street, near the flower shop, crowds of expectant children would gather and sit at his feet, with their parents - just as eager and delighted - standing behind them. Even watching the set-up was intriguing. Each wooden marionette had been hand-carved by this master artist, and the cast of

characters included a witch who would approach children inquisitively and sweep their shoes, a devil, a saber-wielding warrior, a violinist, a curious little bird, acrobats, skeletons, clowns, and perhaps best-loved by all, a little character named Doo-Doo who resembled a small elephant whose trunk was in the form of a recorder. Doo-Doo wore trousers, shoes, and a shirt and would walk on two feet, do a little dance, sit on children's laps, lean his head on them, and gaze at them longingly with his adorable, big eyes.

Or rather, these marionettes would seem to do all these things as if magically alive, but in truth it was the puppet master, Igor Fokin, whose expertise and dexterity brought them to life and gave them each a story to tell. It seemed that hundreds of years of the art of puppetry, with its links to theater, childsplay, magic, ritual, story-telling, and fine art, breathed through this man, electrified his muscles and movements and animated the very strings and wood of his creations, giving them each a soul, at least for a few moments. Each character was an individual with a distinct "personality," but Igor's spirit came through all of them in the way they approached the audience - his gentleness, humor, and capacity for delight.

Writes filmmaker Yel ena Demikovsky on her website about Igor, "Igor used to say that his first puppets were rather difficult to make. He carved them of wood, injuring his hands frequently. But with time, he became so skillful that he was able to carve wood like soap. Most often, Igor could just glance at a piece of wood to imagine its future character. He'd say, 'I just cut away what's not needed.' " Many artists with real genius describe a similar process: Michelangelo, who would liberate his statues from their marble blocks; writers who describe scenes or characters appearing in their minds almost with a will of their own; composers who hear the music internally and become like conduits for its notation.

Before we had our kids my husband and I would stop and watch Igor's performances whenever we were in the Square. Like the children sitting in the first row we secretly hoped the marionettes would come to us, sit on our laps, play with us, but of course that was reserved for audience members who were children in body as well as at heart. We would watch as the tiniest movement of his hands on the wooden mechanisms he had designed and built for the marionettes, or sometimes just a subtle adjustment of a little finger on one string, would transform a puppet's movements and create magic that would make a child laugh or a grown man smile. Sometimes he seemed to dance with his characters. He would smile at them, with them, and through them. "When we have kids, we've got to bring them here to see him," my husband and I agreed. "They can't miss this." We couldn't wait.

But alas, it was not to be. In 1996, two weeks after his youngest child was born, Igor came home from a show in Harvard Square and died suddenly of a heart attack at the age of 36. Our community was heartbroken at the loss of such a wonderful artist and person. I wrote a letter to his wife expressing my condolences and offering whatever help I could - at the time I was newly married, not in school, with no job, and unsure of what the future held, and I thought I could at least offer to run errands for her and help out in small ways. Somehow we became friends - sometimes you just connect with people, and conversations and confidences flow naturally as if they were meant to be. When she and her kids had to move back to St. Petersburg months later, there was definitely an ache in my heart at their absence.

Igor's wife and I kept in touch off and on over the years - letters, Christmas cards, photos of growing kids. When my family and I arrived in St. Petersburg on this last trip she and I hadn't seen each other in thirteen years. As soon as I saw her and her eldest son on the platform at the train station, though, it was as if all those years had dissolved. We hugged like long-lost sisters and talked non-stop on the way to our bed-and-breakfast. She and her son took us around the city the following day, then invited us to her place for the afternoon, where he offered our kids what we had always dreamed they could experience: a performance by Igor's marionettes. It was magical. Igor's spirit was with us again for a few moments, and all the wonder of his skill and art came alive again through his very talented son. We hung out for hours that day. It was like old times, easy and comfortable. I was so sad to say goodbye.

This is why when people ask me, "What did you like best about Russia?" I cannot say St. Basil's, or Red Square, or the gorgeous cathedrals of the Kremlin, or the Hermitage, or even the most glorious sights of St. Petersburg. I left my heart in Russia because of my cousins in Moscow and my dear, dear friend in St. Petersburg, her children, and the time we spent reconnecting in their homes.

There's a little memorial to Igor in Brattle Square now - a small sculpture of Doo-Doo with a plaque among the cobblestones. At least now when my children walk by it they will understand what a treasure we lost, and they'll know too that friendship, even across vast expanses of space and time, is a gift whose worth can never be measured.

