Tales from Saint Boonie's: One of the Gang (a fictitious true story)

"You don't deserve to live."

There's rage on his face. Rage and outrage. How dare you diss me, it says. Me. ME! He pulls out a handgun without a whisper of doubt or hesitation. Not a whiff. I will not be loathed. The thought comes not as a bunch of words - he has little use for those - but rather as an overpowering urge, strong and sure as his own heartbeat. And with it comes the dark satisfaction of his own hatred - the certainty of it, which lends steadiness to his hand - and a certain smug pleasure in his own entitlement.

He shoots the other teenager twice, then snickers as the boy's body falls against the steering wheel, the deep brown skin of his neck now staining purple with a wash of blood.

You don't deserve to live. Those words hadn't crossed his mind, exactly, when he'd shot at other people. But he knew well what feeling them felt like - the weighty power and intoxicating sense of justice they gave him, almost palpable across his chest with every breath he took, like armor, a breastplate to be respected. No one had the right to diss him. No one. And no one would dare. He would make sure of that.

***

The radio in the emergency department at St. Boonie's crackles. Personnel are already scurrying to get ready to receive an ambulance en route with a seventeen-year-old shooting victim. Fragments of conversation between the E.D. nurse and the paramedic on the radio are audible above the hubbub. GSW to the chest...Copy that...What's your ETA?...Five minutes...Thank you, St. B's...

As doctors and nurses swarm around the patient to try to attend to his injuries, a boy of about fourteen bursts into the emergency department demanding to be allowed near the patient. He's screaming at the top of his lungs that he's going to finish the job. The patient had shot his brother while his brother had been sitting in a parked car. The boy is using foul language and gesturing violently with one hand; the other he keeps stuffed into the pocket of his jacket. He threatens the staff and all who try to come near him.

"Scumbag," mutters a woman in scrubs, safely out of earshot. "Worthless animal scumbag."

***

The storm passes without further harm done. Conversation in the break room is tense. Bitter. Like the dregs at the bottom of the coffee pot that's been sitting un-refilled all day.

"I think those pieces of sh__ should just curl up and die. They wanna kill each other? I say let 'em."

"Oh, you're no fun - then they'd have to spend your taxes on something that might actually HELP society."

"Those people are beyond useless, man. They're a waste of space and oxygen. No, lemme take that back. A lazy lump on the couch is a waste of space and oxygen. THOSE people are WORSE."

"Yeah - they exist just to MAKE life miserable. Not better, not neutral, MISERABLE. Worthless, worthless, worthless."

The undercurrent is clear. There's resentment there - lots of it. Even hate. And it isn't hard to understand. Why wouldn't anyone feel inexpressibly frustrated? Angry? Not just angry - enraged. Enraged and outraged. Not hard to understand at all.

We've all felt that way at one time or another, especially in health care. That our efforts are a futile waste of energy. That our patients don't even deserve the help we're working so hard to give, so why on earth bother?

We're entitled to those feelings. Aren't we?

We've all felt the feeling, if not thought the thought.

You don't deserve to live.

In a way you have to wonder how different we really are.

________________________________________________________

The real-life St. Boonie's hospitals, though situated in "the boonies," do on occasion have to deal with local gang violence. Although at one of the hospitals there was a time when members of the staff were indeed threatened by an angry youth, the above scenario is essentially fabricated - an exploration of the ambivalence and occasional hopelessness we face and experience in our day-to-day work. This post is fiction, but the issues it's trying to grapple with/meditate on are very much non-fiction. I aspire NOT to be so bitter as to resent the patients whose life choices make me cringe, and intellectually I know we are called to rise above such judgment, but I'll be the first to admit that I don't always have an easy time practicing, or even sometimes continuing to believe in, some of my own ideals. I think I may not be alone in this, though...And I also think that on the whole, we who choose to take care of others for a living try our best to really stick to our duty and be of real help and service, despite some of our inner struggles.

Photo credit: Firestar handgun by MJCDetroit, GNU Free Documentation license.

The Grass Isn't Always Greener...

I got this idea from OldMDGirl, who writes a blog entitled The Long Road to Medical School. She made a list entitled "Career Preferences du Jour," which intrigued me because every time I go on vacation, my mind starts wandering about what I could do with my life if I weren't an anesthesiologist.

