Music and Silence

Monday, July 25, 2007:

We’re on VACATION!!!

We set off westward found ourselves near the Massachusetts-New York border by lunch time, so we had a home-packed lunch of sandwiches and strawberries at Tanglewood, right in front of the Hawthorne Cottage. What a great start – a picnic in a place permeated with music and literature, my favorites!

***

In the car on the way to New York I was so pleased when my daughter asked, “Is this Holst?” and started humming along to Jupiter. I also played a mix of violin selections, some of which included Joshua Bell in belated honor of his busking experience.

I always think of Perlman when I hear the Mendelssohn concerto and of Gil Shaham when I hear Sarasate’s Zigeunerweisen. Thoughts of Perlman made me recall Youtube footage of a master class he taught in Russia. What a great “bedside manner!” He was supportive of his students, acknowledged them as musicians without being condescending, and offered corrections in a way that was so clearly meant to help the musician be the best he or she could be. Watching one of Heifetz’s master classes (the clip I saw is no longer up) gave me a totally different feeling – intimidated, threatened, disdained, like my hard work and efforts would cause the guy nothing but exasperation. It was like reliving residency all over again. He’s such an unbelievable technical wonder, though.

I believe teaching should come from a love of what is being taught and a desire to transmit that love to one’s students, and with it the commitment to strive for excellence. I believe in respecting students, whatever their abilities or background, and in approaching them with an attitude that says, “I believe you can learn this, and it’s my job to help you do that, and it’s okay if you have a hard time with it at first.” No condescension, put-downs, scorn, resentment, or rage when something is not known or understood or immediately done well by the student. In other words, the opposite of most medical education, at least in my experience.

I hope when I teach I come across more like Perlman.

***

We spent the afternoon at the Shrine of the North American Martyrs in Auriesville, NY – a peaceful place with a gigantic round church surrounded by meadows and trees. It was a personal pilgrimage of sorts for me – the patron saint of anesthetists, St. René Goupil, died there after being tortured for weeks with his fellow-captives. I was surprised that a place with such a sad and violent history should have such tranquility about it. My husband and children were very supportive of my desire to visit this place, “where Mommy’s special saint died.” Our favorite part of the visit as a family walking down the ravine where René was killed by two natives and later buried, in an unknown location, by his friend St. Isaac Jogues. Posted for visitors to read on the trail down were excerpts of Jogues’s first-hand account of René’s death. It was an indescribably peaceful walk, despite the tragic story, and at the bottom the trail suddenly opened up into a beautiful clearing, where we spent several minutes just enjoying the sacred atmosphere of the place. It was strange to think part of him was still physically there, somewhere in that clearing, and wonderful to enjoy the silence of the place. It’s not often any of us has a chance to enter into some quiet contemplation on our own, much less as a family, so this moment of tranquility and renewal was like a drink of water in the desert.

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Addendum, July 11, 2007:

Found this description from a reflection by William McNichols, S.J.: "Walking down the pathway into the ravine at Auriesville where it is said René was murdered, one knows why pilgrims come especially to the ravine, and will always come there. For it is in the ravine that one senses something of God - some touch, some peace, some blessing. This place does not attract the sensation seeker, looking for the morbid or the macabre. Rather, one finds that the earth there, sown in red seeds, has brought forth a verdant, shimmering landscape Pope Pius XII called 'Nature's Reliquary.' " Jesuit Bulletin. Fall 1984. p.12-14.

On Seeing and Being Seen: a meditation on the social psychology of medical intervention

I thought Bill Clinton's graduation advice to make sure you really see the person next to you was good.

I thought the failure of people to notice Joshua Bell playing at the Lafayette Metro Station was bad.

But there's worse.

What's worse is people NOTICING something notable, but ignoring it.

And worst of all is when failure to see, or act on, a noticeable crisis costs a life. It was one of this week's buzz stories in the O.R.: the death of Edith Rodriguez.

Edith Isabel Rodriguez went to the E.R. at Martin Luther King, Jr. Hospital in L.A. - also known as King-Harbor and formerly known as King/Drew - doubled over with abdominal pain. According to the Associated Press, "It was at least her third visit to Martin Luther King Jr.-Harbor Hospital in as many days. 'You have already been seen, and there is nothing we can do,' a nurse told her.”

