End of an Era

"My brother need not be idealized or enlarged in death beyond what he was in life, to be remembered as a good and decent man, who saw wrong and tried to right it, saw suffering and tried to heal it, saw war and tried to stop it.

Those of us who loved him and who take him to his rest today, pray that what he was to us and what he wished for others will some day come to pass for all the world."

-- Ted Kennedy's eulogy for Robert F. Kennedy, June 1968.

***

Please read this beautiful post about Ted Kennedy by Lisa Johnson, author of the blog Anali's First Amendment.

Nada Te Turbe

I've been thinking a lot lately about the what stresses me out most in life.  It's not the tough clinical scenarios, busy days, practical aspects of maintaining a household, or parenting responsibilities that get to me, I find.  It's the toxic nature of certain people.

I tend to get very strong "vibes" from, and have equally strong reactions to, other people.  I'm not claiming that the vibes I sense are always accurate - though my husband and I believe they are, actually - but only that they can create very strong feelings in me, and sometimes the intensity of these feelings causes me great stress.

Today I had the kind of day that might have been stressful for a number of reasons.  I had to come in extra early to relieve the night doc.  I was the physician in charge today and that, in and of itself, usually raises my blood pressure a few notches.  There's always a lot of busy work to do as the charge person, with constant interruptions by beeper tones, phone calls, surgeons with questions, nurses with questions, patients with questions.  Moreover, we had at least two clinically difficult patients in the rooms today, one of whom almost coded on me.  But I wasn't that stressed.  In fact, I was pretty calm and content.

And I knew why.  The absence of toxic coworkers made all the difference.  

There have been a few people in my work life, at other hospitals and at my current one, who are like poison to my day, for any number of different reasons - lack of integrity; pathetic or non-existent work ethic; arrogance; contentiousness; snide or critical speaking tones; biting hostility; back-stabbing tendencies; bullying; hypocrisy; narcissism; disrespect; a lazy or indifferent attitude to patient care.  When I sense "vibes" of this nature from other people, I tend to develop very strong feelings about their behavior patterns.  More than anything else, the effects of their actions on the quality of my day, and the feelings they inspire, are a noxious presence in my life - largely because I allow them to be.

I know, however, that I have some control over that.  That I can train myself to choose not to let my strong reactions to toxic people have such a hold on me.  I know I can be a little less perturbed by the scripts others are acting out and just focus on my own.  But like any spiritual habit, this effort to reclaim an inner peace, this way of living in the world with less reactivity and stress and greater mindfulness of what's truly at work, is going to take time and practice.

Pray more, said a voice in my head when I was meditating during Mass this weekend.  I guess that wouldn't be a bad way to start; after all, prayer - or meditation, or focused awareness, or connection to the sacred, or whatever label suits your understanding - does have the power to transform us, whether or not anyone seems to be listening.  I've been too content with the idea of my entire life being a kind of prayer; I haven't been proactive enough, like an athlete training to keep her body in shape.  It's time to stop neglecting that dimension of my life and start practicing a little better.

Guest Post: Notes on Copland's Fanfare for the Common Man

It is my great honor and pleasure to commemorate this Philippine holiday, the 26th anniversary of Ninoy Aquino's assassination, with this reflection by my talented friend Jeffrey E. Salzberg (used by permission; photos added by me):

I had an epiphany some time ago. I listened to Aaron Copland's Fanfare for the Common Man.

I'd heard it before, of course - it's long been one of my favorite pieces of American music, actually - but this time I really listened to it. And, for the first time, I understood it.

It helps to know the background. In 1942, the Cincinnati Orchestra invited 18 composers to submit new pieces expressing their feelings about America. At the time, Nazi Germany had conquered most of Europe. Much of Asia was under the control of Imperial Japan. Mussolini was carving out his own empire in Africa and southern Europe. Freedom and democracy, it's not an overstatement to say, seemed doomed.

Aaron Copland entered the competition.

Tympani - the cannons of war.

...And silence...Evil appears triumphant and unstoppable.

...But a single horn enters, playing the theme...a single man, who realizes that Evil must be opposed, even though opposition will surely cost him his life.

More cannons.

A second person, seeing the first, stands with him. It's still hopeless - what can two people do against such an overwhelming enemy? - but Evil must be opposed; it cannot be allowed to stand.

...But a third person stands...and a fourth...and a fifth. The tide begins to turn.

...And now there's a mighty army, invincible. Evil is vanquished.

...Because one person had the courage to stand against it.

-Jeffrey E. Salzberg, February 6, 2009

***

For more about Ninoy, please see my post about him from last January here, a Wikipedia article here, or an online tribute for him here.

