Wound Care

Not too long ago I had to counsel a family about a surgical procedure their loved one needed in order to have a chance at survival but which, at the same time, she might not survive. I told the family I needed to place a breathing tube for the surgery but that I was also unlikely to be able to remove it afterward. Our conversation was long and quiet but intense, and in the end I could offer no better news for them. "Thanks for explaining it to us, doc. You do what you gotta do." What I was able to do for that patient was very little. She survived the surgery and was in guarded condition when I left the hospital for the day, but she died later that night.

There's a lot that's hard in medicine. The hours. The demands. The stresses. These are merely exhausting or frustrating, but confronting our own impotence - that has something else to it. Something really humbling, a kind of sadness.

So why do it? Why did I? How did I end up in med school at all?

I was an English major in college, and a good one. I loved to read great books and write good papers. I was into music and dance, medieval and Renaissance history, ancient languages, modern languages, scripture exegesis, art history. I dabbled in theater and even performed the role of Connie in A Chorus Line. Later I would get interested in social psychology and anthropology. In short, I was a humanities student through and through, not an ounce of the science geek in me, nor the aptitude of one. I was fascinated and awed by science - especially molecular biology and astrophysics - but I had no facility with it. If I managed to get through a science class at all, it was with a lot of tears and sweat.

In my last year of college, while I was writing my English thesis, I took an EMT class for fun. Should I have or shouldn't I have? I ask, facetiously, because in the middle of that course a voice in my mind said, "Uh-oh. I think I want to be a doctor. I love taking care of people, and using clinical skills and science to do it." Here was science that had the breath of life in it! Physiology, the logic of the body, was a tantalizing intellectual pleasure. I wanted to learn all I could about it, and use it to be of service to people. The first (and, intially, the only) person I admitted this to at the time was the man I would eventually marry (at a time when we were "in neutral," between fitful bouts of dating). His reaction then is what it still is: whole-hearted, affirming, faithful support. We would wind up marrying and starting a family before I ever set foot in medical school, but set foot I did, for better or worse.

I wasn't always going to be an anesthesiologist, though. I was going to be a pediatric specialist and spent most of my electives in medical school preparing for a life in pediatrics. I took a special course in an inner city hospital in New York on the evaluation of victims of child abuse. I was attracted to the field of medical genetics because of its integration of child development, in which I had a master's degree, and counseling, and I had the chance to spend several stimulating weeks at the National Institutes of Health learning the ropes in its division of medical genetics. They wanted to hire me as a resident and fellow, in fact, but sometimes life takes its own circuitous path. Choosing anesthesia involved a "voice in my head" kind of moment too: after mask-ventilating a child for the first time, I knew I wanted to be the doc that was doing that every day. So here I am.

Sitting here on the eve of the anniversary of 9/11 I realize that though my life was left intact by those dramatic moments in our history, I was not entirely untouched by those events. When the planes hit the towers I was in New York, completing another elective in medical genetics at Mount Sinai Medical Center. The first nail in the coffin of my dream of becoming a medical geneticist was hearing one of the medical geneticists comment, "Should we go and help? Oh, wait, we can't really...unless they need IVs or something..." I was bothered by that. I wanted to be a doctor who COULD help in that situation, and even though I knew the ongoing care given by medical geneticists to their patients was irreplaceable to those patients, I also knew how abstract it could be, and I realized I wanted to be able to see the help I was giving. I'm a lot like Doubting Thomas in many ways.

Academic activity was suspended that day, but all fourth-year medical students were asked to assemble in one place and offer assistance if needed. Someone had the presence of mind to make a note of anyone who was multilingual. It was all for naught, as we now know: there were few if any survivors to help, and rescue workers needing medical attention would go to hospitals downtown, where some of my classmates were on rotation, not uptown.

That day was the most intense example of what for many physicians is one of the worst aspects of medicine: its limitations. When I look back on the times in medical school or residency that left me feeling utterly disconsolate, I remember moments when I or the clinician next to me would have to say some variation of "I'm sorry, but there's nothing I can do."

I recall a beautiful young girl who had been maimed somehow and who came to the orthopedist's office with the hope of restoring some function to her arm, the upper part of which had been shattered and faultily repaired in some foreign country. She couldn't lift her arm to the side, so when I asked her to extend it she had to unfold it in a broken-winged sort of move. The orthopedist was using my imperfect Spanish to communicate with this lovely girl and her mother, and I felt stupid, frustrated, and helpless telling them we couldn't do anything for them.

Another time in the ear/nose/throat clinic I examined an African American woman with downcast eyes whose eardrum was blown wide open.

"How did this happen?" the ENT fellow asked.
Her bottom lip started to quiver. "My boyfriend..."
We remained silent, hoping to give her space to tell the story.
"We got into a fight..." Large tears started to roll down her cheeks.
"He hit you," the fellow said quietly.
"Will I be able to go back to my job?"
"What sort of work do you do?"
"I'm a..." The woman was laboring to suppress a sob, but couldn't. "I'm a telemarketer."
"Oh," said the fellow. His manner was serious but gentle, like his voice. "The injury is quite severe. We could attempt a surgical repair, but I can't guarantee that surgery would help."
"But it don't feel right. Can't you do nothin'?"
"I'm sorry..."