Her "Career Preferences du Jour":
#1 - Bench to Bedside Research in Field of Choice
#2 - Psychiatrist
#3 - Neurologist...
#25 - Pediatric Orthopedist...
#10,000 - Housewife
#999,999,999 - Stick needle in own eyeball
#1,000,000,000 - Ob/Gyn

I laughed out loud at that last one because I couldn't agree more. I am certainly not cut out for that medical specialty! (And though OldMDGirl came away from her anesthesia rotation too with, unfortunately, a very negative impression of the field, and she considers people around my age "really REALLY OLD" :(, we do agree on at least one other thing: one of my favorite books.)

If I had to pick another field within medicine it would probably be neonatology, to combine my love of infants with issues of critical care. But if I weren't currently in medicine, or had never chosen to pursue it, or were to drop it now and change, what would I do? Setting aside for a moment the fact that I have few if any other marketable skills? :)

Fantasy "Career Preferences" du Jour (somewhat tongue-in-cheek), after OldMDGirl

#1 - Chocolate taster - hee-hee!

#2 - Tour guide in Florence or Paris

#3 - Bookstore-café owner

#5 - Museum curator

#7 - Oboist - but I think I wouldn't in a million years have the talent or skill required
#8- Teacher

#9 - Ballet teacher

#10 - Housewife

#11 - Parish educational coordinator

#12 - Art Therapist

#20 - Lab tech

#25 - Food critic
#30 - Caterer...but I think the stress and organization that's part of preparing food for other people might take away my love of food
#50 - Wedding coordinator...but I dread making phone calls and would't love dealing with demanding family members
#999,999,999 - Do something self-injurious

#1,000,000,000 - Ob/Gyn

Hmm...I think I'm gonna have to stick to anesthesia for the time being...so I guess it's back to the O.R. on Monday!

_______________________________________________________

Addendum:

Did I do anything new during this break?

Answer: Why, yes, as a matter of fact.

-New sight: saw Lake Winnipesaukee from the top of the old Abenaki Fire Tower near Wolfeboro

-New movie: finally saw Almodóvar's film Volver starring Penelope Cruz and loved it so much I watched it again the following morning and added it to my "favorite movies" list

-New dish: made flan for the first time (food scenes in movies and books do that - I either have to try and make what I see, or eat it, or both...)

-New oboe piece: started working on a little Gavotte by Bach. My endurance has really suffered in these last few weeks of spotty practicing. I am paying for it now! Nothing like a little Baroque Boot-camp for us truants...

Excursions in Medical History: Brief Walk Through Medicine in Art

This coming August The Gross Clinic, painted by American master Thomas Eakins in 1875, will be exhibited at the Philadelphia Museum of Art until February of next year. Hat tip to Kathleen Stocker at A Repository for Bottled Monsters (a blog for the National Museum of Health and Medicine in D.C.) for the alert.

The New York Tribune described this masterpiece, which depicts American trauma surgeon Samuel D. Gross, as "one of the most powerful, horrible, yet fascinating pictures that has been painted anywhere in this century...but the more one praises it, the more one must condemn its admission to a gallery where men and women of weak nerves must be compelled to look at it, for not to look at it is impossible."

A lot of art depicting medical subjects is like this. It can be hard to look at and hard not to look at too. One of the scariest paintings I've ever seen is Sir Charles Bell's 1809 work depicting a patient suffering from tetanus. But there are other less gruesome examples throughout history, and I enjoy perusing them for the clues they provide about the history of medicine.

Here's the painter Goya getting some medicine from a doctor-friend (Self-Portrait with Dr. Arrieta, 1820).

In this painting on a Grecian urn from ca. 500 B.C., Achilles binds up Patroclus's wound from an arrow. With what? A swathe of linen? Would he have soaked it in something first, or applied a poultice?

Anatomic illustrations have a long and marvelous history, from Persian medicine centuries ago to Leonardo's famous drawings to today's med school anatomy "bible," the atlas illustrated by Netter. The National Library of Medicine has uploaded several pages from historic Persian, French, Dutch, German, Japanese, and Italian, anatomy books here and here for our perusal. Thanks, NLM!