Russia: the last few days of our trip

2010-04-23T07:20:00.015-04:00

Photo exhibit we stumbled upon in a park along Tverskaya,

just in front of the Pushkin Café.

Landscape seen from the high-speed "Sapsan" train

from Moscow to St. Petersburg. All the little villages on the way looked like they could have been Anatevka from Fiddler on the Roof. Not a paved road to be found in the rural areas between the two cities. How do the grocery trucks make it in the winter?

Freedom of expression in a little train station somewhere between Moscow and St. Petersburg. ("Putin is an a__h____.")

Bank Bridge, St. Petersburg, just outside our bed and breakfast. I love it because it reminds of the end of the film White Nights, and because it's just a beautiful little pedestrian bridge.

Cathedral of the Resurrection of Christ (Собор Воскресения Христова), or Church [of the Savior] on Spilled Blood (Храм Спаса на Крови) as it is more commonly known, on the Canal Griboedova.

Ballroom at the Hermitage

Stroll along Canal Moyka, St. Petersburg

Canal Moyka, St. Petersburg

The Mariinsky Theatre

Anesthesioboist in Russia: Days 2 and 3

2010-04-19T12:23:00.010-04:00

Cathedral of the Assumption, South Portal

Izmaylovo Market

Old Arbat

Tsar Bell in the Kremlin: 200 tons of regret

(minus the 11.5 tons that broke off...)

Cathedral of the Annunciation in the Kremlin

Red Square

St. Basil's Cathedral

View of Red Square from near the river

To Russia (with love)

2010-04-17T23:48:00.008-04:00

One of my dreams has been to travel to Russia...and I did it! I'm in Moscow visiting my cousins!

We almost didn't make it here. First, bureaucracy: the Russian consulate sent our applications BACK to us saying we hadn't calculated the fee appropriately (grrrr...we followed the instructions on their website to the LETTER), then they took their sweet time to process the "corrected" application, and our passports arrived at our house THE DAY OUR FLIGHT WAS SCHEDULED to take off! So we packed in a frenzy, only to find that because of the volcano in Iceland our flight had been CANCELLED. More frenzy as we re-booked ourselves on a flight out of New York the following day and got a rental car to drive to the airport there. Whew. (I just learned that the equivalent flight the next day ended up being cancelled too, so we really just made it to Russia! Hope we can get back without too much trouble...)

Our flight took a longer flight path than usual, cutting aross Northern Italy. We made up a little time getting blown across the Adriatic by a mighty tail wind, but it was pretty long all the same. I was SO relieved when we finally touched down. The passport control guy was a dead ringer for Val Kilmer (but cuter!). I've been having fun practicing my cyrillic reading.

We had a very relaxed, delicious lunch at my cousins' place before heading out to evening Mass (the closest experience we're probably going to get to a clandestine Mass - the Catholic Church's position here in Russia's somewhat unclear to us but seems little tenuous). The priest's apartment was in a building with a very Soviet feel (and aroma!) to it; it even had the diminished-visibility screens on the windows. Mass was intimate and lovely, bilingual in French and English (so my husband was invited to do the second reading in French), with the priest singing the prayers in a deep plainchant that transported us back a few hundred years.

Afterward we took my cousin's son shopping for suit pants at Gum, which has to be the most gorgeous shopping mall, inside and out, that I've ever seen. Red Square is right outside Gum, so I peeked into the soul-stirring interior of little Kazan Cathedral and was thrilled to walk across the vast expanse of Red Square, toward colorful and iconic St. Basil's. Then home again to a home-cooked dinner, showers, staying up till midnight talking, and a deep, restful sleep. A really great first day in Russia!

When Your Life ALMOST Flashes Before Your Eyes

2010-04-12T22:00:00.004-04:00

One day, recently, there was a disturbing hissing sound in the O.R. from one of the gas tanks. A huddle of O.R. personnel got on it right away and tried to trouble-shoot for several minutes.

All of a sudden there was a loud popping sound, like a pistol going off, and the hissing crescendoed so that we could barely hear each other above it.

The surgeons and I exchanged looks, eyes wide. They stopped what they were doing. We all turned to the culprit tank and tried to see, tried to understand, what was happening. Meanwhile, the people on the team whose task was to make sure the equipment was functioning properly were still hard at work doing their job. The rest of us were ready to offer our teammates help but were also limited by our obligation to stay physically close to our areas of responsibility - for me, the patient's airway, and for the surgeons, the patient's surgical site. A technician was called from outside to assist.

