Tales from St. Boonie's

Welcome to St. Boonie's!

St. Boonie's Hospital is a semi-fictionalized institution based on the three in which I practice. It is situated among a bunch of dairy farms in Elsewhere, New England. For the most part it takes good care of its patients and ships the really tough ones to The Big House, somewhere beyond all the pasture land.

I was going to call this post "Why I Can't Leave the Periphery of Excellence," in homage to a post at the blogofbleedingheart entitled "Why I Left the Centre of Excellence." I'm trying to figure out why, for all my behind-closed-doors moaning and complaining about work (which almost all of us do at one point or another, right?), after interviewing at several other possible work places all of which have made me attractive offers, I am still at St. Boonie's.

I think it's because I love village life. And St. Boonie's is just that - a village, a small town, with a sense of community and familiarity, but also with its share of the same frustrations and misunderstandings that might beset those who inhabit a small town or a family.

By way of introduction to some of those frustrations and a typical St. Boonie way of coping with it, let me introduce you to the Potty-Mouth Bucket.

We have a surgeon I will call Dr. Buddock who has a puerile habit of whining, speaking rudely, and/or expressing himself like a stubborn spoiled brat when things aren't quite the way he wants them to be. He was written up recently for his failure to refrain from frequent use of the "F" word in the O.R.

The incidents were addressed formally, of course. But after the smoke cleared, the nurses put together this contraption. He's supposed to put in a dollar for every expletive, $10 for each tantrum, and $20 for a meltdown. Yes, there is money in the bucket. We use it for chocolate.

Ah, St. Boonie's - where in the O.R. scheduling office instead of a portrait of Virginia Apgar or Rudolf Virchow, we have...Johnny Depp.



Look out for another installment of Tales from St. Boonie's, wherein I muse about the case of the disappearing hummus...or about the singing pig who makes rounds...or perhaps about why Fabio is standing in the lunchroom...

Reed-Making Tips, Time Capsules, and Trampoline Secrets

I laughed out loud over breakfast this morning when I read this excerpt from Elaine Fine's beloved copy of Incomplete Method fur die Holzblasinstrumente (if it won't enlarge when you click on it try this link):



Thank you, Professor Schmutzig - I'll remember to stomp all over the reeds I under-soak, over-scrape, and chip as I tie!

This made me think back to my own childhood. What books or other treasures did I carry around with me everywhere or have my calligraphic scrawl lovingly inscribed on them? What would I rejoice over if I were to find it again in some not-for-yard-sale box in my closet? What would I put in a "time capsule" today, and would it still be a treasure years from now, when I finally turn my house into an archaeological dig and unearth it?

The book I remember carrying around and poring over endlessly when I was in grade school was a volume entitled The Hodgepodge Book: An Almanac of American Folklore; containing all manner of curious, interesting, and out-of-the-way information drawn from American folklore, and not to be found anywhere else in the world; as well as jokes, conundrums, riddles, puzzles, and other matter designed to amuse and entertain - all of it most instructive and delightful by Duncan Emrich, illustrated by Ib Ohlsson. I must have checked it out of my school library a dozen times.

As for my time capsule...I'm realizing that the things I enjoy today, as much as I enjoy them, I could ultimately live without. I have tremendous fun when I dig up unintentional time capsules - a box of school day mementos, gifts from faraway loved ones, old letters and photos. And I do have pack-rat tendencies with the like. But I can't think of what I'd put in a capsule at this stage of my life. A laryngoscope? Too useful to store. An oboe? Need it beside me, and too expensive to hide. Missives? Pictures? Programs from shows? News articles? Maybe. But maybe it's a good sign that I don't have too many ideas or any real desire for creating a time capsule right now. I'm hoping it means I'm living in the moment as much as I can.

My daughter, on the other hand, has actually put together a time capsule with her dearest friend, a lovely boy I'll call Adam. That I can totally understand. They are in the waning years of what we're hoping has been a happy childhood, about to enter adolescence. Adam expects to be moving away. I think if I had a friendship as special as theirs I would certainly commemorate it with a time capsule to open in later adolescence or even adulthood. I don't know what they've included in it, but I don't want to pry about it, either. They really have a wonderful relationship that deserves its own space and time in the world.

Last night Adam was over along with our niece and nephew, and the five kids played delightful games on the giant trampoline in our back yard. (As a former pediatrician-in-the-making I was at first reluctant to accept the apparatus, certain it was an unadvisable threat to our kids' safety, but I've slowly come around to the idea that it is, as my husband says, "the best 50 bucks we ever spent.") The four kids next door have a trampoline in their back yard as well, so sometimes there are double-trampoline neighborhood ball tosses in addition to the usual rounds of Sardines, Ghosts in the Graveyard, and our contribution, a game called Signal in French, till dusk.