When something of ourselves rips or breaks, there is grief, a futile yearning for things to be as they were, unhurt, unchanged. Healing is an astonishing process, as is our capacity for it; but there is a melancholy aspect to it: we are forced to learn to live with scar tissue, with changed selves, and to accept that things can never be as they were before a blow was dealt, whether with words or ideas or fists or fortune. Perhaps in the end our scars are meant to teach us that while in some respects "there is nothing we can do" but let things be, and find new ways of accepting and transforming imperfection, it's also true that we can do more than we realize, especially when we recognize, get involved with, and learn from the wounded around us, and the wounded within.

Cooking Up an Anesthetic

I have been on-call quite a bit this month. Today I am post-call and off for the weekend, ah...


For lunch I wanted Linguini Aglio Olio. Unfortunately this is not so straight-forward without the olio. How can there be no olive oil in my kitchen? After scrambling around for a bit I ended up using some olive oil spray, a teaspoon of butter, and a couple of drops of canola oil and to my great surprise, the dish came out edible and pretty tasty. But I guess it's not that easily messed-up as dishes go!


***

When I was a medical student I watched a senior anesthesia resident during a case, tweaking the rate of IV fluid administration here, adjusting the dial on the vaporizer there. It all seemed so mysterious - why did he pick that particular moment to turn the gas flow up a notch or down a notch? The patient looked just the same. I asked him, "How do you know when to do that?" He answered laconically, "Practice."

As I learned to do the job, and found myself making the very same moves, I asked myself the same question, and my answer was, "Cooking." How many times have I turned the heat up or down on garlic being sautéed in the pan, or added an ingredient to a simmering sauce, or taken a spoon to toss a vegetable around, simply because my instincts told me it was the right move for that moment? And how did these instincts arise? From making the dish a number of different ways about a hundred times.




I find there's a lot in common between delivering anesthesia and cooking without a recipe (though when I mentioned this comparison during residency once, my attending shot it down instantly with a, "No there isn't." Different strokes...). I emphasize without a recipe, because with the exception of resuscitation algorithms, recipes can make for faulty medical practice. It's true that there are drugs and techniques I can say I usually use for any given case, but I try to practice flexibly. The minute we start handing out drugs according to some preconceived "cookbook" - remifentanil and propofol for this, midazolam and fentanyl for that, every time, all day, every day - we've stopped using judgment, creativity, knowledge, and adaptability. We've stopped being physicians, designing anesthetics in an actively engaged way, taking into account the needs of each particular patient or case.

Moreover, very often plan A just doesn't work out. No one starts the day wanting to perform an awake fiberoptic intubation on someone, but if safety concerns arise, and it's the right decision, then plan B it is. It's not what the patient wants, and it's not what I want in terms of comfort for my patient - but it's the right thing to do, and it's not a judgment I would make lightly. Cases like that highlight the folly of a consumer model of health care delivery. "Customer satisfaction" - or its equivalent, patient satisfaction, because patients are not customers - comes second; patient safety comes first. Always.

That said, I try my best every day to be open with my patients, hear their concerns, and carry out a plan that results in maximal safety and comfort for everyone. This is why when a patient once adamantly said she did not want a particular drug, and I was trying to ask questions to clarify my understanding of her experience and her position (i.e. doing my job), so that I could come up with a safe and viable alternative, I was offended and irritated when her husband yelled at me, "Why do you people always start asking all these questions the minute she says that? She doesn't want it, period! We don't need all these questions!" Well, sir, you're wrong, we do need these questions if we're going to be prepared and provide the best care we can for your wife. It's a shame you're too short-sighted and hot-tempered to appreciate that, but that's the truth of it. I didn't reply in those words, of course, but I said to his wife something like, "Your experience with this drug is important for me to know about, because I care about making your comfortable and keeping you safe. Could you tell me a little more about the reaction you had...?"

Speaking of communication, a couple of things keep coming up (most recently, just last night) that I want to highlight because they really help us anesthesia folks provide the safest anesthetic we can (the following is just a sample; I'm sure I could think up more):

-Please follow any instructions you receive about eating and drinking prior to surgery, to the letter (usually some variation of DON'T eat or drink for 8 hours prior). And if you have consumed anything, please say so - this is a SAFETY issue.

-Please remove all contact lenses and piercings. Yes, even those piercings. :)

-If you drink 12 beers a day, please don't say you only drink on holidays. First of all, it's not safe to understimate the amount, because then we might incorrectly estimate the anesthetic dose for you. Secondly, once you are under, we can tell. Trust me. Your body will reveal to us that you in fact drink ten times more than you say you do.

-If you just had cocaine yesterday, or today, please don't tell us you've been off it for months. Again, it's NOT SAFE. And again, once you're unconscious, we'll be able to tell that your body is in fact totally revved on crack. But more importantly, something really BAD could happen to you on the table that we can do something to prevent if we know ahead of time, and we'll be able to choose the RIGHT drugs to help you, as opposed to the drugs that might indirectly contribute to your having a brain hemorrhage.

-Last but not least, please, please, please tell us what you're most concerned about. Your anesthesiologist should WANT to listen and do everything in his or her power to care for you attentively and safely. Please also hear us out if there's something we're concerned about explaining, from our end of things. We are NOT trying to be pains in the neck, but rather to provide thorough and good care. Our job is to protect and watch over you, and most of us do take that very seriously and wish to do our best.

Epidurazilla

I couldn't go back to sleep after getting called to place an epidural for a laboring woman at about 3:45 this morning, , so here I am, walking down Memory Lane again. After a string of fairly gentle call nights, I was due for a busier one, and I got it. It's 5 a.m. I've had two hours of sleep.