Anatomy lessons were depicted by Dutch painters Mierevelt and Rembrandt, who portrayed Professor Nicolaes Tulp examining the flexor digitorum superficialis and Dr. Joan Deyman exploring the brain.

But to my mind Eakins' painting surpasses even these works by Rembrandt. There's something about The Gross Clinic that holds my attention - is it the way the light is striking Dr. Gross's forehead as well as the surgical field, or the way the "minor characters" have little stories of their own without distracting too much from the central focus of the painting? Is it the fact that here, clearly, the need for aseptic surgical techniques was unknown, whereas 14 years later, in 1889, when Eakins painted The Agnew Clinic, surgical gowns and sterilized instruments had become the norm, thanks to Lister? Looking through acts of medicine as portrayed by artists around the world (and throughout history) is like leafing through a family album, or trying to reconstruct stories for a family tree. It's nice to see how much we've grown...and humbling to realize how much farther we have to go.

More than Words

I'd met Angie a year ago, prior to a surgical procedure for which I provided her anesthesia. She and her husband are both deaf.

I was glad to see her again, this time under happier circumstances: the birth of their next child.

"How are you?" I gestured with my hands, pulling out the one ASL phrase I could always count on.

I added, awkwardly, "My signing is not better," then realized, Oh crap, how do you say, "since we last met?" At that time, the previous year, I had introduced myself, "I'm Dr. So-and-so," and it had taken me almost as many seconds as letters in my name to do the fingerspelling. So sad.

She smiled and answered through her interpreter, "No worries."

I have an "accent," I'm sure. A hearing person's accent, and a beginner's manual stutter.

Sometimes I wonder, is it annoying for someone who communicates in another language to have a non-fluent person try, or is it accepted in the spirit of fellowship in which the effort is intended? I guess it depends on the individual and the circumstances.

In any case, I was off the hook, for more than one reason: the presence of a terrific interpreter, and the need to get busy with my hands and prepare for the epidural placement.

Immediately I had an issue I hadn't thought of before: how best to position a deaf patient so she could still communicate. Lying on her side, she would probably find her interpreter easier to see, but one of her arms less mobile for signing. We opted to keep her in a sitting position and her interpreter seated on a footrest in front of her, in her line of sight even with her head bent down and her body curled up. Her hands and arms would be free to move with the caveat that she would have to keep them in front of her, away from the sterile field.

The epidural placement was an easy one. Easy enough to allow the labor nurse and me the opportunity for quiet conversation during the placement.

"Where did Angie and John meet?" I asked her. "She might feel a little pressure in her back now," I added, as an aside. The interpreter translated my question and my word of warning.

"We met at school," John signed in reply, behind her.

"You can really feel how much they love each other," I said, talking as much to myself as to the nurse and the interpreter. The interpreter conveyed my thoughts, which John would not be able to lip-read through my surgical mask. I started passing the catheter into Angie's body. It went in smoothly.

The labor nurse concurred. "Exactly. I felt it as soon as I walked in. Really felt it, in the air."

"Right? It's like something that wraps right around you right as you enter the room."

I finished taping the epidural catheter into place. It had gone without a hitch.

The labor nurse nodded. "A lotta love there. A lotta love. Not something you usually get when you walk into these rooms, lemme tell ya."

It was true. There was something special about the vibe in that room, emanating from this couple. Something palpably different from the feeling (or lack of feeling) you got in the presence of other couples. A warmth and tenderness that extended beyond them, easily.

I wondered if a lifetime of having to rely on means of communication other than speech had given these two wonderful people a special ability to communicate better in other ways, to transmit more than the average. We all marveled at Angie and John that night - at their kindness to us and each other, their radiance, the quiet joy and love they expressed, mostly without spoken words.

Sad to say, we're just as often discouraged as happy for the babies born to the families who usually come to this maternity ward. On this particular night, though, we knew we could rest easy and just celebrate - "no worries," as Angie had said. This baby was going to be way ahead of the game.

***

What I Want to Get Accomplished on this Break

1. Brush up on my sign language!

2. Brush up on my flagging Arabic.

3. Read the next book on my summer reading list.

4. Read the latest Oprah magazine, which has all the summer book recommendations.

5. Change nail color, just for fun. Or actually put some on to begin with...a rare event, because of work! Do something about eyebrows. Maybe even hair.