This kind of situation can put any doctor or nurse in a tough spot. A patient presenting with a history like this is usually either afflicted with an ill-defined medical problem, sometimes chronically, often more than one, and typically difficult to relieve completely, OR...the patient is in SERIOUS TROUBLE.

Jonathan Larson, composer of the famous Pulitzer Prize and Tony Award-winning musical Rent, got sent home when more than one emergency department failed to diagnose the cause of his chest pain and nausea: aortic dissection, which killed him the day before Rent opened.

Sometimes it can be a tough call, but I think when someone goes from abdominal pain to vomiting blood, it's usually a clue that something really BAD might be going on, depending on the nature of the vomitus and the amount of blood present, and I have to wonder what the thought process was in that emergency department. I admit I don't know all the details, and hindsight after someone codes and dies is certainly 20/20, so I am in no way trying to point the finger here. I'm just wondering, like everyone else, what happened, and how could it have happened?

Edith Rodriguez's story has by now been publicized widely in the media. The articles I saw were on MSN and the L.A. Times, but I was struck most by the CNN video on glumbert.com. It relates how Ms. Rodriguez lay on the floor vomiting blood, and somehow got help from NO ONE except a couple of individuals who tried to call 911 for an ambulance to take her to ANOTHER hospital. From the video and the articles I read, I've reconstructed part of the transcript of these calls here:

First call, 1:43 a.m.:
Caller: My wife is dying and the nurses don't want to help her.
Dispatcher: Okay, what do you mean she’s dying? What’s wrong with her?
Caller: She’s vomiting blood
Dispatcher: Okay, and why aren’t they helping her?
Caller: They’re watching her...uh...they're watching her there, and they’re just not doing anything. They’re just watching her.

Second call, from a different person, 1:51 a.m.:
Dispatcher: What’s your emergency?
Caller: It’s a lady on the ground here at the emergency room at Martin Luther King.
Dispatcher: Well, what do you want me to do for you, ma’am?
Caller: Send an ambulance out here to take her somewhere where she can get medical help.
Dispatcher: Okay, you’re at the hospital, ma’am, you have to contact them.
Caller: They have a problem, they won’t help her.
Dispatcher: Well, you know, they’re the medical professionals, okay? You’re already at the hospital. This line is for emergency purposes only. 911 is used for emergency purposes only.
Caller: This IS an emergency!
Dispatcher: It’s not an emergency. It is NOT an emergency, ma’am.
Caller: It is!
Dispatcher: It is not an emergency.
Caller: You have to see how they’re treating her.
Dispatcher: Okay, well, that’s not a criminal thing. You understand what I’m saying? We handle-
Caller: Excuse me, if this woman all out dies, what you mean there ain’t a criminal thing?

The call did not end well. The dispatcher insisted again that the situation was not an emergency and offered the caller a business number if she was displeased with what was going on. Just before 2 a.m. the caller said, "May God strike you too for acting the way you just acted." The dispatcher's reply: "No. Negative ma'am, you're the one." He has since received "written counseling" for the way he handled the call.

Edith Rodriguez was pronounced dead at 2:17 a.m.

Zev Yaroslavsky, LA County Supervisor, was flabbergasted at the security video of the incident. He said it was even worse than the audio tapes. “Not one person out of a couple of dozen, including citizens and staff and doctors and nurses…[They] didn’t lift a finger to help her. They just ignored her. Even the janitors who were cleaning up the vomit from around the woman who was on the floor did a very elegant job of cleaning up the vomit but didn’t do a thing to help her. It was just indescribable.”

With her writhing on the floor in pain, vomiting blood, and her loved ones begging for help, how could someone NOT have assessed the need for some intervention? If nothing else, isn't that what emergency departments DO?

Now, I know about the Bystander Effect. I've heard of Darley and Latané's social psychology experiments demonstrating the failure of people to help others in a crisis if other people are also present. I've read about the terrifying case of Kitty Genovese, who was stabbed, raped, and killed over the course of half an hour even though 38 witnesses heard her desperate cries. I've even been a cautious bystander myself.