As darkness set in and voices of parents called to their young to come in for baths and showers or pre-bedtime activities, Adam and my kids found themselves sitting or lying on the trampoline talking quietly together. My second story window overlooks the back yard, so I can see the kids down there, but I can only get snatches of their conversations, and I found myself smiling as I overheard bits and pieces like, "What's said on the trampoline STAYS on the trampoline!" And..."Trampoline secrets!" It's hard not to want to be a closer fly on the wall, and I have to laugh at my fantasies of hooking up a microphone to the underside of the giant disc just to monitor for sketchy content or misinformation. But I also believe kids need and should have this protected, private space and time for their own conversations...even if they sometimes stumble or misuse it, as we all have. Their expanding minds have bouncing of their own to do, off each other.

I was awed and delighted as these snatches wafted up from my daughter's lips (by this time, her brother had gone in for his shower, and she and Adam were looking up at the sky and talking quietly by themselves): "Seriously, why are humans here?...Why are we even alive...?...The world is tiny. It’s, like, one of the smallest planets...Our sun is one of the smallest stars...a little speck...So what are we?...Think about the poor molecule!” I wonder what their answers were. I would have loved to have been part of their conversation. But I also love that they were having this kind of conversation alone with each other, challenging and learning from one another, and having such a nice, peaceful time. Not long afterward I heard my husband's voice from a downstairs window calling them in out of the crisp evening air. I caught only timbre and rhythm then, a few last words, snatches of song and laughter, before they came into the house for the night.

An Anesthesiologist's Holiday Breakfast

This morning I woke up to sunlight spilling around the edges of the window shade, the distant sound of birds in the trees, and..."Anesthesia stat to ICU! Anesthesia stat to ICU!" on the overhead paging system.

I lifted my head with a start and looked at the clock. Six minutes past the end of my 24-hour shift. *Insert mental expletive here.* I still felt a little groggy from our midnight C-section hours ago, after a full day of O.R. cases and labor epidurals yesterday. I threw on my shoes and scrub jacket and ran to the ICU.

There was already a crowd of nurses and residents there. A cardiologist and two hospitalists were there as well but only one of them ended up staying. I got the story in bits and pieces from various people - the patient had been throwing up greenish-brownish, coffee-ground textured stuff and the oxygen saturation was (of course) low. After being brought to the ICU from a regular room the patient continued to throw up the stuff. The heart rhythm was abnormal, heart rate was high, and blood pressure was low. I got to my usual spot at the head of the bed, glanced down, and through all the wires, mask ventilator, and other paraphernalia recognized a patient I had just seen the previous night, to do a preoperative evaluation.

One of the memorable lessons that I took away from spending time in a medical simulator was this: one of the most common group errors at a code was to fail to designate a code leader, or "event manager." During the analysis of this tendency, we participants found that people were often hesitant to volunteer, either because of lack of experience or knowledge or because they were afraid to appear cocky, and people were also hesitant to nominate others. When we were prodded to express and explore these feelings, however, it became clear that we would all have felt relieved to have someone volunteer to take the helm; arrogance was the last thing we would have criticized a volunteer for at a moment like that. It was also clear that the person running the code, ideally, had to be someone who was not involved in performing a resuscitation task, like intubation or I.V. access - someone who could survey the whole scene, take in a lot of information, relay communication, and direct people's efforts efficiently.

I have a mental mnemonic for what I think a code leader needs to do. (Speaking of mental expletives, if you're easily offended, don't look at the mnemonic too carefully...)

-Own it. Step up to the plate, or agree to be volunteered to do so, or gracefully but quickly say, "I would prefer that you designate so-and-so to manage the event." The person who takes ownership of the manager's role has to do so unambiguously and expeditiously.

-See things. Stand in a position where all monitors and activity are visible, notice changes in vital signs or clinical status, pay FULL ATTENTION to all the action at hand, and communicate observations.

-Hear things. Listen, and HEAR. Information from participants, alarms from the monitors, and any other pertinent sounds.

-Integrate. All the input has to be processed quickly, judgments made, and action taken. Stat. Don't be afraid to use help or resources around you. Ask for differential diagnoses, suggestions, or reminders if you blank out. But however you do it, GET the info, put it together, then DO something.