6. Watch reruns of 7th Heaven.

7. Try to make Stilton Cheese & Swiss Chocolate truffles (don't ask).

8. Get through a ballet barre, again.

9. Restore hibernating oboe skills!

10. Sleep. Sleep. Sleep. Sleep.

I think if I even get just #10 accomplished my life will be rejuvenated tenfold...

Summer Reading Time

I'm taking a little time off this week for a much-needed break way from the usual pace of work, putting dinner on the table, getting mundane errands done, etc. A pause at the Well of What's-not-bread-alone. A luxuriation in the things that nourish my spirit.

And one of those things, of course, is BOOKS.

I once entered a beautiful home and felt strongly that something was missing. The living room was lovely. The kitchen was a dream, spacious and attractive. There were lots of windows to let in natural light, morning and afternoon. But where were the...books? A well-to-do home with no BOOKS...?! I went back to my humble little house, looked at my book shelves, and thought to myself, now this, THIS, is a home. Nothing Architectural Digest would be interested in, but a cozy little place where my children and I can be enfolded in the aroma of bound pages and the vibe of stories all around us. It was the same feeling I'd get whenever I walked into a kitchen with fresh vegetables brimming over in baskets and saucepans filled with goodies simmering on the stove. I'd feel well-fed even before sitting down to the feast.

I've started my summer reading on this very day. I probably won't get through this whole list by autumn; work life always tugs me away. But I'd like to!

I start with Walking the Wrack Line by Barbara Hurd. This woman's prose is breathtaking, almost literally: the writing breathes, in and out, up and down, and its beauty does take the reader's breath away. It has rhythm and cadence, used wisely and naturally - as befits a nature writer, in the great tradition* of Annie Dillard or Loren Eiseley, and the literary and scientific writing of Lewis Thomas. It makes you want to read her words out loud and savor them in your mouth, be slowly transformed by the way they lap like waves at the edges of your mind. An example: "Underfoot that day was the usual medley of seaweed and shells, bits of plastic and driftwood, the ordinary ravel of wrack line every high tide leaves behind." Then, in the next paragraph,

Out in the harbor to my left, a dozen small sailboats practiced their maneuvers, tacking port then starboard in choreographed glissades of clean white triangles. Like sailors everywhere, they must have studied the jetty and shoals ahead and laid out a course to avoid them. Behind me, the narrow streets were crowded with sunglassed people who wove between slow-moving cars and children with ice cream cones. Wandering on the beach, I watched an object out in the waves, spent twenty minutes trying to figure out what it was. It hadn't bobbed so much as ridden, appearing on the top of a wave, disappearing behind it. Its rhythmic lift and sink had made it hard to identify - large fish? a log? a swimmer's rubber flipper? The closer it got, the flatter it looked, floating like something wooden, and by the time the skim of water twirled it clockwise and left it in the jumble of wrack, I could see it was a plank of some sort, a crafted thing, not a limb or something drowned, and then, finally, that it was a broken oar.

This passage is a microcosm of the process she as a writer and we as readers experience through this book - the gradual deciphering of a bit of knowledge or wisdom through ever-sharper observation of minute details, some beautiful, some astonishing, accumulating into a broader meditation on what washes ashore for all of us, "what might be rescued - from near destruction, from invisibility, from silence." I will finish this gorgeous book by tomorrow.

After Hurd's book I may stay near the water, so to speak, and turn to Exiles by Ron Hansen - a fictional exploration of the literary and spiritual struggles of Jesuit poet Gerard Manley Hopkins as he tries to make sense of the wreck of the steamship Deutschland, a vessel which had been carrying five young nuns who were bound for a new life in America because of Bismarck's laws against Catholic orders. I've been awed by Hopkins' poems since high school, when we read "As kingfishers catch fire..." (reproduced below). I never really thought about his inner life, though, and look forward to seeing an imagining of it, from an author who considers imagining an act of prayer, and who can use the words "anesthetic," "chamber pot" and "snowflakes" in the first paragraph alone.