When I was walking back to my hotel from dinner with an anesthesiologist friend of mine (we were in D.C. about to take our oral boards, actually), we noticed a pair of human legs protruding from the bottom of the potted plant decorating the entrance of her hotel. We came upon a man passed out on the sidewalk, his head and neck cocked to a rather concerning angle. There was already someone palpating the carotid for a pulse (correctly, we observed), and we didn't want to contribute to a "too many cooks spoil the soup" situation, so we lingered in case our help was needed but stood quietly in the background. I did go into the lobby and try to get the hotel management to bring out any first aid or medical equipment they might have had, but they just stared at me blankly and said 911 had already been called. I insisted that someone go and retrieve the stuff anyway, and one of the employees went, but I didn't see him again. Anyway, the paramedics arrived and packed the guy up, and my friend and I saw that they needed no interference from us. But I should hope we would both have asserted ourselves immediately if the situation had really called for it.

What bothers me about the Edith Rodriguez case is that I could easily have been one of the bystanders in that hospital lobby and contributed to her death, although I can't say for sure what my reaction would have been without knowing all the details of the actual situation. We all want to think we would have been the different ones, the types who would have said "no" to the authority figure in the Milgram experiment and refused to apply the electric shocks to the subject, the types who would have called for help in Darley and Latané's experiment when the stranger started seizing. We all imagine we would have bent down in concern toward Edith Rodriguez and at least tried to figure out what was going on, if not offer actual assistance. I think I would have done this, I hope I would have...but I also think deep down we all know that it's easy for ANYONE to be swept into the middle of an inert crowd and stay there dumbly looking on.

Edith Rodriguez's brother, Eddie Sanchez, made this poignant comment on the glumbert video: “You go there to get help, and nothing happens, like…You get ignored like if you’re nobody.” How many times have I failed to SEE my patients, or unwittingly treated them as if they were "nobody?" I cringe to think that I may have done the very same, albeit without the fatal consequences. Or, even if I paid adequate attention to a patient, what if I made the wrong judgment about how to manage the patient's problem, out of a reluctance to admit, "Yes, we have a disaster, and it's right in front of our eyes?"

I pray every day for the ability and courage to make the right calls. A couple of weeks ago our friend who's a flight attendant was describing a flight during which a passenger was found doubled-over in his seat. She announced the need for a physician and said it took a long time for one to come forward. I understand that - the daunting sense of responsibility often competes with the desire to serve and relieve suffering. As it turns out, the physician who did examine the man also told our friend that the captain had to land the plane immediately because the man was in acute heart failure. I think that was a very brave doctor in there. That's a heck of a call to make, diverting a flight filled with passengers to save one life on the suspicion of a life-threatening condition NOT confirmed by the technological aids we get so used to relying on in hospitals. I spiritually bow my forehead to the ground in respect and admiration and pray I never have to make a call like that. Although, what's worse - being wrong about the heart failure, and causing an inconvenience, or being right but lacking the confidence to make the move, thus costing a life? I guess the answer's pretty unambiguous.

I've alluded to the training we got in our medical simulator during residency. I am not allowed to comment specifically on our training scenarios or on people's actions within them, but I think I can make some general remarks on the experience. While the medical aspects of those scenarios were useful, I think a key element in teaching crisis management of any kind is a rehearsal and discussion of group behavioral dynamics. We did bring up and discuss issues like those raised by the Edith Rodriguez story. What makes us blind to another's needs? What makes us ignore data that's right in front of us, or help that's offered? How can we best structure a group's interactions so that efforts to provide help are focused and organized?

One take-home message I valued was that there should always be an "event manager" - one who's NOT involved in DOING tasks, but rather is WATCHING everything that's going on, processing it, and determining what steps are needed next. But of course, in the real world, this role separation is difficult, and often it's not possible to delegate. Or, people are reluctant to step forward to claim the role.

My heart goes out to Edith Rodriguez's loved ones. We in the medical profession failed them, egregiously. The only personal offering I can make at this point is a commitment not to rest smugly in the position of critic and judge, thinking, "Well, I would have seen her there, and I would have done something. I'm not blind." Sure I am. Or can be. And it makes me think twice about an old, familiar New Testament quote from a blunt, rather ticked-off Jesus:

Jesus said, "If you were blind, you would not be guilty of sin; but since you say, 'We see,' your sin remains." (John 9:41)

All I can honestly say is I would LIKE to think I would have treated the situation differently. But I cannot say that I would surely have been immune to group blindness or inertia. I think we need to learn to acknowledge our blind spots and make a promise to all patients, "We don't always see well, but we will always work to see better. Always."