I started to feel nauseated. I put an oxygen mask on myself as a precaution - the last person who needed to feel queasy was the person in the O.R. directly responsible for the patient's safety - and set about making sure my patient was still okay under the drapes. Breathing tube: check. Monitors: check. Eye covers: check. IV access: running. Warming blanket: on. Vital signs: stable.

My thoughts went whizzing around in my head like ricocheting bullets. What's going on? What can I do to fix it? What if we have an explosion - do I throw myself over the patient or on the ground? Boy, it would really be a bummer if we all went up in flames in here...I have so many things I wanted to enjoy with my husband and kids...

Thankfully whatever valve needed turning or tweaking got tweaked, and the deafening hiss stopped. As it turned out there wasn't any major or prolonged danger. But the incident reminded me that all those things we are trained to be vigilant for in addition to patients needing resuscitation - fires in the O.R., falling objects or projectiles, unexpected chemical hazards, aggressive patients, falls, and the like - are real possibilities, and that we really can't take our training or teamwork for granted.

Reflections During the High Holy Days, Part Two: Belief and Ritual

2010-04-02T23:28:00.004-04:00

[Photo: Dazu Wheel of Reincarnation by Calton.]

Last night the obstetric doctor on-call and I stayed up late in the call room waiting for the dreaded beepers to go off and playing with the Belief-O-matic quiz on Beliefnet.com, according to which I am only 65% Roman Catholic. Deep down, it diagnoses, I am 100% mainline-to-liberal Christian Protestant, and my colleague is either a Unitarian Universalist or a neopagan.

As I've written before, my beliefs are a jumble and at times inconsistent. Sometimes I suspect there may be a personal God at work in the world and other times I suspect there may not be one at all. Yet I pray/talk to the dead, and sometimes even think I perceive some very concrete help from them in the "happy coincidences" that arise in my life every so often.

Inspired by the Belief-O-matic game, my friend and I started to talk about belief and realized most religions give their members a framework in which to fit in some answers to the following:

Do you believe in God? What kind of God?
Do you believe in the existence of the soul / consciousness without form / an energy that lives on after death?
What is the basis of your moral convictions (i.e. what makes something right or wrong)?
Where do we come from?
Where are we going?
Why are we here?
Does free will exist?
Does evil exist?
Does fate or destiny exist?
Why do we suffer?
What are your views on gender identity, gender roles, sexual relationships, abortion, euthanasia?

My answers to many questions like this are along the lines of "possibly" / "yes and no" / "I have no idea." The only thing I know for sure is that the basis for my faith - whether it includes belief in God or not - is the idea that every human being is precious (a conviction with, admittedly, deep roots in my study of the teachings of Jesus in the New Testament). I may be unable to articulate a concept of God, but I keep searching - and if theological musings don't make you fall asleep right in your chair, you're welcome to a glimpse (below) of what goes on faith-wise in my head - and why, despite my doubts and struggles, I still try to participate in the rituals and practices of my home religion.

***

[Photo source here.]

There are two moments in Catholic liturgical life that I await and savor each year.

The first is the singing of the Exultet at the beginning of Easter Vigil, when the darkened church gradually fills with the light of hundreds of candles and the story of the Church as a people from its ancient (even prehistoric) origins to the Resurrection unfolds ritually through the songs, readings, and prayers of the most special Mass of the year.

The second is also during the Triduum, at the very beginning of the Good Friday liturgy. The priest and deacon enter the church in silence, then lie prostrate before the bare altar for several minutes. It's shocking and arresting, and somehow deeply moving too. Incarnate in their bodies is grief, profound humility, and the striking image of the person who has been struck down, by death or suffering or personal failing or all the above. The presiders of the liturgy express for the assembled people what no words can express. They look like they're weeping silently, motionlessly.

All my life I have struggled with the death of Jesus. I struggle with its cruelty, which shows so starkly our darkest side, what we human beings are capable of inflicting on one another, as much today as back then. I struggle with the meanings others have read into it. For so many people it was more than just a political inevitability; it holds mystical meaning.

I cannot say that I can easily accept concepts of atonement so readily when I believe that Jesus life was about our worthiness, not our unworthiness. I believe his gospel, his "good news," was that far from being a fallen, intrinsically unworthy people, we are instead so love-able and so gifted with love that we are precious beyond estimation, and if we could embrace that truth about ourselves, we'd have no need for the paltry comforts that come from arrogance, prestige, material success, praise, etc. Our true nature makes our betrayals of each other all the more tragic.