As kingfishers catch fire, dragonflies dráw fláme;
As tumbled over rim in roundy wells
Stones ring; like each tucked string tells, each hung bell’s
Bow swung finds tongue to fling out broad its name;
Each mortal thing does one thing and the same:
Deals out that being indoors each one dwells;
Selves—goes itself; myself it speaks and spells,
Crying Whát I do is me: for that I came.

Í say móre: the just man justices;
Kéeps gráce: thát keeps all his goings graces;
Acts in God’s eye what in God’s eye he is—
Chríst—for Christ plays in ten thousand places,
Lovely in limbs, and lovely in eyes not his
To the Father through the features of men’s faces.

I'm intrigued by descriptions of Sebastian Barry's book The Secret Scripture, a novel about a 100-year-old mental patient who starts to reflect on and write about her past and hides her manuscript beneath the floor boards of her room. Meanwhile, a doctor is in the process of reevaluating all the patients in the ward - including her - to see which ones might be released back into the world...

After hearing last Sunday about how Francis Xavier Nguyen Van Thuan spent nine years in solitary confinement, often in the dark, because of his faith, I really want to read his books The Road of Hope: a gospel from prison and Testimony of Hope, a course of spiritual exercises he was invited to offer the Roman Catholic Curia. In it he expresses the desolation he felt during his ordeal and how he found hope in the depths of darkness and despair. How does anyone endure such a thing and emerge still capable of love and joy, as he did? Some people remain open to these gifts in unbelievable ways...

A Death Retold is long and dense, so it's probably not a realistic goal to for this summer, but I want to try. It recounts the tragedy of a botched transplant in an undocument Mexican teen immigrant and discusses the social and ethical issues in our tiered health care system, as well us in transplant medicine in general, brought to light by that terrible case. It sounds like a story that weaves together a lot of compelling fields of inquiry - medicine, sociology, ethics, and history.

Last but not least, every year I try to read or reread at least one "classic." Last summer when I was on my René Goupil mini-pilgrimage I came across this eerily relevant passage from Death Comes for the Archbishop and decided I had to get reacquainted with Willa Cather's work:

Before him, on the grey floor, in the grey light, a group of bright shawls and blankets, some fifty or sixty silent faces; above and behind them the grey walls. He felt as if he were celebrating Mass at the bottom of the sea, for antediluvian creatures; for types of life so old, so hardened, so shut within their shells, that the sacrifice on Calvary could hardly reach back so far…When he blessed them and sent them away, it was with a sense of inadequacy and spiritual defeat. -Death Comes for the Archbishop, Part III, Chapter 3.

That's my ideal reading list for this summer. I know I'll get through Walking the Wrack Line, and soon. As for the rest...they may get supplanted by other discoveries along the way, or put off for another time, but the desire to spend time with them is certainly there!

I welcome other suggestions too, so please let me know if you're reading anything good!

________________________________________________________

*Addendum: Toward the end of Hurd's book she mentions valuing Annie Dillard and Loren Eiseley. What a relief to know she wouldn't have minded my placing her in their company!

SurgeXperiences 124: Season Finale

Welcome to the last edition of this season's SurgeXperiences blog carnival!

The loose theme for the collection was "Secrets and Surprises" - what season finale would be complete without a few of those?

Yet there's another ingredient that no real season finale would be complete without. It's The Unanswered Question. The Unsolved Mystery. Unfinished Business. Arguably it's why any of us keeps returning to any realm of inquiry or learning.

The world of medicine abounds with unanswered questions. While they might not show up here in the form of a conventional "cliffhanger ending," they're here all right...lurking behind the answers to other questions, the often-untidy "resolutions" to stories, and in situations that remain unresolved altogether and that keep us wondering about doctors, nurses, patients, the O.R., the characters in the vast series of episodes that comprise life in medicine today.

So without further ado I give you Secrets, Deep Dark Secrets, and Surprises.

Secrets

Aggravated Doc Surg has written several truly enjoyable posts about hospital life behind-the-scenes. Read here about the five people you DON'T meet in the hospital, usually, but should still appreciate, and here and here about how doctors REALLY feel about JCAHO, the folks that go around making surprise visits to hospitals and subsequently determine what should be changed about them and whether they should even stay accredited. I confess to enjoying Doc Surg's satirical and sardonic bent in the latter.