My call started yesterday. My first case yesterday involved an elderly man with numerous medical problems including a serious heart condition that made me warn the nurse on my team - a smart, reliable guy with years of E.R. and O.R. experience - "FYI - if he codes, he dies." I wanted to be sure we were all on the same page. With the kind of heart lesion this guy had, conventional CPR, using external chest compressions, was not likely to help him. My seasoned O.R. nurse said something like, "Yeah, let's not go there today." No, let's not. The patient did fine.

After that there was a cute little 8-year-old who needed her broken wrist fixed. She did fine too.

Then I drove to one of our other hospitals, where I got paged to do an epidural for a woman whose baby had died inside her. It was her first pregnancy. I was sad, but glad I was able to contribute to some physical pain relief, even if I couldn't make a difference to her emotional pain.

As soon as I left her room, there was a flurry of activity because another woman needed a C-section for worrisome fetal heart rates. Placing the spinal in this woman, who was morbidly obese, was difficult. We got through it and got the baby out, which was a good thing because it had been swimming in meconium.

After I was done with that, the vascular surgeon paged me and said there was a young guy in the E.R. who had pulsatile bleeding from his arm after he smashed it through some glass. When the E.R. nurses brought the patient down to the O.R., the smell of alcohol emanating from his mouth as he answered my preop questions was so overpowering I thought I was going to pass out. I anesthetized him, watched over him, woke him up. He looked happy as a clam later when the recovery room nurses were wheeling him upstairs to his room.

By then it was past midnight. I was too wound up to sleep. I read a little more of The Last Duel, which is riveting, an outstanding piece of writing and research. I hear it's Martin Scorsese's next film project, and what a worthy project it is. I'm thrilled for Eric Jager. Eventually I got to sleep, but I awoke a couple of hours later when the phone in the call room rang - 3:45, epidural please. *sigh*

Which brings me to Epidurazilla. No, not the 3:45 woman, who actually turned out to be fairly pleasant when she finally got some pain relief after holding out for hours without. But the way she walked right past me - actually, around me - in her room without even looking my way triggered a memory. I hadn't dredged up this memory in a while, but I found myself thinking of a woman from a hospital in my past.

Believe me, I understand labor pain. I understand how it can not only blind you to the people around you but also make you perfectly disinterested in being in any way civilized to anyone. If you're like me, all you can think about is the PAIN - when it's coming, how you're going to survive it when it's here, and what you can do so it won't be so BAD. When I was having contractions at 9 centimeters of dilation, between humiliatingly loud sobs of agony and blubbering whimpers of dread, I wanted to ask my husband to cut off my head. I hope I was still somewhat nice to people, but you know, I may very well have turned into an Epidurazilla myself, especially when I assumed the position to receive my epidural, had to hunch over with my nurse standing in front of me, and found that her enormous breasts were an inch away from my face and suffocating me. Yet as I recall I was a paragon of obedience and cooperation.

But I digress. Back to Epidurazilla, a ghost from OB wards past. Epidurazilla was pale, skinny, educated, and rich. She came to the hospital with a plethora of accoutriments. A CD player and George Winston piano CD. Burt's Bees lip balm. Popsicles, which she ordered her labor nurse to fetch and over which she showed considerable exasperation when people had trouble locating them, even after she sent her husband out to help (read, supervise) the nurses.

When I arrived in her room after her nurse paged me there for an epidural, I began to introduce myself, "Hi, I'm Dr. - "

"SHH!!" she cut me off, with an irate swat of her hand. I had unfortunately begun to speak just as a contraction was beginning. My mistake; I'm usually pretty good at timing the conversation, but I was a little off that time.

I understand not being able to focus on someone's words when your insides feel like they are being yanked from Alaska to Dubai, ripped into pieces, and set on fire. I've been there. But usually the NICE women either pant until the contraction is done and ask you to repeat what you said, or manage to groan, "Sorry-doc-just-a-sec..." I had never been shushed and swatted at before.

That pretty much set the tone for this woman's interactions with the entire staff. The more I listened to her snapping at people and ordering the hospital staff around, the more I felt like saying, "Yes, Massuh" to her face. She was impatient with the questions I asked her as part of my preop evaluation and with the directions I gave her to facilitate placement of the epidural. She gave me the impression after it was placed that she felt quite entitled to have it there now and what took us all so long to serve her anyway? It was clear she was used to relating to people as their superior and had scads of servants at home waiting on her hand and foot.

I'm ashamed to admit it, but when I checked on this woman the following day during my rounds, I was civil, and even dutifully kind, but nothing more. Usually I'm warm and sweet, but I couldn't be my usual self with her. That's ultimately a reflection of me, not of her, I regret to say. And to her credit, at the end of our conversation, she did thank me.

Overall I was so appalled by what I saw of this woman's demeanor with the nurses, and other docs too, that I googled her. And there it was, confirmation of what I suspected. Engagement announced in the society pages of a prominent national newspaper. Wealthy family united in marriage to another wealthy family. Advanced studies in Paris. Ivy League degree.

She must be one of the stereotypes people think of when they think of Ivy League schools. So then I started to wonder, have I ever been like that? I went to a "prestigious" college. I speak a foreign language or two, on a good day. My family is relatively well-off and well-known in our country. Part of what bothered me about Epidurazilla was the familiarity of her behavior. I've seen it before. The stereotype of the master or mistress who's mean to the servants or who barely even notices their service comes up on Philippine TV shows a lot. Although some of the wealthiest people I know are also the kindest, most humble, most generous people, I know there is a basis for the stereotype. But there was more to it than that. I think I was also bothered by Epidurazilla because I recognized in her a capacity for narcissism and elitism that I fear within myself. I think when I met her, I thought, "I could totally have become that, under the wrong circumstances..." My husband doesn't think so, bless his heart; I'm touched by his faith in my character; but we all know the potential evil that lurks within us, and I don't imagine for a second that I'm any less vulnerable to its traps than the next person.