Patient: "One Who Suffers"

[Picture source.]

We all have patients sometimes with whom we absolutely dread interacting.  

We had one such patient recently - a sullen, angry, hate-filled man who acknowledged others only rarely and, if he did deign to respond to inquiries at all, did so with unabashed hostility.

Imagine my delight when I was informed that five or six people had attempted to get an I.V. into this gentleman without success while I was in the operating room taking care of another patient. By the time I came out no one wanted to go near the man, or speak to him, much less try again.

When I approached the patient and introduced myself he didn't look at me or reply.  He ignored every question I asked.  When the first I.V. cannula I inserted entered the vein but then refused to advance further, he swore and threatened to leave.  I couldn't blame him; he had been made into a pincushion by several others, after all, and now by me too.  I finally managed to get the I.V. on the third attempt and was able to bring him to the operating room.

All the while despite his unpleasant manner and occasional sniping comments I made a special effort to speak with calm and respect, to touch gently, to be attentive to his comfort.  It wasn't so easy.  Gradually his manner softened a little.  As I was applying the last of my monitors I told him I would be giving him the anesthetic soon.

"Can you..." he began.

"Can I what?" I replied, trying to encourage him to ask what was on his mind.

"You could make it so I don't wake up, couldn't you?"

"I could, but my job's to make sure you do wake up."

"No, please, I don't want to."

All of a sudden he sounded scared, and very, very sad.  Not at all the hard, furious man from the preop area.

"Please don't wake me up. Just let me die."

"I can't do that."

"No one would ever have to know.  Please just kill me.  Please.  I know you can."

"But I can't.  It's not up to me," I said.

"But I don't want to wake up.  Please."

All the layers of anger and hate he had put on over his hurt and fear had lifted like veils.  When I saw his face, his true face, all I could see was suffering profound enough to make his life unbearable to him, and my own negative feelings melted away. I felt unkind for having resented his earlier demeanor so, and clueless for not having remembered that hostility almost always conceals some kind of fear or pain.

"All I can do is give you a brief rest," I said.  "That I can give you."

The disappointment in his sigh cut deeply.

We still have so much to learn from you, I thought as the anesthetic took hold.  So much to learn.

Sometimes the ones we think we don't want to take care of are the ones who teach and take care of us.

Bracing Ourselves

This is one of my favorite pictures of my daughter.

The first thing I noticed when the orthodontist e-mailed it to me, of course, was the beautifully patent airway, a dark passageway beside the column of stacked cervical vertebrae.  

After that I couldn't help admiring the specter of her facial features over her bone structure, so lovely and young yet also with the timeless look of a wise old soul, a spirit that has known lifetimes of joy and sorrow, or one that is innocent of it all - a pure heart.  She is Nefertiti looking out across the Nile toward Amarna, she is the Little Match Girl of Andersen's tale, she is Mary with her secret garden, she's the Princess of Genovia.  She's all these and none of these.  She's the girl we love most in all the world.

She has a will of iron and a heart of gold.  She is bubbly and carefree, yet capable of a depth of feeling that might seem well beyond her years.  She's a "Tween" through and through:  on the phone rhapsodizing about Twilight's Edward one moment, hugging her teddy the next; pushing our rules to the limit, and sometimes overstepping them; developing political opinions and a social conscience; sweet and loving with us, certainly, but also possessed of a tone and attitude that sometimes send her stomping up the stairs and us throwing up our hands wondering how to get our messages through.

She got braces this past week - a reminder that time just keeps flowing onward, and we have to try and keep up.  Every adolescent needs braces of some kind.  Little guiding supports, pushes and tugs to maneuver things into place and get them in the best possible alignment.  We're just trying to figure out how to apply ours without too much hurt and discomfort, and with some hope of compliance.  

Already I've messed up.  Pushed a little too hard, shown sometimes more anger than understanding, perhaps expected too much.  

I wonder if she'll look back and resent this period of tested limits and battling wills, or whether like a patient I had today she'll look back on her parents' "strictness" with an understanding that it sprang from a deep caring about her choices and her well-being, her health and her character.  I hope she does see someday that the "tough love" that sometimes drives her up the wall is the same love that lights up my face whenever I see her, that makes me hug her extra hard for no reason at all, and that keeps her always in my mind and heart even when I'm faraway.

If I Weren't An Anesthesiologist, I'd Want to Be...

...someone like Tim Hammack.

When I heard about the work of Chef Tim Hammack on NPR's Morning Edition this morning, I was filled with such admiration that I was talking out loud into an empty car at 6 o'clock in the morning. (Click here to read about him in the New York Times and here to see a feature about him in The California Report.)