-Talk. Tell people what you know, what you're thinking, what the next step should be, what's needed, where to go, what to do. Quickly. This is not the time for social niceties. They're called orders for a reason.

So when I got to my spot at the head of the bed, I said, "I want suction and a free-flowing I.V. I need a Mac 3 blade and a Mac 4 ready, an 8.0 ET tube with stylet, and drugs drawn up." I gave a short list of the drugs I wanted and how many cc's of each. "And I need one of you," I said, pointing my finger at a couple of individuals whose "rank" or "position" I won't specify, "you or you, to run this. It's better if it's someone who's not managing the airway or getting stuff. Who's it going to be?"

The people I pointed to and many others in the room could be assumed to have had training in advanced cardiac life support (ACLS). One of those people took the job.

I did a rapid-sequence intubation and got a large breathing tube in. The nurses and respiratory therapists who assisted me with the actual intubation were totally stellar. But as I kept watching the monitors, I noticed the heart rhythm was beginning to do sketchier things. My code leader wasn't saying anything. Did he even notice? The blood pressure was dropping again too. Hellooo?! What was my code leader doing?

"I want someone to go mix up a phenylephrine drip now and hang it," I said loudly. "Who's going to get that?" A nurse gave me a verbal affirmation and went to get the drug.

"Someone should get started on an arterial line and another I.V." I turned to the code leader, who was staring blankly at me. "Don't you agree?" I said to him.

We secured the airway, and once the vital signs had improved I went to write a note in the chart. One of my colleagues - the person on call for today - arrived, and we had to help the code leader read the x-ray confirming placement of the breathing tube and explain why we chose the drugs we did.

After all that I spent a little time venting to my colleague, a very experienced anesthesiologist whose skill and judgment I hold up for myself as a model. I was upset that even after designating an event manager, I still ended up essentially having to run the code (or near-code) myself, when I was already engaged doing a crucial task that demanded all my attention and energy. What are you supposed to do when other supposedly-qualified people around you are rusty, nervous, un-assertive, out-to-lunch, or unwilling to admit they're not so comfortable in the assigned role after all, and you're in a public crisis that's unraveling right then and there? I guess you're stuck trying to manage the event AND do the required resuscitation tasks. But having one clinician fulfill both or multiple roles is less efficient and potentially less effective than dividing the labor in an organized way. It's possible to do things the first way, and not necessarily harmful, and in fact it happens frequently, but it's really not ideal.

Needless to say, driving home to oboe-laden strains of Ravel's Tombeau de Couperin on the radio was like cool water on a hot day. And the clear, blue sky and sunny, breezy weather we had as we congregated at the neighborhood baseball field to enjoy our town's Memorial Day parade was truly healing.

I always well up a little during military rituals of remembrance. Our baseball field is right across the street from our town cemetery, so when those marching in the parade arrived - little flocks of Brownies and adolescents in school bands side by side with veterans who had seen a lot of years, lived through a lot of stories - they stopped in at the cemetery for a brief memorial ceremony. Thanks to Dr. Wes for this link to moving tributes to individuals who have served this country in the name of peace and freedom.

I'm still on call, but today it's beeper call from home. Hope I can just spend the day enjoying this weather and a barbecue and the comforting company of my family. I'm tired. I just wanna go back to sleep.

My Favorite Things: A Light, Mindless "Fluff" Post for the Weekend

"Brown paper packages tied up with strings /

These are a few of my favorite things..." -The Sound of Music

The thesis of the song "My Favorite Things," of course, is that thinking of life's little blessings, things that make one happy, might take the edge of any unpleasantness at hand and actually remind us to be grateful.

Let's see if it works.

This week has been a bit of a roller coaster.

Earlier this week I walked in to help a couple of colleagues with a patient who was hypotensive with septic shock on the table and subsequently got a lot of appreciation from the people involved with the case.

Then a surgeon at one of my hospitals complained I had insulted her after I told her in a pretty determined way that her patient was not an appropriate candidate for surgery at that particular hospital in the current state the patient was in.

Then at another hospital a patient's family told me I was their favorite doctor during their whole ordeal at the place and that I had really made a difference in a way that reduced their anxiety about their loved one's care.

Then I got into a disagreement with someone in my anesthesia group (now smoothed-over).

At some point I had some good news, about an essay I wrote getting included in an anthology due to be published this fall.