I said to a couple of my friends, "Please, if I EVER start speaking or behaving like an entitled prima donna, please whap me across the face, okay?" My husband's pretty good at being honest with me if I fail to be at my best, so I'm hopeful all these allies and teachers can help keep me in line.
_______________________________________________________
(The photo shows one of my friends placing a lumbar drain, not an epidural, but the procedures are similar and for the most part, with a little local anesthetic, well tolerated by patients.)

(This) Sux

In November of 1993, thanks to the FDA, the package insert for Succinylcholine (or if you're British, Suxamethonium, or if you're most anesthesiologists and emergency physicians, just Sux) was changed. The new label stated that the drug was contraindicated in children and adolescents "except when used for emergency tracheal intubation or in instances where immediate securing of the airway is necessary."

This means if we give Sux to children, we had better have a darn good reason for doing so, like, "the kid's gonna die before my eyes unless I give it."

I gave it to a 5-year-old.

First day back after a vacation, first case of the morning at the "main" hospital my group serves.

I came in to set up my drugs and equipment in the morning as always - first a suction, laryngoscope, and machine check, then drug preparations. For children I whip out my little home-made table of specific doses, intravenous and intramuscular, for specific drugs by child's weight. I look at the weight that corresponds to my patient at that particular time and memorize the doses for the most crucial drugs. I draw up these "rescue" drugs before the case and place them in syringes that are always within my reach. Then I put a few bottles of candy scent in my pocket, go out and see the kids, and ask them which scent they'd like their "magic air" to smell like when it's time for them to breathe the magic air that will make them sleepy.

My little 5-year-old patient was going to have her tonsils out. She had little braids and a wiggly tooth. She had a little white sheep named Little Bear who had a little lamb.

Everything was going just like every other anesthetic for a tonsillectomy; she breathed her bubble-gum scented magic air, she went unconscious, my wonderful O.R. nurse was getting an IV, everything was going according to plan...

Then it happened. One moment I was giving her manual breaths through a mask snugly held to her face; the next moment, after a couple of coughs, she stopped breathing and I could not, try as I might, squeeze any more breaths into her little lungs. Her saturation dropped, 99%, 90%, 85%, 77%...in a matter of seconds it had plunged to terrifying. Mask ventilation was futile.

I asked my O.R. nurse to grab the Sux syringe next to me and push 2 milliliters of it into the IV she had just placed, and I asked a second nurse to call other anesthesiologists stat to the room for extra pairs of hands. Help arrived in a matter of seconds; by then I had an endotracheal tube in place and was ventilating the child again, and her saturation came back up rapidly to 100%. My colleagues, Maddog and Fred, drew up and gave one or two other protective drugs while my hands were full, saw that the kid was stable, patted me on the back, and took their leave.

It happened so fast. It took me maybe half a second to think, "Oh, crappe,* I need Sux" and another half-second to say, "Get that Sux and give 2 cc's of it now." But in that one second, if you were to project my thoughts on a screen slow-motion, I think you'd read something like this: This is laryngospasm. I can't believe this kid is actually laryngospazzing on me. Or could it be bronchospasm? No history of asthma...What else makes someone desaturate fast? Airway obstruction? So-called chest wall rigidity? Masseter spasm? But the IV's barely even in; we haven't given something that would cause that. Well, we're about to...Is that really the heart rate? Could be worse I guess, she's only bradycardic by five-year-old standards; if she were an adult she'd be fine. What if she goes into hyperkalemic cardiac arrest when I give the Sux? Or malignant hyperthermia...but how likely is that? She's more likely to stay desaturated (and croak) from no airway than to do all that...Still, I hope she doesn't have pseudocholinesterase deficiency, or an undiagnosed myopathy that would predispose her to cardiac arrest...Here goes...

As soon as the Sux went in, her entire body including her airway relaxed perceptibly under my hands and I was able to intubate her and secure her airway. All I can say is, thank goodness the FDA didn't outright ban this drug. It may be dangerous for a few in rare cases but when you need it, you need it badly.

She did beautifully the rest of the case. Then I was able to move on to the adult patient I had to intubated blindly because a plum-sized thyroglossal duct cyst was obscuring my view of the vocal cords...and after that I almost got the man whose every organ had something wrong with it (heart didn't work, pancreas didn't work, kidneys didn't work, lower esophageal sphincter didn't work, peripheral nerves didn't work, brain was kinda on-the-fritz too...), except my colleague George was on late-shift and wound up taking the case...

Somebody please tell me why I shouldn't quit my day job and move on to something that doesn't entail being responsible for other people's lives...

_____________________________________________________

*"Crappe," according to Wikipedia, is a Middle English word meaning " 'chaff, or grain that has been trodden underfoot in a barn' (c. 1440s), deriving ultimately from Late Latin crappa..." The other word, meaning excrement, is slang derived centuries later by Americans. I admit I actually was thinking the latter at the time, but I can't bring myself to use it in writing.

Have You Hugged Your Anesthesiologist Today?

That’s it. I’ve had it. I’ve read yet another piece of writing that demonstrates a complete lack of understanding of what anesthesiology is and entails, and I need to vent.