Chef Hammack left his post at Bouchon in the Napa Valley to be executive chef at the Bay Area Rescue Mission because he wanted to put his creativity, passion for food, and talent for preparing it to the service of those without means as well as those with.  

Can I just say, MY HERO?!

I must admit there's a fine line between admiration and good-natured career envy.  This is a man who gets to work with food all day, transform the ordinary into the extraordinary, and serve others, not only by providing nourishment and comfort but also by providing some useful skills to those who want to learn them and need a little boost in the right direction.  What GREAT WORK!

You can just hear the deep satisfaction and love-of-the-work in his voice as he describes one meal at the Rescue Mission, which serves meals to 1200 people a day:

"Yesterday for lunch we made a creamed vegetable soup, garnished it with fried carrot shreds, and we made a home-made crême fraiche, croutons, and some shredded bacon on top - you know, something that I would serve in a restaurant...Their eyes open up and they say, 'Wow, this is really something special!' "

It really is.  Bravo, Chef Hammack.  You're an inspiration!

End-of-Life Preparation Is a Responsibility, NOT a "Death Panel"

"Anesthesia, STAT to Unit Five.  Anesthesia to Unit Five, STAT."

I bolted up the stairs and then down a long corridor.   The room I needed to find was of course the very last one.  Just outside the doorway a woman with greying hair stood weeping, and beside her a younger woman was wringing her hands.  Beyond them I saw a male patient lying on the bed.  A man in a white coat was performing chest compressions.  Another man in a white coat stood at the foot of the bed managing the code.  There were a respiratory therapist and two nurses assisting, one to record data, another to fetch and push drugs.

The man at the foot of the bed turned and saw me.  "Good, the anesthesiologist is here."

He turned to the two frightened, distraught women in the doorway.  

"If we're going to continue with the resuscitation, we need to get a breathing tube in.  May we proceed?"

The bewildered women turned to each other.  "What?  Um, I don't know.  I don't think he wanted that," said one of them.

"Yes he did - he said we should do everything," said the other.

"But he told me he didn't want to linger on machines..."

Meanwhile, the doctor and nurses in the room were trying to get our attention.  "We need to intubate him now." 

The first doctor turned to the women once again.  

"I don't know, I don't know!"  they said, with panic in their eyes and voices.  

I started preparing equipment and drugs, but eventually, the family decided against continuing the resuscitation.  They sent me away.  The other doctors and nurses stopped what they were doing.  The patient died.

***

It's because of situations like this that I cannot believe, absolutely cannot BELIEVE, that anyone, solely for political scare-mongering, should be so misleading and ludicrous as to attack the idea of end-of-life counseling - especially considering the fact that the proposed counseling is VOLUNTARY.  

Frankly, as a physician I actually think it SHOULD be mandatory rather than voluntary.  Too few families are prepared for their loved ones' impending deaths - the decisions that have to be made, the ability to respect their loved ones wishes.  How can families make sound decisions if they are completely uninformed of the choices they have?  

The House bill requires "an explanation by the practitioner of the continuum of end-of-life services and supports available."  It is insulting to the public's intelligence to try to propagate the idea that the government is trying to end people's lives sooner simply by proposing the means by which to educate the public about their options and to encourage dialogue both among family members and between health care providers and families.  How can doctors and nurses provide the care and service patients want if patients haven't reflected on their own wishes and made them known?  

I mean, are people like Palin, Grassley, and Isakson really that obtuse, or are they just faking it, twisting the truth or downright making stuff up, for ideologic reasons?

Health care is ALREADY rationed.  It's called being DENIED health insurance claims for things like cancer surgery, denied coverage because of a "preexisting condition," and the like.  While we might complain about the details and be concerned about the funding, we really shouldn't be complaining about the idea of making health care more AVAILABLE.

The woman who is worried that people over the age of 65 are going to be "told to decide how they wish to die," and others like her, should realize that that's EXACTLY what they should be thinking about and working on, for their own sake and the sake of the loved ones and caregivers who will be part of that final journey.  Artificial feeding or not?  Breathing machines or not?  Comfort measures only, or full invasive resuscitation, including cracked chest and internal cardiac massage?  People SHOULD decide as best they can how they wish to die.  They should then make their wishes known as clearly as they can, both to their families and to their physicians.  Then their FAMILES in concert with their PHYSICIANS, NOT their insurance companies, should come to some final decisions together. Maybe then they can actually have a chance at exiting this life with the peace and dignity that each person hopes for and deserves.