Recipe for Humble Pie

"To eat humble pie" (from Wikipedia):

"The expression derives from umble pie, which was a pie filled with liver, heart, and other offal, especially of cow but often deer or boar. Umble evolved from numble (after the French nomble) meaning 'deer's innards.' Umbles were considered inferior food; in medieval times the pie was often served to lower-class people...While 'umble' is now gone from the language, the phrase ['humble pie'] remains, carrying the fossilized word as an idiom."

Ingredients:

1. BRAIN - an incident involving a public display of one's knowledge, skill, and/or talent (optional)

2. HEART/GUTS - a subsequent challenging situation requiring a public display of one's knowledge, skill, and/or talent

3. OTHER OFFAL - an inability to use one's knowledge, skill, and/or talent effectively in the aforesaid challenging situation

4. LILY-LIVER - the arrival of another individual with comparable or superior knowledge, skill, and/or talent

5. GREEN EYES - successful application of that individual's gifts to the challenging situation, effecting the desired relief of suffering / completion of a procedure / facilitation of a needed protocol

Directions:

-Take brain, heart, and guts and stir together.

-After several minutes, toss in other offal. Mix well.

-When other ingredients translucent, grind up pieces of lily-liver and fold into mixture. Top with green eyes.

-Wrap in pre-made crust of past experiences and messages about self, perceived from others and cured in one's own mullings.

-Bake at low heat for several hours to days.

-For an unhealthy meal, eat entire pie at once. May cause lacrimation, nausea, or chest tightness.

Or, discard ingredients and start from scratch with fresh brain, heart, regenerated liver, clear eyes, and other vigorous, healthy internal organs.

***

It took some time and hard work for me to learn to do what I do. So when I can do a good job putting my training to the service of those who need help, I am happy.

When I sometimes need help with that job, I am unhappy.

Not long ago a woman I was working with was having trouble with an airway. She has been doing the work we do for as long as I've been alive. She is experienced and well-trained. But she couldn't get a good view of the vocal cords, couldn't intubate a patient, and asked me to take a look.

The tension of such a situation is heightened, of course, by two things: airway equals lifeline, so if we mess up there, someone's life is at stake; and, this type of procedure feels very public, with everyone else in the room staring at you as you try to succeed at something challenging, and all action halted because continuation depends on you completing this step.

The view was indeed difficult, but I managed to slide a breathing tube in on the first try, using some adjusted manuevers I had picked up during residency.

The woman I helped thanked me. We were both relieved. Did I think any less of her knowledge and skill because of the help I gave? Of course not. Our roles could easily, EASILY have been reversed. These things happen to EVERYBODY, regardless of training level, skill, and experience.

So why, when my colleague M. had to rescue a spinal I just could not for the life of me get in, did I feel so very, very bad?

I had trouble locating the patient's anatomical landmarks, which were obscured and a little distorted due to steatopygia and other physical features. I tried for several minutes at different locations and felt like I was hitting bone everywhere. There were two surgeons and two or three nurses in the room watching and waiting as I inserted the needle into the patient and kept failing. I called a colleague into the room to help me out.

M. arrived. M. is the best anesthesiologist in my group. He is young and smart , wonderful with his patients, and he never misses a procedure. He is leaving our group to practice in a hospital closer to where he lives, and the entire hospital is abuzz over his departure, saddened to lose such a great talent. He inserted the spinal needle into a different spot. He hit resistance and withdrew it again, saying it felt like bone. He reinserted the needle, pulled out the stylet, and out came a beautiful, clear, slow stream of cerebrospinal fluid. Bingo. He was in. He injected the spinal medication, and we were ready to go.

He graciously tried to console me by saying the ligament felt like bone the whole time, and maybe I withdrew when I was actually in the right place.

It didn't matter. I felt like a mediocre schmuck. I had a feeling he would get it in about two seconds, and he basically did. I was glad for the patient, of course, because even though we had numbed the area with local anesthetic for comfort, it's still a drag to have to sit there while someone pokes you with needles, no matter how fine. But the humble pie was churning around in my stomach.

Is there such a thing as a job where you don't have to be 100% good at something 100% of the time and be 100% responsible for people in a workplace that's open 100% of the day and 100% of the year?

I've felt a lot of things about work. Satisfied. Tired. Occasionally proud. Sometimes frustrated. But complacent? Not a chance.

Paul Levy, How Could You Do This To Me?! :)

Paul Levy, I'm gonna have ta kill ya! (She writes, entirely facetiously, of course.)

I went to Russo and Sons in Watertown today, or Russo's ("the food lover's food store"), as it's more commonly known - only the best food market EVER - because of you, and there I tasted gelato master Eduardo Kreindel's pistachio gelato (and of course bought a basketful of other goodies), and now I'm an ADDICT! A bona fide, pistachio gelato ADDICT!