So allow me to lower the mysterious drapes for a moment and let you into my world.

No one gets up one day and says, “I want to be an anesthesiologist when I grow up.” I wanted to be a ballerina, or a bookstore-café owner, or an artist of some kind – someone who was required to pay close attention to the world, take real notice of it, and take creative and compassionate action. But I am neither a ballerina nor a bookseller. I am an anesthesiologist.

Frequently people ask me a version of “What on earth made you choose that?” I try to explain that I love the way anatomy and physiology come alive moment-to-moment in daily practice. Or I try the concrete approach and admit that I actually enjoy placing intravenous lines and breathing tubes. The response I get is usually a glassy-eyed “Uh-huh” or, occasionally, a nose-wrinkling “Eew.” If the conversation progresses beyond “eew,” the more people talk to me about what they think I do – that is, if they think I actually do anything in the first place – the more bewildered I get over how difficult it is to convey to others an understanding of my work.

One time I visited a patient the day before her planned surgery. After I explained what she could expect, she exchanged a few words with her family in her native language. They clearly assumed I couldn’t understand them. An older woman instructed my patient not to bother asking me too many questions, saying, “She’s just an anesthesiologist; what do they know?”

After years of annoyance at many people’s assumptions that I was not a physician because of my gender or my young appearance, this remark – not the first I’d heard along those lines – made me take stock. I realized that not even other physicians understand what we anesthesiologists do, sitting back there in our little cockpits behind some blue drapes (“the blood/brain barrier”), periodically looking up at large machines but appearing otherwise idle. One doctor asked me once, “You have to take an oral exam? For anesthesia? Is there enough material in anesthesiology for an oral exam?” Considering the profound suffering the ordeal of the orals caused me, and causes many anesthesiologists, I felt like shaking the guy by the hair – except he didn’t have any. If other doctors don’t get it, how could I hope to find anything but murkiness and misunderstanding in the perceptions of non-doctors?

I did a little experiment. I constructed a detailed questionnaire about what kind of physician people would want to come to their rescue if they collapsed in a public place. No one wrote down that they would be glad if an anesthesiologist were around.

I figured out about four broad, wide-spread misconceptions about anesthesiologists:
-we are not doctors
-what we do is easy
-we don’t establish rapport with our patients
-if anything goes wrong, “it’s Anesthesia’s fault.”

Then I realized something else: because people have absolutely no idea what to imagine about our work, they decide to make stuff up. It’s amazing.

People react to the mysterious in one of three ways: with fear, with fabrication, or with efforts to deepen their understanding. The fear I see daily. The fabrication – well, let’s just say if I hear one more person declare that all I do is put people to sleep, then sit next to my anesthesia machine and—what? Daydream? Wait for the patient to wake up? Twiddle my thumbs?—that will be one person too many. But that is what people say.

I have heard more times than I can count, “Well, all you do is knock people out. How hard can that be?” My hairdresser asked me when we first met, “So, once you put the patient to sleep, do you leave the room since your job is done?” Excuse me? My job is done? Then who did he think was keeping the patient alive while the surgeon was mucking around with his vital organs and causing all sorts of dangerous disturbances to his vital signs? Who was going to make judgments about what was specifically appropriate for that patient’s particular brand of heart defect, or lung disease, or neurologic abnormality? And then there’s my personal favorite: “You mean, anesthesia for appendicitis is different from anesthesia for heart surgery?” Hmm. 1-inch abdominal incision versus sawing through a person's chest. Yes, it's different.

My husband once tried to mollify my irritation by pointing out that people just couldn’t be expected to know about anesthesia. “Do you know what a machinist does? Or a gaffer?” To which I replied, “Of course not. I have no idea. But I don’t assume that their jobs are easy, and I don’t presume that their work can be summed up by one simple task.” Even my lawyer husband had to admit I had a point. “Well,” he said, “what DO you do, and what do you want people to know about it?”

I don’t think of myself as a doctor whose function is to induce sleep. My primary function is to resuscitate those who need resuscitating. Yes, about 1% of what we do does involve calculating the appropriate dose of the appropriate drug, drawing it up into a syringe, and injecting it into the veins of people who would like to avoid feeling pain or hearing unfamiliar noises during surgery. But I spend most of my energy making sure that I can bring them back. Designing an anesthetic is a thoughtful act. My resuscitation of my patients often begins the night before I meet them, when I am going over safety plans in my head.

Most of my training, in fact, was focused on becoming an expert at resuscitation in its various forms – reviving patients who were dead or near death; intubating those who could not breathe; rehydrating the dehydrated; unparalyzing those I had paralyzed chemically for surgical purposes; awakening the unconscious with judicious use of anesthetic drugs and gases; creating pain relief and anti-nausea regimens for the afflicted; and making sure failing heads, hearts, or lungs functioned well enough to ensure survival of a given surgical procedure.

Late in my training, I realized our level of expertise when I asked a resident in a different specialty – one whose members also take pride in their resuscitation skills – how many intubations she had done after two years. I was expecting to hear perhaps half of my quota of about 1200. “I’ve logged about 84,” she replied. And this was the physician-type people wanted nearby if they collapsed in a public place and needed a breathing tube to stay alive.