Then yesterday a CRNA I was working with had trouble intubating her patient and I stepped in to try, certain that if she, who had been practicing anesthesia for as long as I'd been alive and had actually helped train some of my colleagues, couldn't get the airway, then I certainly didn't have a better chance. Relief replaced alarm when the tube went into the right place. But after that the O.R. kept running till midnight. Again.

Now I'm a little tired. But I'm also on call. As luck would have it the weather's supposed to be glorious this whole holiday weekend.

Thus I'm trying to think of my favorite things, so that

"when the call bites /

when O.B. stings /

when I'm feeling sad /

I simply remember my favorite things /

and then I don't feel so bad..."

Here they are, then, like a giant meme. I've grouped my "things" into four sections: general, books, movies/music/performing arts, and food. Thanks to Katy who writes the blog Funny Girl for getting me thinking about the book section!

My Favorite Things

Accent:  Scottish, Australian

Animal: Alpaca

Artist:  Norman Rockwell

Bird: Snowy owl

Building: The National Shrine of the Immaculate Conception in Washington, D.C.; Chartres Cathedral

Cities: Florence; Paris; Boston; London

Color: Blue
Country: France; the U.S.

Experience: hearing a brass concert at Gore Place, or Dixieland at Cate Park, on a picnic blanket w/ husband and kids; a great, relaxing massage

Flower: rose (red or white)

"Foreign" accent: Scottish

Historical person: hmm...gotta come back to that one

Hobby: blogging! and of course, oboe

Holiday: Christmas

Invention: writing; indoor plumbing; warm showers

Language: to hear – French, Russian; to express ideas – English

Make-up: MAC

Outfit: comfortable blue jeans, tank top, and button-down work shirt

Painting: Hilltop Farm in Winter by Maxfield Parrish

Pen: Sanford Uniball Grip Fine (micro tip)

Place: our cabin in New Hampshire

Saint: René Goupil

School: Stone Ridge School of the Sacred Heart; Harvard College

School subject: English, French, social studies

Scripture passage: Romans 8: 38-39

Sport to do: if dance could be considered a sport, I’d say that

Sport to watch: Men’s gymnastics

State: Vermont

Store: Borders

Time period: 19th century

Thing-to-do from a to-do list: Wrap Christmas presents

Books / Literary Favorites

Fictional characters: Atticus Finch, Sherlock Holmes, Elizabeth Proctor

Magazine/periodical: Image Journal; O

Nonfiction book: On Writing Well by William Zinsser

Novels for adults: To Kill a Mockingbird by Harper Lee; The Help by Kathryn Stockett; Prodigal Summer by Barbara Kingsolver; The Curious Incident of the Dog in the Night-time by Mark Haddon; Gilead by Marilynne Robinson; Lying Awake by Mark Salzman

Novel for children: Tuck Everlasting by Natalie Babbitt

Novel for young adults: A Ring of Endless Light by Madeleine L’Engle; Two from Galilee by Marjorie Holmes

Picture book for children: The Christmas Miracle of Jonathan Toomey by Susan Wojciekowski and The Fourth Wise Man by Summers; Hooway for Wodney Wat by Helen Lester

Poem: Barter by Sara Teasdale, Stammerer on Scree by Owen Sheers

Poet(s): Herbert, Hopkins, Donne

Short story: The Expert on God by John L’Heureux and Roman Fever by Edith Wharton

Movies, Music, & Performing Arts Faves

Action movie: Independence Day; King Arthur; Troy; Kingdom of Heaven

Actor: Edward Norton, Hugh Jackman

Actress: Scarlett Johansson, Reese Witherspoon, Anna Popplewell

Black-and-white movie: To Kill a Mockingbird; also, Roman Holiday & Casablanca

Cartoon: Pinky & the Brain

Comedy (movie): By the Light of the Silvery Moon; While You Were Sleeping; Elf; The Trouble with Angels; Little Miss Sunshine

Drama (movie): The Mission; The Illusionist

Movie moment: dictation scene in Amadeus

Musicals:  The Secret Garden, Jesus Christ Superstar, Annie, Chess, Les Miz, Miss Saigon, Wicked, The Sound of Music, Legally Blonde

Period flick: A Christmas Carol starring George C. Scott; A Room with a View

Scary movie: The Exorcism of Emily Rose

Sci Fi movie: Independence Day

Screen kiss: Jeremy Irons' in And Now Ladies and Gentlemen

T.V. Show: Bones; The West Wing; Star Trek: the Next Generation; Star Trek: Voyager; Boomtown