By reading his ministry and life this way, I find it impossible to read Scripture apart from this over-arching theme of intrinsic worth. Because I read his ministry and life this way, I see many more consistencies than inconsistencies in his teachings - love one another, don't ostracize the lepers and outcasts, respect women and children, take care of the sick and the poor, see the divine presence in each person.

I've been reading lately the letters and journals of women who chose to live out this very gospel every day (and, by the way, also ended up getting killed for those choices). From them I've learned that we are called to ever-deeper commitments to compassion that we may not be able to reach. Concern for others is manageable for most people; empathy that impels action is also relatively within-reach; but solidarity, true solidarity with those who need help - that, I think, is tough and rare. In the end if there's any mystical meaning in the death of Jesus that I can grasp, it's that ultimate commitment - that solidarity that he entered into with the suffering, broken, sinful world. I actually think the existence of a just God would almost make such solidarity a moral imperative for a God who calls all people to it. But what do I know...

Which brings me back to that shocking moment when the priest prostrates himself before the cross. If I'm right about Jesus' "take" on his own life, he threw himself right into our experience to the bitter end because he was willing to make the leap of ultimate compassion, and that's what that prostration expresses. I find the real saving grace lies not some magic blood ransom to right wrongs we can never undo or make up for, but rather in the possibility or truth of a God whose compassion is so infinite that it carries him into a life of solidarity with us.

Reflections During the High Holy Days, Part One: Why I'm Still Here

2010-03-31T21:38:00.008-04:00

I can truly understand the criticisms of those who feel religions do more harm than good. I don't agree, because I think there often exist in such criticisms a willful neglect of the good inspired by so many faiths, but I can definitely see the harm people can do in the name of their interpretations of their own religions and why the bitter opinions arise.

I'll be the first to admit that of all the times I've ever felt like rolling my eyes at, taking by the shoulders and shaking, or feeling totally embarrassed for the Catholic Church, this current period ranks right up there with any number of historic moments people have pointed to ad nauseum as evidence for why the institutional Church sucks.

And I can understand why Christians in general, not just the Catholic ones, can be a real turn-off. Who wouldn't be frustrated by a group that seems, despite a Messiah who taught, "Do not judge," to be comprised of some of the most judgmental people on the planet?

Then there's Islam. The religion of peace if one looks at all my wonderful Muslim friends and colleagues, but just the opposite if you're choosing to look only at Islamists: the misguided militant, the suicide bombers in Russia and the Middle East. If it's hard to be a Christian in today's world, it's probably even harder to be a true and faithful Muslim.

I have tried to learn about many of the world's religions in an effort to develop my own beliefs, moral convictions, and practices. I embrace the interconnectedness taught in many faiths of the near and far east, but I cannot relate to spirituality that seeks to cultivate indifference or imperviousness to physical realities, relationships, and sufferings, or to distance individuals from the world they inhabit. Archbishop Oscar Romero once said, "The Christian faith does not cut us off from the world but immerses us in it." I related more to that kind of statement of faith than any other. Faith, for me, is a way of seeing the world and living in it, not a set of beliefs. I want my faith to put me in the trenches.

Why, by this time, have I not left this troubled Church, with its frustrating history and frustrating issues and frustrating people?

Part of the answer can be understand by simply substituting the word "family" for "Church." It's home. I may need a break sometimes, but in the end I've accepted an identity that is rooted in the stories, symbols, pains, and hopes of this ancient People.

Another part of the answer is the person of Jesus. I won't go into my understanding of him here - that's a reflection for another day, and perhaps even another blog. But as I've tried to examine how the leaders or founders of religions have lived - not their successors, necessarily, who may have distorted their messages or used power to hurt rather than heal - I've asked myself questions like, Have they valued children and other powerless members of society? Treated women with respect (or disrespect)? Waged war? Regarded human beings as full of worth and wonder? I've concluded that Jesus is still the teacher from whom I want to learn the most important lessons.

So here I am. Still in the fold. Reluctantly at times, and in fact sometimes kicking and screaming and tearing my hair out, but definitely present and participating and trying to make my way. I may not believe some of what other Catholics believe, or express my beliefs in the same way, or even conceptualize Christ or the key ideas of Christian thought the way as many Catholics do, but I have an approach to scripture and an interpretation of Jesus' life that has enriched my own life and work, so for me faith, despite the struggles, has been a positive force.