Anesthesia affects consciousness, blood pressure, heart rate, respiration, and a whole host of other body processes. If I am not there to watch over you, that first injection can harm you. And that’s just the first step. I should be breathing for you if you stop (and you will), administering fluids when your surgeon nicks a “bleeder,” and giving you the medications you need to wake up safely and comfortably. This can mean a lot of scurrying around, checking, and readjusting within the confines of my “cockpit.” Is the IV running too fast? Is the machine blowing in enough air with each breath? How’s the urine output? Oh, they’re closing – should I turn the gas down now, or will he take a while? Is that heart rate a little too high for his aortic or mitral valve problem? Did I give the drug to slow it down? Let me dive down under the drape to make sure his eyes are still protected…This is all behind-the-scenes, largely unacknowledged work, but it makes even the tiniest task a meaningful act, and I love that about my job.

And that’s just in the O.R.

I've written elsewhere about my E.R. and I.C.U. intubations, but I haven’t even addressed the expertise anesthesiologists bring to laboring women, not only in placing and ensuring the safety of epidurals for labor and spinals for C-section at any given moment, day or night, but also in caring for mothers when childbirth becomes dangerous. On occasion help is needed for an alarmingly sluggish newborn, and yes, we are useful for that too. The code that made my heart beat the fastest was when “Anesthesia, Stat” was paged overhead to the labor and delivery suite and I realized the person coding wasn’t one of the moms, but rather a minutes-old newborn. The family practice attending physician handed over the laryngoscope he was holding, and I intubated the baby so we could bring her oxygen saturation back up to liveable.

Many people have assumed that their limited understanding of our profession reflects a limited scope of medical practice on our part. Assumptions can be unfortunate, but I prefer to focus on the things that keep me coming back to the O.R. despite people’s colossal lack of awareness about what I try to do for them. I know what you’re thinking: it’s gotta be the paycheck, right? Never mind that childcare costs and six-digit educational loans eat up half of it. Sure, the pay is good, but it’s good because of what we are capable of doing for people, and the amount of sweat and tears it took to acquire and prove those capabilities. This is not a job you can commit to just for the pay and be truly happy. It’s too hard.

Nor can anesthesiologists be motivated simply by glamour and prestige – there’s too much ignorance about anesthesiology to allow for either. For me, real job satisfaction has to rest on tenacity, self-respect, humility, kindness, and happiness with the work itself. The big pay-off, in my mind, lies in my relationships with my patients, whom I may meet only briefly but during intensely significant moments in their lives, when they may need the most comfort. All the scientific gobbledygook that goes into the practice of anesthesiology has a chance to get sifted and transformed into a true human connection, into resuscitation that goes well beyond the needs of the body.

It’s my hope that someday, when a person collapses in the bookstore-café that I don’t own, or in the opera house in which I’m not dancing (or playing the oboe!), and an anesthesiologist responds, it will be common knowledge that the professional responding to the situation is providing expert care in the truest sense of the phrase.

Lesson 7

Good lesson today! I'm improving! Kyoko will be leaving for the Colorado Music Festival, so I won't have another lesson till August. We crammed a lot of material in - long tones, little etudes from the method book, a teensy bit of repertoire, reed adjustments. One of my favorite moments was when she connected for me the anatomy/physiology of wind production with the physics of the oboe - and explained the greater breath support needed to counter the loss of wind velocity for notes played further down the length of the instrument. The doctor in me thought, This, I get!

She gave me one of her reeds as a summer gift, and it's the best one I have so far. And she gave me homework: Jesu, Joy of Man's Desiring. I'm going to have to work on my breathing for that one! One of my other favorite moments of the lesson was at the end, when, after talking about Bach for a bit, we started humming Sleepers Awake together and couldn't bring ourselves to stop. Bach has a way of reeling you in...

I've figured out why, for me, oboe is harder than piano. I need to recruit more of me to play the oboe - lungs, abdominal muscles, and oropharyngeal muscles in addition to arms and hands. When I hit a key on a piano, a sound is guaranteed; not so on the oboe. And notes on the piano keyboard are spatially arranged in ascending/descending order, logically. On the oboe there's definitely more jumping around that's not always intuitive. On the plus side, with the oboe we only have to worry about one note at a time...but I think it's harder to make that note sound "just right."

I've listened to more oboe music now and have come to the conclusion that pieces written specifically for the oboe are often less appealing than oboe parts written within larger orchestral works. That said, I have to admit I can't seem to go a day without hearing at least the first movement of Vaughan Williams' Concerto for Oboe and Strings, the second movement of Saint-Saens' Sonata for Oboe and Piano, and little snippets of Albinoni's and Marcello's concertos. I've also found some shorter works by Henri Sauget and Fernando Sor that I really like.

Yesterday my daughter had a piano recital and did beautifully. I don't know how she can be so relaxed about them. That's probably WHY she does well. I have been plagued by terrible stage fright in more than one area of my life and I've already told my oboe teacher I can't possibly EVER do a recital. At most maybe I'll play at church someday. Maybe. Years from now.

***

At work my colleagues and I take turns providing anesthesia for patients undergoing elecroconvulsive therapy (ECT). Today it was my turn. It's not like it is on One Flew Over the Cuckoo's Nest; it's a pity that it's such a demonized procedure. For some people it's literally the difference between life and death. Again I face the marvels and mysteries of the human brain and its workings during my day-to-day tasks at work...and participate in both altering and protecting it. This is always in the back of my mind during ECT's, which are some of the shortest procedures for which we provide anesthesia: the fact that the psychiatrist and I really have to take care of our patient's brain and concentrate every effort on helping it heal. And of course I'm also preoccupied with the airway, the cardiovascular system, the musculoskeletal responses...