And Russo's won't get another batch in till Monday! Am I on call?! Paul! What have you done to me?! :)

(The interior of Russo's in Watertown, where you can get fresh produce, artisan cheeses, delectable pastries, delicious deli meals...and the best gelato this side of the Atlantic, all for about a third of what you'd pay at the other fresh food market. It's a food-lover's wonderland. So, not surprising to those who know me, I had the cheery holiday song "Winter Wonderland" stuck in my head (a little wishful thinking, perhaps, in this weather) as I wandered down the aisles following my nose toward the freshly baked amaretti cookies, with a linger at the salad bar to sample some sun-dried tomato vinaigrette over fresh greens and vegetables...)

***

Gelato has a special place in my heart.

I fell in love for the first time over gelato. In a corner gelateria in Florence at the northern end of the Ponte Vecchio (Duomo/Signoria side). Ah, the folly of youth...

But that was then. Here and now, I have a highly pertinent quote regarding pistachio gelato, from an NPR food article (emphasis mine):

"Pistachio gelato is the benchmark by which many gelaterie are judged. You can tell at a glance if an artificial base has been used, just by the color. If the gelato maker is using real pistachio nuts, the color will be an almost drab green. If the bin flashes a neon green, keep walking!"

Needless to say, Eduardo's (which goes by the name Giovanna Gelato) was a very pale shade of pistachio green, and tasted all-natural, without that over-bearing almond-extract taste with which so many ordinary ice cream manufacturers overwhelm their pistachio ice cream. Nutty and delicious!

***

For all gelato lovers out there and for those in the Boston area who can't get to Russo's and are withering in the current heat wave, here's the recipe NPR quotes from Gelato! by Pamela Sheldon-Johns, Ten Speed Press, 2008 (other recipes here and here):

1 cup (6 ounces) shelled pistachios, lightly toasted (about 12 ounces in the shell)

3 cups whole milk

3/4 cup sugar

In a food processor or coffee grinder, coarsely chop the pistachios, reserving a few whole ones for garnish. In a medium saucepan, combine the milk and sugar. Cook over medium heat, stirring until the sugar is dissolved, and bubbles form around the edges of the pan. Remove from heat, add the pistachios, cool, cover, and refrigerate overnight.Strain the milk mixture through a fine-meshed sieve, pressing on the nuts with the back of a large spoon to get as much liquid from the nuts as possible. Transfer to an ice cream maker and freeze according to the manufacturer's instructions.

Stay cool!

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Addendum for locals: tonight we went to Rancatore's and tried their ginger snap & molasses ice cream. SOOOOOOOOOOOO good! A pleasing medley not only of flavors but also of contrasting textures, creamy with softly-gritty. YUM!

Oboe Debut!

Remember when I was debating whether or not to play publicly with my chamber group of beginner musicians?

Well, I missed that first opportunity because of my call schedule, but tonight's the night. Tonight we've invited family and close friends to hear us play

Symphony #18 in F major K. 130, First Movement, by Mozart;
Aase's Death and Anitra's Dance by Grieg; and the

Agrippina Overture by Handel

Our little chamber orchestra has stopped calling our more "public" playing events "concerts." We now call them "open rehearsals," because we are soooooo un-rehearsed, and such relative beginners at our instruments, that it's not unusual for us to have to stop in the middle of a piece and start over from a particular measure.

By musician standards, we are pretty darn bad. But we are all having a BLAST - so, so what if we're the WWO, the World's Worst Orchestra? At least we're participating, learning, and having a wonderful time together! :)

***

(Photo credit: "Cocktail by Candlelight" by Mike Gifford)

Well, I did it! I played the oboe in a group in front of other people, and I'm still alive!

Usually on performance days I have the show on my mind all day, not in the foreground but rather as a backdrop to my thoughts and activities as I go about doing ordinary things like fixing lunch and running errands. And usually I am nervous...just nervous enough to be a little uncomfortable all day long. But today I felt pretty much fine until right before the appointed time. In fact, I was excited, and I had the music playing in my head off and on in little snatches. Once I got to the auditorium and started warming up with the others, and playing around on Perelandra (my oboe), even the nerves calmed down some. My cheering section consisted of my husband, children, father-in-law, and oboe teacher, who also instructs the group's principal oboist (he has visited here as fellowkyokostudent - and he played wonderfully tonight).

How do "real" musicians, dancers, and actors feel on the morning or afternoon before they have to go on stage? Does it become routine, just another day on the job, or is there always a little undercurrent of excitement there? Does everyone have special rituals or superstitions - a "lucky" or "unlucky" article of clothing, a way of packing up an instrument? There's a doctor at St. Boonie's who refuses to go into O.R. #9 because he feels it's "The Room of Doom..."

I have to thank Anali for posting a recipe for "Obama Celebration Cake." I made it today for the after-party, substituting zucchini for the bananas and Grand Marnier liqueur for the Southern comfort. It came out super-moist and made for a festive end to a happy evening. Next time I think I'll add even more chocolate...