In this post, Dr. Bates at Suture for a Living navigates the sometimes-tricky situation of meeting a patient outside the expected setting.

And speaking of the expected setting, what goes on, exactly, in the O.R.? Katy at her engaging blog Funny Girl once invited folks to go ahead and ask, through her comments section, and graciously, she answered.

She also writes of a recurring anxiety dream that materializes in her sleeping mind once in a while in response to her work as an O.R. nurse. We all know about those recurring dreams. Being late for class, or showing up without your homework, getting lost on a familiar route, or teeth or hair falling out in public, or missing some other crucial necessity at the most inopportune moment. Dr. Bates shares a very interesting dream one of her patients had regarding her upcoming surgery. It doesn't matter which side of the surgical drapery we're on. Those secret concerns come out at night for our brains to play with and puzzle over.

That is, if we care enough to take responsibility for the work. Buckeye Surgeon describes the issues involved in being the kind of surgeon who takes this "You operate, you own it" type of resonsibility for patients. The discussion generated in the comments section is enlightening.

On a lighter note, if you missed my recent post on the yuckiest things I can think of from hospital life, here it is in all its repugnant glory. I pair it here with a post by Oystein Horgmo, our Sterile Eye, about "Inner Scents." Enjoy.

In a well-written post I consider one of the most important in this collection, Dr. Bruce Campbell, ENT surgeon and author of the blog Reflections in a Head Mirror, discusses the perils of losing the capacity for empathy during one's medical training, while in his beautiful and bittersweet post on empathy, Dr. Sid Schwab reflects with both hope and perhaps a hint of sadness, "If empathy can be learned, I'm not sure it can be unlearned."

Deep, Dark Secrets

Photo: Premier secret confié à Vénus by François Jouffroy, photographed by Christophe Moustier

If you haven't visited Respiratory Therapy 101, please do - it's a wonderfully-written window into the world of respiratory therapy and critical care medicine. And while you're there, check out this post about little human touches in the ICU, and what a mixed blessing they can sometimes be, along with the thought-provoking comment from RogueMedic that follows it.

The Sterile Eye gets a pretty intimate view of some patients who often end up in surgical ICU's. He shares his work with us in this post containing sarcoma videos.

If a life in medicine shows us anything it's that there is just so much pain in the world. We could all probably make a list of the worst stories we've ever heard / seen / been involved with, and I even wrote a post once entitled "The Worst Story I've Ever Heard." But there's never only one such story, and certainly not just within the confines of our hospitals, as Bongi painfully recounts.

There's less dramatic, silent suffering too - amorphous, almost like a vapor you can smell but not see. Elusive pains like those fomented by doubt, distrust, suspicion, ill-repute, as Sheepish describes in The Paper Mask.

When bad things, really bad things, happen to good people on both sides of the drape - the caregivers and the patients - there are several ways to respond. Denial. Rage. Hiding or giving in to despair. Or you can do what this outstanding individual did, generously and courageously and with consummate integrity, and try not only to become a better person and physician but also to transform the systems around oneself for the better.

And groups can do the same. Here Paul Levy writes about M&M, morbidity and mortality conference, during which docs discuss adverse events behind closed doors and try to establish ways to prevent future errors or disasters. Far from being a dismaying and dismal post, this narrative leaves us with a sense of hope that we can and will do better.

Surprises

This surprised me: a patient writes, "Interestingly...I owe my blogging hobby to being stented," referring to the placement of a stent into an obstructed ureter. Glad to have a patient's input in SurgeXperiences!

I was also surprised to see some insider info and an entreaty from a Beverly Hills plastic surgery blog about how the stars should just quit trying to make their lips bigger!

The Repository for Bottled Monsters highlights the "clearest pictures ever taken" of human ovulation as it is occurring.

Next, some stories that I found both refreshing and refreshingly well-written. Quietus Leo describes how one of his patients finally came to give herself a much-needed rest, even from the preparations for the highest holy day she traditionally honored. Sid Schwab writes about fainting. TBTAM who writes The Blog that Ate Manhattan relates a lesson from Italy about caring for aging parents.