Cellist: Rufus Cappadocia

Choral piece: Os justi by Bruckner; There is No Rose by Stroope

Christmas carol: In Dulci Jubilo; Ding Dong Merrily on High; O Come, O Come Emmanuel; O Come All Ye Faithful

Concerto: Concierto de Aranjuez by Rodrigo; Piano Concerto #17 in D by Mozart

Oboe piece: Concerto for Oboe and Strings by Ralph Vaughan Williams

Oboist: Celia Nicklin

Orchestral work(s): Appalachian Spring, Fanfare for the Common Man, and Rodeo by Copland; millennium parade music from Epcot Center; 4th Movement of Tchaikovsky's Suite #4

Piano piece: Prelude in G minor by Rachmaninoff; Sonata in B minor by Liszt

Pop Song: Who Knew

Violinist:  Gil Shaham

Religious song: By the Rivers of Babylon by Marty Haugen

Ballet, classical: Sleeping Beauty

Ballet, contemporary: In the Middle Somewhat Elevated by William Forsythe

Ballet, overall: Revelations by Alvin Ailey

Dance company: Alvin Ailey Dance Company

Sung play, not exactly a musical: Missionaries by Elizabeth Swados

Opera: Amahl and the Night Visitors by Giancarlo Menotti; Der Rosenkavalier; La Boheme; Tosca

Operetta: Die Fledermaus

Play, comic: Noises Off by Michael Frayn and You Can't Take It With You by George S. Kaufman and Moss Hart (esp. the Jason Robards production that aired on TV in the'80's)

Play, dramatic: The Crucible by Arthur Miller; The Arabian Nights by Mary Zimmerman; Proof; Copenhagen; Amadeus; Equus

Food Favorites

Appetizer: baked brie en croute with a bit of a fruit-&-nut layer

Beverage, cold: water

Beverage, hot: Viennese Chocolate Café coffee by International Foods

Breakfast: coffee & croissant, just like Dr. Crusher on Star Trek:  the Next Generation; cereal & berries with a little fromage blanc or Greek-style yogurt; tartines; Tita M’s ensaymadas

Cake: opera gateau; the Philippine cake known as sans rival; sachertorte; one at Whole Foods that has little pink flowers on it and beige buttercream icing

Cheese: Bailey Hazen Blue; Stichelton; Reypenaer; Comte; Boursin

Chocolate: Godiva; Toblerone (milk > dark > white)

Cookie: chocolate chip cookies from the now-closed “David’s Cookies” chain in New York (the online version’s not the same, somehow, and you miss out on the amazing aroma of fresh-out-of-the-oven, warm, chocolate chunk cookies at the bakeshop…); also, Taiwanese "ChocoRoll: pudding flavor" cylindral cookies covered with milk chocolate

Dessert: crème brûlée

Dip: Whole Foods' Smoky Harissa Hummus; fresh guacamole

Fruit: Philippine mango; blackberry

Hors d’oeuvres: bacon-wrapped scallops; crab rangoon

Ice cream: Oreo ice cream by J.P. Licks, slathered with hot fudge of course; Ginger Snap & Molasses ice cream at Rancatore's; Tres Leches by Haagen-Dasz

Main Course: really good Thai food

Meat/Fish: teriyaki beef skewers; great prime rib; grilled trout

Merienda: Philippine mangoes with bagoong; croissants; churros con chocolate

Pasta: butternut squash ravioli with a light sage-infused or maple-cream sauce

Rice dish: wild mushroom/porcini/morel risotto; Philippine garlic fried rice

Salad: my cousin Gaita’s Insalata Pacifica at her restaurant, Cibo; Thai Crunch Salad or Field Greens Salad at CPK; Cobb salad with sherry vinaigrette at Not Your Average Joe’s

Side order: the now-defunct Tony Roma’s onion ring loaf; sauteed onions and potatoes seasoned with a little salt and pepper; brown or white rice

Sidewalk snack: French crêpes

Soup: lobster bisque with lemon grass and coconut milk at Top of the Hub in Boston

Really, really, really bad, eat-it-only-once-a-year-in-small-servings type of junk food: Barbecue-flavored Doritos (I think they stopped making these…thank goodness…)

Really, really, really bad, eat-it-only-once-a-year-in-small-servings type of sweet food: chocolate-frosted Krispy Kreme doughnuts; cupcakes

Vegetable: green bean, I guess

I do feel a little better. I think I'll go have a cupcake...

The "F" Word

Doctors won't talk about it. Patients don't want to know about it. Try doing an internet search on the topic and you come up dry.