I've been feeling contemplative lately, more so now that the Triduum is upon us, so stay tuned for "Part Two" wherein I may try to grapple with some questions that are probably thousands of years old.

Oscar Romero

2010-03-24T01:45:00.003-04:00

Romero.

August 15, 1917 - March 24, 1980.

Prophet of the people,

voice for social justice, human rights and dignity,

freedom, and non-violence,

killed by an assassin's bullet while celebrating Mass.

Remember him today.

If, like Patricia Hardy of the Texas school board,

you have no idea who he is and what he has done for the world,

learn about him today.

Thirty years later, his light still shines.

May we grow to be worthy of it.

[Icon by Robert Lentz, available at www.trinitystores.com]

For further reading, click here and here.

Too Good Not to Share

2010-03-14T11:26:00.013-04:00

For those of you who have cringed when I've mentioned awake intubation, here's a video that might make you feel better...or worse...In any case, I think the Massachusetts General Hospital residents are incredibly fortunate to have such a committed and courageous teacher!

(Click here to watch it on Youtube.)

***

Hubby's Birthday Cake

This is the best cake I've ever made, so I want to share all the sinful delight here for posterity (adapted from a ricotta pound cake recipe by Gina DePalma in her book Dolce Italiano):

Preheat oven to 350.

Generously grease and flour a rectangular (13 x 9) cake pan.

In a medium bowl sift together
-2 c+ 3 Tb all-purpose flour
-5 Tb cornstarch
-4 tsp baking powder

In a large bowl cream together
-2 1/2 sticks unsalted butter
-2 1/2 c part-skim ricotta cheese
-2 1/2 c sugar

Add
-4 tsp vanilla (can replace some of this with scrapings from a vanilla bean - haven't tried that yet)
-1 tsp almond extract
-5 eggs, one a time, beating well after each addition

Gradually add dry ingredients + 1 1/2 tsp coarse salt, stirring well after each addition.

Pour batter into prepared baking pan and bake at 350 till inserted knife or toothpick comes out clean (45-55 min).

Top with lemon glaze or buttercream frosting of choice. This cake should be allowed to rest overnight and be served the day after baking because for whatever reason it always tastes better the second day!

Thinking About the First Time

2010-03-06T21:01:00.005-05:00

A life in medicine is filled with milestones large and small.

The first time you touch a dead body.

Or hold a human heart in your hands.

The first time you pierce another's skin with a needle.

Or cut it with a scalpel.

The first time you witness a birth.

Or a death.

Your first code.

Your first infant intubation or spinal tap.

Your first solo anesthetic.

Your first job.

Not to mention licensure boards, three different sets.

On top of those, separate written specialty boards.

And of course, oral boards, everybody's favorite.

Recent events have caused me to reflect on the first time I and my classmates performed pelvic exams. As I recall, most of us anticipated this particular lesson with a little dread - at best, some mild anxiety. Physicians and nurses have to do such invasive things - stab people, gaze at parts of them even their spouses or parents have never seen, listen to their secrets, probe the most private areas of body and life. As a woman who has never particularly enjoyed visits to the doctor for a complete physical or to the gynecologist for a check-up, I was particularly un-enthused at having to inflict on even a comfortable volunteer such an invasion of her privacy.

The special instructors hired by my medical school to guide us through the process of examining their pelvic areas were highly trained educators who unselfishly allowed us novices to practice an examination on them that would require, for our patients' sake, our very best in terms of skill, gentleness, and respect. I know I couldn't do what they did - allow myself to be examined and give constructive, moment-to-moment feedback during the exam. I've volunteered my veins for students to practice I.V. insertion - that's about as far as I go.

We were divided into small groups of four, I think. I remember the sound of the speculum rattling as one of the students ahead of me trembled nervously while inserting it. I remember how we giggled nervously when another in the group asked the instructor, "Uh, could you uh, drop your top" and was gently given the feedback, "Perhaps you could rephrase that with, 'could you lower your gown,' or something like that?" I remember thinking how much more comfortable the instructors were with the whole process than I felt, and how embarrassed I was when I let out a surprised "Whoa!" when the woman I was examining did a mega-strong Kegel move while I was doing her pelvic exam.