Meet Selah, Hear Bell

My son brought home this print entitled "My Clever Creature," which he made at school. I love it.

He doesn't realize it, but it looks just like Selah. Selah is a little character that I imagine popping up to ask me questions about my world whenever something astounds me about people, or makes me shake my head in disbelief. I am too old to have an imaginary friend, but lately my mind has conjured little Selah up quite frequently, usually in the car during my long-ish commute, when listening to NPR becomes a quick education on all sorts of issues from around the world.

Lest it seem the stress has finally made me crack, let me affirm that this little guy is completely imaginary, a character in a little mental game I play that could be entitled something like, "How to Explain Earthlings to a Visitor from Another World." I used to think of him as a "Little Yoda," but his English was too good.

I named him after the Hebrew word that recurs among the psalms calling listeners or readers to pause and reflect. Selah is not of this world, and the questions he asks about our world do make me stop and think.

In the past when Selah has materialized in my mind, he has asked things like,

• What is race?
• If medicine is the profession of compassion, why is it so riddled with disdain?
• Why do people believe in God?
• Why don't people believe in God?
• Why have you had two female presidents in the Philippines but none in the United States?
• Why do people hate each other? Why can't they respect each other more?
• Why are people so afraid of differences?
• Why are athletes and entertainers paid more than school teachers?

The thing that made me shake my head in both wonder and disbelief today was an old article from the Washington Post detailing virtuoso violinist Joshua Bell's experience as a busker at the L'Enfant Plaza Metro Station. Thanks, by the way, go to Elaine Fine and L. Lee Lowe for passing this story along. I found this project astonishing as a social psychology experiment as well as a philosophical study about the arts and artistic talent.

Joshua Bell, who commands ticket sales upwards of $100 per person per concert, agreed to play at the metro station at rush hour as a "street musician" and to let cameras roll to see what would happen. So there he was, a world-class and world-famous violinist playing Bach's "Chaconne" from the Partita No. 2 in D Minor on a three-and-a-half million dollar Stradivarius. What happened?

What happened was, Joshua Bell was ignored. He was playing for FREE right in front of them, and most people rushed on by with not so much as a glance his way. No one paid any attention. No one, that is, except for the occasional child who passed by, being pulled along by a rushing parent or caregiver. And a handful of adults, maybe three or four.

After reading this article, I played "what would an alien visitor think?" and in my mind Selah and I went back and forth as follows:

Selah: Are human beings deaf and blind?
Me: Um, no, we're not. Really.
Selah: Can people feel wonder?
Me: Of course.
Selah: Do they like good and beautiful things?
Me: Absolutely.
Selah: Do they notice good and beautiful things?
Me: Not always.
Selah: Why not?
Me: Hmmm.

The article's author, Gene Weingarten, wrote (and I really hope it's okay to include this here):

"It was all videotaped by a hidden camera. You can play the recording once or 15 times, and it never gets any easier to watch. Try speeding it up, and it becomes one of those herky-jerky World War I-era silent newsreels. The people scurry by in comical little hops and starts, cups of coffee in their hands, cellphones at their ears, ID tags slapping at their bellies, a grim danse macabre to indifference, inertia and the dingy, gray rush of modernity.

"Even at this accelerated pace, though, the fiddler's movements remain fluid and graceful; he seems so apart from his audience -- unseen, unheard, otherworldly -- that you find yourself thinking that he's not really there. A ghost.

"Only then do you see it: He is the one who is real. They are the ghosts."

This piece made me think longer and harder than I have in a long time. Then I put in some violin music and just listened.

***

I have since read SawLady's and Elaine Fine's responses to the Bell Busking Bust, and I am relieved there's more to the story than the "spin" placed on it by the Post. Thanks to these talented and experienced musicians for teaching me more about the art of busking, and helping me reflect on things like approach to one's art, expectation, and context!

I do still think people should at least have LOOKED UP once or twice and acknowledged the musician's fine efforts, though...I mean, it was Joshua BELL...

Makes me wonder how often I walk by people and never see them. Bill Clinton recently gave a graduation speech about noticing the guy next to you on the street. I need to work on this more! Gives new meaning to the New Testament words, "You listen, but you do not hear."