It's a subject so taboo in medicine that there may be readers out there who'll want to question the validity or veracity of what I write here. It's the ultimate four-letter-word for physicians: FEAR.

A few days ago a premed student named Jack wrote this comment for me:

"During your work as an anesthesiologist, when was the time where you felt most afraid, if there has been one which sticks out? I ask because im soon to be entering medical school and I feel that fear is a topic which has not been touched on by those advising me."

I'm not surprised about that last part. No one talks about fear in medicine because no want wants to admit a) that it exists b) that it's NORMAL and c) that physicians experience it. People don't want their physicians to be normal, human. Humane, yes, but human - with normal aspects of humanity such as fallibility, frailty, fatigue, and, yes, fear? Not really. I've often felt we're expected to be as faultless as God but without god complexes. I agree with the latter: the best doctors I know have the wisdom and self-possession to have true humility. But strive though we might, how can any of us expect perfection of ourselves, or criticize others for failing to attain it?

True humility accepts imperfection, refrains from passing harsh judgment on it, and instead recognizes where successes come from, where the limits are within a given situation, and, without lapsing into contempt, where there might be room for improvement.

The question is, why this reluctance to admit to fallibility, to error, to fear? It's not simply because human lives are at stake, though naturally the high stakes create high standards. I think there is a deeper problem within medicine, and that is the pervasiveness of hubris and disdain in the culture of medicine, a culture which has deep roots in the DE-humanizing training process, the very system which forms physicians from their embryonic, idealistic beginnings into the clinicians that must go out and meet suffering face-to-face, touch the very margins of some very dramatic and important stories, and sometimes get pulled into the fray without warning. I've seen this culture destroy the very best in people, rip out their still-beating hearts - the ones that contain all their hope and compassion - chew them up, and spit out the bloody mess as if it were worthless trash. It's a culture where the highest compliment a doctor or doctor-in-training can be given is the phrase "Strong work." Strong. Not weak. Finding something difficult is weak. Having needs, physical or emotional, is weak. And being scared, even just a little, is very, very weak. Or so the unspoken message goes.

But the truth is, what we do can be scary. Really scary. I remember thinking on my very first day of anesthesia residency that any of the drugs I was drawing up into syringes that day and administering into people's IV's could KILL SOMEBODY. That is still true today - there is still the potential for any action I take to cause great harm instead of doing good - but at least today I have some training and experience under my belt to allow me to use these drugs as part of a design thought out carefully ahead of time or quickly adapted to a given situation.

The answer to the first part of Jack's question is that several moments stand out in my mind as ones during which I felt "most afraid." Even in the midst of a bustling room crowded with lots of people helping, it's easy to feel incredibly ALONE at the head of the bed, watching a blood pressure go from 80 to 70 to 60 to 50 even though you're pushing pressors and inotropes into the IV as fast as you can, then having to make split-second judgments and life-and-death decisions. There's nothing like watching someone's vital signs tank, circling an ever-widening imaginary drain, the cardiac rhythm waveform shifting and getting ominously squigglier before your eyes, as you ask out loud if the code cart is in the room.

Interestingly, during moments like these I don't find myself asking other fear-based questions like what will I tell the family, what will my colleagues think, what if I lose this person, what if nothing I try works. So far the fear has acted as a spur to action - let's try this; get help, get an arterial line in, try another approach, do, do, do. It's only later, when the crisis is over and there's time to think, that the emotional after-shocks come. The what-if questions. The I-should-have ruminations.

The scariest moments, though, aren't even ones like these in the operating room. For me, despite my background in pediatrics, nothing is scarier than a newborn needing to be resuscitated. (Well...maybe a pregnant woman with a difficult airway is scarier,or at least as scary...but that's about it.) I am very comfortable with children. I doctored children for a while before I started doctoring all ages. But when a voice on the overhead system at the hospital says, "Attention all personnel. Attention all personnel. Respiratory stat to labor and delivery," I still go into fight or flight mode. I run up to the floor to offer help. I know what I need to do. I have lots of help around me, and I know they know what to do too. But I see a lifeless-looking, tiny little infant as grey as ash, whose limbs flop back down to the bed when lifted and released, whose chest shows no sign of respiratory effort - all very, very abnormal signs - and my heart races. Still. Even though I've seen this before. Meanwhile the parents are behind us, mother perhaps still receiving sutures after the delivery, father nervous or in tears, and lots of people crowd a tiny little space where we're supposed to bring this baby out of trouble in its first few minutes of life on earth. We all do what needs to be done, outwardly composed, business-like in the urgency, but inwardly, speaking for myself at least, SCARED the whole time.