As with everything in medicine, after a while even the most invasive and intimate action can go from being completely foreign and frightening to being completely familiar and comfortable. Whether I'm the patient lying on the table or the clinician doing the exam or procedure, I have individuals like those pelvic exam instructors during med school to thank for what I or my physician is doing with confidence and competence. I thanked them when they came to school to teach us, but I want to thank them again, many years later. They made a difference they'll never be able to know or see.

Making Whole Wheat Pasta Palatable

2010-02-23T09:45:00.003-05:00

My curse is that I love carbs. I love Asian-style sticky white rice. I love pasta. I LOVE bread. I also know that when I eat a higher ratio of proteins to carbs and eat "better" carbs than the lily-white kind I so enjoy, I feel and probably look better. This is a problem when one is not over-fond of fowl. *Sigh*

Last night I decided to try once again to prepare a "healthier" pasta dish, using Barilla Plus multigrain rotini with ALA omega-3. Each cup contains 17 g of protein, 360 mg of ALA 0mega-3, and 7 g of fiber. I would roll my eyes if I hadn't given up sarcastic and resentful thoughts for Lent.

Well, my dish was devoured with enthusiasm by the entire family, and I have Larry Elder of Charlotte, NC to thank for his recipe for Sicilian Lemon Chicken with Raisin-Tomato Sauce, which I found on Allrecipes.com and adapted for my family. Thank you, Larry!

Here's what I did.

Mediterranean Whole Wheat Pasta D'Après Larry Elder

Soak 1 cup of golden raisins in warm water to plump.
Zest 1 lemon and set aside the zest
Thinly slice 2 small onions and 6 garlic cloves.
Chop up half a can of medium pitted black olives (about 20 olives).
Heat some olive oil (about 3 Tbs).
Dump onions, garlic, olives, and 2 Tb pistachios (supposed to be pine nuts, but I only had pistachios) into it, and cook till soft and fragrant.
Season with 1/4 tsp dry oregano, 2 bay leaves, and a dash of cayenne pepper.
Stir in 2 cans of diced tomatoes (15-oz each).
Season w/ salt & pepper. Cook 5 minutes.
Drain raisins and add.
Add 2 Tbs balsamic vinegar and 1 1/2 tsp sugar.
Cook 5 more minutes.
Remove bay leaves and add some shredded fresh basil (which I didn't have, sadly).
Cook till heated through. Toss with 1 to 1 1/2 lbs whole wheat pasta along with lemon zest and, if desired, some shredded fresh Parmesan or Piave di Vecchio.

Larry's recipe also calls for some cooked chicken breast that has been tossed with the juice from the zested lemon - I did that, too, but the pasta-and-sauce part can stand on its own.

Photo source.

Satisfaction II

2010-02-20T14:53:00.006-05:00

Recently a patient was describing how much he had enjoyed spending time with members of the film-making industry in L.A. "It's so great to be around be people who love - absolutely LOVE - what they do for a living. Everyone -the actors, the directors, the make-up people, the camera guys - they all LOVE their work! For most people, their jobs are just...jobs."

People who are able to do what they love most in the world for a living are truly fortunate. Most people in the world don't have that opportunity, either because of lack of talent or lack of resources. But there must be ways to find some fulfillment even in "ordinary" jobs.

Recently I wrote about going through a slump in terms of my work satisfaction. I've been trying to turn my attitude around, and I'm finding that cherishing small / hidden moments, and focusing on those rather than on frustrations, can be really helpful.

One afternoon I brought an elderly woman with a potentially difficult airway and not one but two heart problems, one of them fairly risky, to the operating room. This was someone for whom every cubic centimeter of drug administered had to be given gingerly and deliberately, each drug with a very clear and concrete purpose. Most people can be given a variation on the same combination of medications for the induction of anesthesia: a syringe of propofol, some muscle relaxant, maybe a little narcotic. For some, though - either because of their medical history or because of surgical issues - "the usual" isn't appropriate. For this woman, the usual mix could have been quite perilous.

I had goals in mind. I wanted to get her heart rate below its rather rapid baseline. I wanted her pressure not to fall sharply below a systolic of 120, even 130 if possible, during induction of anesthesia. I chose my drugs carefully and I gave some of them practically a cc at a time. As she fell into unconsciousness I watched as her vital signs did exactly what I wanted: heart rate down to the 70's, blood pressure 132/77, breathing tube placed smoothly (with emergency airway equipment at the ready), patient completely safe every moment of the induction. It was one of the most elegant inductions I had done recently.