Found this on Panda Bear's blog, and it made my day: "I’ve seen an Emergency Medicine Chief resident and a Medicine chief resident both fail to get an airway which the anesthesia junior resident put in while still half-asleep." At last! Someone who gets what our expertise consists of! Someday I'm going to have to vent about how little people seem to understand my specialty - even other doctors. Right now, though, this little anesthesioboist is bushed. Lights out.

Where does It come from?

I marvel at a gift my daughter has and that I, alas, do not: composing. She took up piano a little over a year ago. I heard her playing something so evocative after only two lessons that I poked my head out of the kitchen, where I was doing something completely ordinary like chopping vegetables, and asked her, "What's that you're playing?" The music reminded me a little bit of a procession for kings in a fairy tale or a bible story. Like something out of Menotti's Amahl and the Night Visitors, which we had recently seen and try to see every Christmas season.

"Oh, I'm just composing."

Composing! Wow, she was making that music up? How do people do that? Where does that music come from?

"It's wonderful, sweetie. Reminds me of Amahl."

"Yeah, actually, I'm calling it A Royal Appearance." That was her first composition. She was 8.

More recently she has composed a piece called At the Arcade, which sounds just like someone playing pinball or video games, and another called (at my suggestion), Stirring the Brew, a playfully spooky piece that sounds just like, guess what, someone stirring brew in a cauldron. She's also working on a musical, and the parts she has sung for me so far have blown me away.

Where does creativity come from?

One could spin an endless web of theories. In ancient Greece there were the nine Muses. Today the fashion is to attribute most things that involve human cognition to the function of little molecular messengers, the neurontransmitters. Some might add genes, spirit guides, environmental factors, God, faith, early childhood education, exposure to music, good nutrition, or any number of influences to explain people's gifts, and logically a combination of any of these factors might certainly contribute to human creativity. But it's like trying to explain how it is we hear certain combinations of sounds and call them "music," or why certain strains of music elicit tears or fears or longings. Ask my daughter where her music comes from, and she'll say, "It's been with me for months," or "I hear it in my head."

"Intuition" is similar. The day before my oral boards, at my husband's suggestion, I booked myself a massage. What better way to de-stress, right? There's a funny story about the whole spa experience that day that would take a whole other post to relate, but for purposes of what I'm thinking about right now, let me skip to the part where the massage therapist, seemingly out of nowhere, placed a hand right in the middle of a muscle in my lower back that couldn't have been more in need of a little un-kinking. I was shocked at the sure-fire accuracy of the maneuver and asked, "Wow, how did you know that?"

The laconic, Italian-accented reply: "Experience."

And I've said the same thing. At one of the hospitals my anesthesia group serves, we teach EMTs and paramedic students about intubation. When they really can't see the vocal cords or can't place the breathing tube in the trachea, I quickly step in and complete the procedure, and often I'm asked, "How did you know how to adjust that so you could get it in?" The answer truly is experience. I always tell the paramedic students it took me HUNDREDS of airways (as in, intubating 3-4 times a day for 2-3 months) to feel really comfortable with the "straightforward" ones, and hundreds more to feel I had the ability to tackle a challenging one.

Once in the ICU during my residency the surgeon in charge watched me do one of those God-help-me intubations, and while I was doing it he asked, "Can you see anything?" The answer was no, but I asked him to hand me the tube anyway. It went in. "Lucky," he said. Maybe, but the more I learn and the more experience I have, the luckier I seem to be. Yet never "lucky" to feel smug about intubating people. If I've learned anything in my line of work, it's respect for the airway!

Just last week at one of the other hospitals we serve, the E.R. doc had a really tough time with the airway, had tried for a while to secure it, but then sent someone to the O.R. to ask me to come and take a look (another long story that would take a separate post to relate). I looked. It was tough. Darn tough. I could easily have missed. But something told me to bend the tube a certain way, and wiggle the laryngoscope just so, and thankfully the tube went in. But no amount of success, at least for me, will make these "scary" airways less caution-worthy. Difficult airways just can't be taken lightly, ever. My heart still quickens a little every time, and I still say a split-second mental prayer over them to help focus my efforts.

But this is all stuff that involves training, learned skills, and practice. Granted, creative acts take work and practice too, but with those, there's that inexplicable element, the mysterious "place" that works of art (and life) come from. How did Ralph Vaughan Williams come up with his Concerto for Oboe and Strings? How did Harper Lee's vision of Calpurnia or Jem come to life so vividly on the page?

Sure, neurotransmitters are important. I've seen and heard of enough anecdotes about people "losing" their creativity when they take certain neurotransmitter-altering drugs. One writer I read recently also describes the opposite - a medication that seemed to give her hypergraphia, a need to write often and copiously (and no, despite what the entries in this blog might suggest, I am not taking the aforementioned medication, unless it's at all similar to any compounds found in chocolate!). So yes, the brain matters. (And just as an aside, I think people should be less critical of the use of some of the medications I've alluded to here. You wouldn't tell diabetics to just "get over" their pancreas problem if they need medication. If people with neurotransmitter issues need medication as well, and have the guidance of experts to help select those medications, they should take the meds they need, and/or practice yoga to boost their levels of GABA, etc.) Clearly, neurotransmitters are powerful agents for human ability, behavior, emotion, health. etc. But are they the whole story?

When I think of my children's faces, my daughter's pieces, places I love, stories I want to write, I have a hard time imagining how those thoughts could simply be stored and recalled, repeatedly, by neurons and their neurotransmitters. I think there's more to thought than we think.