There are those who say admitting to fear weakens one's performance at these events. I say it's weak to deny a very normal emotional reaction, and perhaps even dangerous. I say we can control our responses to fear without having to suppress it, because it can be an ally, maintaining in us a healthy respect for the importance of the task at hand. I say the day my heart rate stops going up when an airway is difficult, when a patient is in septic shock on the table, or when a child's oxygen saturation drops like a stone, put me out to pasture, please. Because that's the day I've spiritually stopped doing my job as a physician.

***

Years ago when I was exploring my own moral formation I made a list for myself of qualities I see in spiritually highly evolved individuals and qualities I would expect to see in spiritually stagnant, unevolved, or stunted individuals. I came up with the first list by thinking of exemplary people, like my in-laws, and friends I admire, then flipped all the qualities around to come up with the second list. One list was essentially the mirror image of the other, and I found a lot of me fitting into the spiritually unevolved side, unfortunately. This is what I jotted down:

The Spiritually Evolved Person…
-Tends to be forgiving, see the best in others, and be accepting of what others can offer.

-Responds to people’s comments / needs / objections with the desire to be better and to serve

-Sees every person as one of great worth and believes all have equal rights

-Works hard
-Has a deep sense of gratitude

-Knows “it’s not about him/her”

-Knows happiness and misery are chosen

-Rolls with the punches – often with a sense of humor

-Takes nothing personally

-Is not reactive and is slow to anger if at all

-Does not pass judgment or need to blame

-Considers others' needs as valid and at least as important as his/her own

-Makes others feel welcome

-Forgives

The Spiritually Unevolved Person...

-Tends to be critical and to look for things to criticize, to feel irritation or anger at others' imperfections, and to look down on those who might have faults or failings to forgive

-Cannot bear to have his/her imperfections or mistakes pointed out or discussed and may in fact feel he/she is beyond reproach

-Feels superior

-Is lazy

-Has a deep sense of entitlement and/or complains a lot

-Feels everything is “about” him/her

-Feels that others / external circumstances make him/her miserable

-Whines, throws a tantrum, or acts like a martyr when things don’t go his/her way

-Takes everything personally

-Is reactive and is often easily angered

-Judges harshly & blames readily

-Thinks his/her own wants take priority over others’ needs and may be incapable of being considerate of others’ needs or see them as important; lords it over others

-Makes others feel alienated or rejected

-Punishes

If the culture of medicine could be personified, the resulting incarnation, I think, would have a lot of the characteristics on the second list - scorn, arrogance, judgmental attitudes, unsupportive perfectionism. By contrast, a lot of the people who pursue careers in medicine aspire to behaviors and ideals such as kindness, cooperativity, compassion, and forgiveness. I think if we could talk about fear and fallibility without being judged, criticized, or blamed, the world would truly be a better place - not only for doctors but also for patients. There are already efforts to bring discussions of medical errors in this direction...but change comes gradually and incrementally.

One individual who has begun to work for change in "the system" is an extraordinary physician who was involved in a devastating medical error but had the courage to face the experience, in all its loneliness and pain, and use it as a springboard from which to start transforming the way the world of medicine responds to adverse events. I admire this man's heroism. Please read his story here.

"I wanted you to see what real courage is...It's when you know you're licked before you begin but you begin anyway and you see it through no matter what." Harper Lee, To Kill a Mockingbird

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Addendum, June 12 2008:

Quietus Leo over at The Sandman has written an incredible post in response to this one with some insights of his own regarding physicians and their fears. I want to highlight an excerpt from his closing paragraph because it really hits the nail on the head:

"The only thing that disgusts me more than incompetence in a physician is vanity. Hubris is born of fear. Fear of exposure, fear of failure and fear of showing weakness. When you see a vain person, scratch the surface (one may need an ice pick) and you will discover a coward. Not a coward in the sense of external bravery, but one who won't face his/her own failings. Such a person has stopped growing, learning and improving."

Amen, amen, amen. May I never lose heart or the ability to see myself honestly and learn to become better.

Commotion of the Heart

What does an anesthesiologist baseball-mom think about at her son's first baseball game?

After the hit, after screaming "Go, go, go!" as his little legs carry him by to first base; or when he's waiting to run to the next base; or when the other team's up and he's the little angel in the outfield, waiting for a ball to come his way?