No one knew or understood my plan or what I was doing differently. No one realized the potential dangers I had avoided. It was a job done completely anonymously, and not even the patient would ever know the kind of moment-to-moment attention her challenges and her anesthetic demanded. Surgeon walked in, did his thing, and left with a quick thank-you to the team, also unaware of the meticulous care taken to protect his patient with her individual medical issues and needs. To everyone else, it was just another anesthetic.

But not to me. And you know something, the fact that I and only I knew that was strangely comforting. It's like producing a poem or painting or short story that you know will never be seen by anyone else but feeling wonderful about it anyway, because you created something beautiful, and it's yours. Sometimes the satisfaction is so fulfilling that external affirmation becomes completely unimportant - in fact, unnecessary.

It's a good feeling.

What's in Your Heart?

2010-02-14T07:37:00.004-05:00

Whenever I hear phrases like, "follow your heart," "trust what's in your heart," "hold it in your heart," I must admit that the first image that comes to my mind is this:

I see chordae tendinae, papillary muscles, ventricular walls: the inside of an actual human heart. What do people mean when they say "in my heart I know this," or "there's so much going on in my heart?" Why do we so easily identify our deepest of emotions and the most important of convictions with a pump inside our chests, rather than with our brains?

It's an ancient tradition, this conflation of the heart and the heartfelt. I think we make the association because among the parts of the body that a person can sense internally, the heart is simply the easiest to feel. Stomach aches and muscle movement can be vague, but the heart speeds up when we're excited or afraid, pounds loudly and palpably when we fall in love, has a rhythm we learned to hear and recognize in the womb, and in addition is almost frighteningly vulnerable, in need of protection from within as well as from the outside.

When I can get past the image of the heart's four chambers through which our lifeblood rushes, in and out, in and out, every moment of our lives, I start to see other things. My children, my husband - they occupy my heart. My heart is full with them. Yet, as is the nature of human hearts - the invisible kind, that is - there's room for more: music, medicine, stories, friends, a longing for God. I can feel them swirling around, and the more I have in there, the more room there seems to be, the more life comes pouring out, bringing exhilaration to body and mind.

What's in your heart? Or, as James Fowler asks in his book Stages of Faith: the Psychology of Human Development and the Quest for Meaning,

What are you spending and being spent for?

What commands and receives your best time, your best energy?

What causes, dreams, goals, or institutions are you pouring out your life for?

As you live your life, what power or powers do you fear or dread?

What power or powers do you rely on and trust?

To what or whom are you committed in life and in death?

With whom or what group do you share your most sacred private hopes for your life and for the lives of those you love?

What are those most sacred hopes, those most compelling goals and purposes in your life?

These are what I think reflections about love should consist of, on Valentine's Day or any day. The rest is just fluff.

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Anatomic illustration above by Patrick J. Lynch, medical illustrator & C. Carl Jaffe, MD, cardiologist

Temple Grandin

2010-02-09T09:18:00.015-05:00

"I believe that doing practical things can make the world a better place."

I first learned about Temple Grandin through NPR's This I Believe series. Now the outstanding HBO film Temple Grandin has brought her experiences as a high-functioning autistic person, her revolutionary creative and scientific work in the humane treatment of animals, and most wondrously, her mind, to life.

Claire Danes is phenomenal in the title role - that, we could have expected, though watching her become Temple Grandin physically, intellectually, and emotionally before our eyes is astonishing even beyond those expectations. But equally impressive is the way in which this breath-taking film captures the lived experience of Grandin's unusual mind. My husband and I were stunned and deeply moved as we watched it last night.

The film Temple Grandin manages to use cinematography to manifest intellect. Sometimes the camera cuts away temporarily to the very concrete images that come to Grandin's mind when people utter words like "miracle" or "animal husbandry," giving viewers an idea of the way she really does think in pictures. Camera angles and direction are used to help us understand her perceptions of the world around her, the discomfort of certain stimuli such as the clatter of eating utensils, the brilliant, intuitive insights she had about the mathematical relations of objects and their mechanics. Small moments convey a lifetime of struggle to understand humanity - her own and others', as well as the inhumanity she witnessed. As she says in the film, "Nature is cruel, but we don't have to be."