***

Had my 5th oboe lesson today. Lots of fun. We laughed over how "I hate half holes!" Went over C, F, & G major scales as planned, and a couple of others, E flat and A major. I have my work cut out for me but I'm excited to get into some "real" music-work. Started to work on dynamics too for the first time - and again, that feeling of "where did that come from" arose when I hit a note more piano by accident after trying several times.

Kyoko asked, "What did you do just then?"

"I don't know, I don't know! What did I do? I have no idea why that worked!"

But just like intubation, playing repeatedly gives you an idea, maybe one that you can't verbalize readily, but it's certainly there. A "gut feeling" about how to move your muscles to produce an effect. I hope as I practice and play more, I'll have more of that inexplicable "instinct" about what adjustments to make. Dance was like this too. After a while, with lots of training, lots of practice, lots of work, I needed less thought to do what I wanted to do. Less thought, more...what? Very mysterious, all this brain / spirit / creativity stuff.

"Oboeitis enthusiasticus"

First I want to say <<Bon anniversaire, Maman!>> to my wonderful mother-in-law, whose boundless spirituality and generous heart are daily gifts to our family and to all the kids tutored through the Earthen Vessels program. I am so blessed to have such a kind and caring mother-in-law.

Thanks too to Bob Heineman for coining a name for our affliction. You're right, Bob - it's INCURABLE!

Yesterday when my teacher & I did those little duets together it brought back memories of the times when piano "wasn't so bad." I took piano from age 5 to age 12, and though I am grateful for the musical education I got taking it, I have to admit piano brought me a LOT of anxiety, especially piano recitals. I still get sick to my stomach before my daughter's recitals - whereas she loves performing! The two times I recall specifically ENJOYING piano were the times when I didn't have to play alone. One time I played a Telemann piece with an accomplished young flutist. I especially loved not being the soloist, but rather the background person, the accompanist. Another time I was accompanied for the 1st movement of Mozart's Piano Concerto No. 17 by a fantastic adult pianist whose presence made the harrowing recital for that piece a little less agonizing. Otherwise, though, the study of piano was a morass of dread for me, probably because of my tendency toward stage fright.

Playing music WITH others is a great pleasure, though. I would have loved to play in an orchestra, to make music with others but also remain anonymous, not in the spotlight. Anesthesia's like that too - our work is so essential to what's going on, and so important, yet so anonymous and under-acknowledged. My favorite musical moments are when my husband pulls out his guitar and we sit down as a family to sing together, or when my daughter and I sit down at the piano to play together.

I got more daring during Indulgence Time at the end of my practice period and tried an arrangement of the Huron Carol / 'Twas in the Moon of Wintertime. I've always liked this carol but when I learned the words were written by Jean de Brebeuf, a Jesuit missionary to the Huron and contemporary of René Goupil, the carol acquired special meaning for me.

I've read and heard many times that oboists are (and need to be) a little obsessed. If I'm this preoccupied now, wait till I start making reeds...

Anesthesia Oral Boards: a thing of the past!

We weren't supposed to find out our results till the 25th, but I happened to check online last Friday, and I PASSED my oral boards!!! The last hurdle! Finally, the rest of my life can begin. No more dissing the kids in favor of anesthesia flash cards. No more weekends & vacations spoiled by practice questions. WOO-HOO!!! Free from the shackles & tyranny of medical certification! No more, "Wait-I thought you already passed your boards." Those were the WRITTEN boards, which we needed to pass first in order to qualify to take our the stinking ORALS during our first year in practice. Before that there were also the USMLE steps, three in all, which were licensing boards. Passed those a while back. So it's all finally OVER! Done! I can live the life I want, read the books I want, think the thoughts I want, Hallelujah!

So what did I do to celebrate? (Besides the obvious & obligatory guzzling of champagne, play-time with husband & kids, etc.) I started taking oboe lessons! (My first one, in fact, was on the anniversary of my graduation from medical school.) Am I crazy, starting such a hard instrument in my thirties? Probably. But would I be crazy not to try to fulfill a lifelong wish now that I'm not chained to my anesthesia review materials? I think so.

Today's lesson was only my second. After sounding like a dying duck (I thought) while practicing at home, I felt a little better when my teacher said my tone was actually promising. She also made a huge difference by shaving several key millimeters off my reed, a commercial thing which came with the rental & which was too long, & therefore quite FLAT. I can see why oboists are so meticulous, & sometimes even neurotic, about their reeds! Getting those shavings off made a world of difference.

I can honestly say I am madly in love. Well, I have been as a listener, for years, but now that I'm trying to play, I'm REALLY in love. I know it's cliché that seeing Jeremy Irons playing "Gabriel's Oboe" in The Mission in theaters in 1986 was the source of my oboe longings, but there it is. That, and years of ballet - all that Swan Lake, the Wedding pas de deux in Sleeping Beauty, the adagio in Raymonda's Grand Pas Hongrois, not to mention non-ballet favorites like Amahl and the Night Visitors, Concierto de Aranjuez, Enescu's Romanian Rhapsody #2, Brahms' Symphony #3...I've been wistful for years!

Still, people have asked me, "Why oboe?" I also often get asked, "Why anesthesia?" I won't go into any deep reflections right now, except I notice they have a lot in common: they're unusual, elegant, mysterious, & challenging and require great attention to detail, dedication, and diligence. Maybe you have to be a little "different" to be attracted to them...who knows?

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Addendum July 21, 2007:

If anyone's interested in checking out one possible path for preparing for the anesthesia oral boards, click here or at the link on the sidebar.