This anesthesiologist baseball-mom, despite the rare occurrence of such disasters, could not help thinking of commotio cordis. Don't get me wrong - I had a blast cheering my little guy on - but that lurking thought did creep around the back of my mind once or twice: what if he takes a ball to the chest at just the wrong moment?

I can usually maintain my composure during acute situations at work, but when it comes to my kids, I can be as much of a worry-wart as any other mom out there. I try not to be too irrational, of course. I try to keep passing thoughts of possible doom from taking away our enjoyment of life's normal little milestones and adventures. My daughter enjoys roller coasters? Have a good time, I tell her as she boards the scariest one in the park. My son enjoys rough-housing with the neighborhood guys (with my husband watching over them)? I cringe inwardly, but I smile and carry on. I even survived my daughter's first trip away from home without us, to go to an ecological campus on a school trip with the rest of her class. And I had a great time at today's baseball game, despite the ice-cold wind. But I'll admit it: the worry-thought crossed my mind. A couple of times.

Commotio cordis is rare - sudden death from cardiac arrest due to blunt force trauma to the chest. Most cases from the United States commotio cordis registry several years ago occurred in Little League baseball, softball, or lacrosse, though soccer, ice hockey, martial arts, polo, boxing, fencing, cricket, and rugby carry the risk as well. The scary part is that the impact doesn't have to be that forceful; it just has to happen at just the right millisecond during the cardiac cycle, "at an electrically vulnerable phase of ventricular excitability," to cause a fatal rhythm abnormality. Timing and rhythm - musicians take note! - are far more important than the strength of the blow. The mechanical properties of children's thoracic cages render them particularly vulnerable, but chest protectors are basically useless, as far as I understand, because the issue is in fact timing rather than force. Finally, there is a dismally low "rate of rescue" for commotio cordis.

I've heard the wisdom of the ages already, countless times: no amount of worry about something can prevent its occurrence, so we might as well let the worry go, appreciate each moment fully, and hope all will be well. I agree. That's all true. But I also think a parent's worry is a pretty natural, normal emotion, and instead of denying that it sometimes occurs, or criticizing those who express it, we should find ways to transform that commotion, that swirling of loving concern in the heart, into something fruitful - perhaps by rejoicing in each little victory, like crossing over home plate, or being fully present to the moment as we hug our little ones in our arms.

Music and Medicine Meet at...Forensic Art?!

Who's this?

Think sheep safely grazing. Sleepers awake. Mass in B minor. It's Bach!

This is totally old news, from last February, but I just found out about it and think it's totally cooooooool. Janice Aitken and Dr. Caroline Wilkinson of the Centre for Forensic and Medical Art at Scotland's Dundee University recreated the face of Bach using a bronze cast of his skull and historical documents describing features such as swollen eyelids from an eye condition. Dr. Wilkinson taught Joerg Hansen, director of the Bachhaus Eisenach, something that dispelled a common myth to which I've often subscribed: the furrow over the nose bridge, and facial furrows in general, have nothing to do with personality or character or temperament but rather are determined by skull anatomy. ""If you have that type of skull you have to furrow over the nose," Hansen explained. "But I also think he looks interesting."

Who hasn't daydreamed about traveling back in time? I think it's natural to be fascinated by the possibility of knowing what someone from the distant past looked like. In the 90's National Geographic put a reconstruction of King Tut's face on its magazine cover. Although it's true that skillfully painted portraits can be almost photographic, their accuracy depends on a contemporary witness, whereas a forensic artist can create an eerily compelling likeness across time by taking actual anatomic structures to recreate a face in three dimensions, layer by layer. It's simultaneously more distant and more intimate as a technique, requiring the artist to reach across sometimes vast chasms of time but also to touch a subject's innermost structures to and make visible "flesh" out of what has been ghostly memory of muscles and skin creases for centuries.

I couldn't resist including one more example here, though of course most people wouldn't consider it valid. An information systems consultant named Sebastian Ferreyra used the mysterious image on the Shroud of Turin, believed by some (but not by most) to be the burial cloth of Jesus Christ, to reconstruct a "face of Jesus." He hasn't finished the computer painting yet; it depicts Christ in death, resting in peace.

Whether it's a bust of Julius Caesar or a bronze mask of Agamemnon, artistic renderings of long-lost individuals captivate us, I think, because we enjoy imagining these almost mythic human beings as real people, flesh and blood just like our next door neighbor, our teacher, our political leaders, our friends, with the same vulnerability, potential for greatness, and mortality as any others. By imagining we can see them, almost touch them, they become less remote, their stories and deeds more accessible and, perhaps, even more thought-provoking and inspiring.