Since I learned about her, Temple Grandin has been an inspiration to me. I am not autistic, but I have had occasion to seek neuropsychological testing for certain cognitive challenges - and it was almost a relief to be told I had outright failed a couple of measures, so I could say to the people who had seen me get straight A's for much of my life and couldn't believe I might have a problem, "See? The world isn't always simple for me! There's a reason I get stressed out!" I grew out of my childhood echolalia and sensory integration issues (for the most part), but I often still feel like a mind in cognito, an individual with subtle issues and challenges passing for "normal" by being capable of achieving things.

Nonsense, some people might be tempted to say; you graduated from medical school - how can you talk about cognitive problems? To them I say, do you have any idea how many people struggle through med school, and succeed and become great physicians, with learning disabilities, mood disorders, ADHD, and other perhaps undefineable brain issues? Don't you realize how ways of thinking, perceiving, and processing just can't be so easily boxed into constructed categories?

I found myself able to relate so well with the perceptions of the world brought to life in the film and in Grandin's own words - especially the "thinking in pictures" (though how I wish I had her photographic memory!), discomfort and stress with certain kinds of sound and touch, and anxiety (and seeming "lost") in new environments or with the way people gIve directions or explanations. Grandin's story reminds me that none of us is alone in our struggle to relate to the world and each other; that there are those like her who have suffered much more and then achieved much more; that we all occupy an intellectual spectrum that connects us much more than it divides us. In the end, it was a story of hope - subversive, uplifting, challenging, and timely.

___________________________________________________________

Just out of curiosity, I took the non-diagnostic Autism-Spectrum Quotient found here. "Average" score was 16, likely to fall on autism spectrum was 32. ("Eighty percent of those diagnosed with autism or a related disorder scored 32 or higher. The test is not a means for making a diagnosis, however, and many who score above 32 and even meet the diagnostic criteria for mild autism or Asperger's report no difficulty functioning in their daily lives.")

I scored a 30, probably kept out of the spectrum by a "normal" empathic ability, ability to process noverbal social cues, and perhaps my love of fiction. When my husband looked at the test with me and gave the answers he thought I should have given, I scored even higher, 31. Good thing he makes such a good "hug machine." :)

Notes of an Anesthesioboist

Haunting Music

What is Death

9/11

Moving Beyond Mammy: Why I Strongly Disagree With Some Criticisms of The Help

To Bare Or Not To Bare

Why I Hate Birth Plans

Anesthesia v. The Joint Commission, Part II

Anesthesia v. The Joint Commission

How I Spent "Judgment Day" 2011

Blog Anniversary - It Kinda Snuck Up On Me!

On Advocating For Patients

Another Pet Peeve: the Finger-Pointing

Sometimes It's Easier Not to Write

Life in Medicine: A Reality Check

Celebrate Poetry Month!

Of Gods and Men

March 24, 1980 - REMEMBER

On Suffering

Diaries at the Morgan

Reflections on Happy Coupledom

Black Swan

I Am an Oboe Too

Snow Day

More Untold Stories

NO RESOLUTIONS!

Merry Christmas

Christmas Treats

On Guadalupe: An Old Favorite

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

Vicarious Trauma

November 22, 1963: Mixed Messages from Trauma Room One

Halloween: Ghost Stories to "Get in the Spirit"

A 7-Word Game

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Sick II

Friendship and Female Physicians II

The Story of My Life

My New Favorite Blog

Continuing Medical Education

Cupcake Disaster

Humanities and Medicine: All the Rage

I Am Not Always Nice

Martha, Martha

The 7-Link Challenge

If I Were a Physician in France

Vacation Highlights and France Top 10 Lists

Rest From Work

V.I.P.'s

The Michelangelo Code

Le Roi Est Mort, Vive Le Roi; or, is God dead? Or alive? And What Does That Mean, Anyway?

A Spouse's Silent Sorrows

Oboe Feast Day

Language Matters

Blog Anniversary #3: Let the Games Begin!

Blogiversary Weekend

A Music Competition Unlike Any Other

Happy Birthday...

Post-Cold War Generation

Door Number Three

Russia's Real Treasures

Russia: the last few days of our trip

Anesthesioboist in Russia: Days 2 and 3

To Russia (with love)

When Your Life ALMOST Flashes Before Your Eyes

Reflections During the High Holy Days, Part Two: Belief and Ritual

Reflections During the High Holy Days, Part One: Why I'm Still Here

Oscar Romero

Too Good Not to Share

Thinking About the First Time

Making Whole Wheat Pasta Palatable

Satisfaction II

What's in Your Heart?

Temple Grandin