A Little Summer Reading

I'd like to close the carnival with some posts to keep us thinking for the summer. Dr. Bates at Suture for a Living gives us useful information about dog bite prevention here. For practicalities involving medical practice, visit Ian Furst's writings about a simulation regarding wait times, and Sid Schwab's (and many other doctors') concerns about appropriate reimbursement. Dr. Schwab also offers a sampler of great posts from his blog for our ongoing perusal as we look forward to the season premiere of SurgeXperiences Season 2, to be hosted by our very own carnival founder, Monash Medical Student Jeffrey Leow.

To be continued...

Excursions in Medical History: Cataract Surgery

Warning: this post may contain some graphic images and descriptions. Viewer discretion advised.

I'm going to try producing a new series here this summer: Excursions in Medical History - an occasional, brief stroll through the annals of our collective clinical past. A kind of "History of Medicine 101."

Photo: Dr. Rizal Treating His Own Mother, Romeo Enriquez, 1960. Courtesy of the National Historical Institute, Manila, the Philippines. Adapted from JAMA.

Because I've had the luxury of being "in eyes" - that is, providing sedation for cataract surgery - not once but twice this week, I started thinking a lot about cataract surgery. What's a cataract? It's a clouding of the crystalline lens in the eye, so named because in antiquity physicians conceived of the clouding material as something that cascaded into the eye.

Some people who haven't undergone the procedure get a little alarmed when I inform them that they'll be awake for the entire surgery, and I don't blame them - who wants to sit there under a giant drape while a masked figure in blue scrubs pokes into your eyeball with a sharp object?

(Taken, with permission from the patient, off a video monitor of cataract surgery at one of the hospitals I serve.)

But the truth is, I have never seen any patient experience pain or distress during cataract surgery. The ophthalmologist numbs the eye completely, with drops of local anesthetic and perhaps a regional block (retrobulbar or subtenons). The anesthetist may give a little sedation through the I.V. And that's really all you need! The incision is tiny - two or three millimeters, tops. The surgeon might occasionally ask the patient to look in a certain direction, or tilt the chin a certain way, the patient says, "Ok," and the surgery progresses - the clouded lens is removed and replaced with a new lens.

Not so back in the day, oh, maybe 2500 years ago. As the American Academy of Ophthalmology recounts, the earliest form of cataract surgery was couching, a procedure described in 5th century B.C. Sanskrit manuscripts. This involved displacing the lens away from the pupil and into the vitreous cavity. Centuries later discission, or needling to break up the cataract into pieces, was practiced. In the mid-1700's Jacques Daviel of France and Samuel Sharp of London began surgically removing the lenses from their patients with "the services of a strong assistant...to hold the patient's head still." Local anesthetic drops would not ease the pain and terror of the procedure until 1884.

Which brings me to José Rizal, my country's national hero, whom I've mentioned briefly before and whose birth anniversary was just yesterday. Rizal was a real Renaissance man - poet, novelist, polyglot, political activist, physician (click here for a wonderful article from the Archives of Ophthalmology by Tracy B. Ravin, M.D. on Rizal's medical training). He studied ophthalmic surgery in Madrid, Paris, and Heidelberg, then brought his skills and other talents back to the Philippines, where he practiced from 1888-1896. People would sometimes travel for miles, through heat and dust and mosquitoes, to receive treatment from him.

After his execution by firing squad for "rebellion" against Spain, Rudolf Virchow (of "Virchow's triad," the first triad I ever learned in medical school) gave a speech in his memory at the annual general meeting of the Berlin Society for Anthropology, Ethnology and Pre-history. Another statement by Virchow seems a fitting reminder of what Rizal's life represented: "Medicine is a social science, and politics is nothing more than medicine on a larger scale." Rizal embodied the old adage about the pen being mightier than the sword and used his gifts as a physician-writer - a good eye and an intelligent use of language - to try to bring about social change, political action, respect for human rights, and freedom for all in his homeland. I am reminded of one last quote, from The Word as Scalpel by Samuel William Bloom: “If words, the main substance of human relations, are so potent for harm, how equally powerful can they be to help if used with disciplined knowledge and understanding? And where more certainly does this simple truth apply than in the making of a physician?”