Tales from Saint Boonie's: Bubba

Meet Bubba.

Bubba is one of my favorite surgeons. Though most other people at St. Boonie's are fictitious recreations, composites, or total fabrications, Bubba is real. "Larger than life," as he himself says. Yes, he gave me permission to post this. And yes, we do call him Bubba to his face.

Who else will look squarely at a necrotic gallbladder on a laparoscopy monitor and start doing the Darth-Vader-breathing noise behind his surgical mask, humming the Star Wars evil theme once in a while?

Who else will call the front desk after he has dictated his op note to make sure the secretary calls the village bakery to ask until what time the anesthesiologist can pick up the First Communion cake she ordered?

Who else will good-naturedly try to push all your buttons to see if he can get you to cuss intraop about the stuff that annoys you, or tell curdmudgeonly stories about his weekends, or abandon his solitaire game between cases to commiserate (snickering) with an anesthesiologist over an incident report written by another surgeon?

One day I offered Bubba a taste of some yummy spicy hummus I had bought. He declined politely. I toasted some slices of multigrain bread and spread the hummus on them for my lunch, and of course just as I was about to take a bite, my beeper went off. I set my bread and hummus down with a sigh.

"I'll be right back," I said to Bubba, who was sitting at the computer checking his e-mail while the nurses were setting up an O.R. for his next case.

I was the anesthesiologist in charge that day. I went to trouble-shoot something in the recovery room.

When I got back to the office area behind the main O.R. desk I looked down at my stack of bread slices topped with spicy hummus. My lunch, which I had so lovingly prepared for my own consumption. Half of it was gone.

"You're right," Bubba said, swallowing something. "That is good hummus." Then he shut down his computer and entered the O.R. for his next case.

We love Bubba. And he's a good surgeon, to boot.

The Eloquent Brain

I've heard people on the radio expressing amazement and, in some cases, a sense of "creepiness" over discussions of Ted Kennedy's awake craniotomy.

I've provided anesthesia for a few brain surgeries during parts of which the patients were supposed to be awake for assessment of neurologic function. It's not so bad. The brain itself is pain-free. It's the stuff covering it that contains pain-sensitive nerves.

We make sure patients are unaware and pain-free during the parts that actually hurt. The pinning of the head frame to the patient's head. The skin incision. The bone-cutting.

Then we wake them up by shutting off whatever drug infusion we've been using to keep them sedated. The surgeon maps out the regions comprising the "eloquent" brain - the parts of the brain that allow an individual to interact with and process the world, via senses, motion, language, memory, and purposeful use of tools. The mapping is often done with small electrodes that stimulate certain areas of the brain and evoke particular responses. Once the surgeon has a good "map" of the eloquent cortex, tumor tissue can be removed with reasonable hope of safety.

Most patients tolerate this surgery quite well. When the surgeon has completed as much tumor resection as possible, patients are usually re-sedated for surgical closure of tissue layers.

There's a neat video of excerpts of an awake crani here. At some points the screen went green for me and the image turned upside-down, but for the most part it's cool to watch. In these other videos (a little more graphic than the first - viewer discretion advised), a British surgeon brings skills, teaching, and discarded equipment to the Ukraine to perform awake craniotomies there (hat tip to SterileEye for the link). The accompanying article decries the wastefulness of medical practice in the U.K. (though I think no country is more wasteful than the U.S.) and describes how the surgeon "is struck by the wastefulness of the NHS: a drill bit he delivered to Igor has been used for ten years. In the NHS it was thrown away after a single use...The lack of equipment in Ukraine has forced the surgeons to improvise when it comes to some of the most basic surgical tools."

I like how the patient in the video at the very top of the British article, with his head secured in a head frame and a surgeon operating on his brain, wryly smiles at the camera and says, "I'll try to stay out of the doctor's way." His eloquent brain, along with its sense of humor, was doing just fine.

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Addendum 6/3/08: Katy at Funny Girl just posted what has to be my favorite neurosurgery post ever! Check it out! :)

Do You See What I See?

Today I went to a lovely baby shower during which we guests got to play some cute, enjoyable games, including "The Clothespin Game" and a scratch-and-sniff one called "Who Smells the Stinky Doo?" My favorite game (of course) was one called "Itty Bitty Baby Parts" (photo credit: http://www.babyshowerstuff.com/), which involved matching each of twelve numbered ultrasound images to an item on a list of anatomical parts we got at the beginning of the game. I didn't think I had an unfair advantage, because I skipped the radiology elective my senior year in medical school, and ultrasounds always look like unintelligible, fuzzy, gray stuff to me, but I ended up winning with a score of 10 correct out of 12 (uh...I kinda got the belly button mixed up with something else...)!

In medical school there was at least one anatomy exam during which we had to file silently past tagged body parts and answer questions about the part in question. Sometimes the task was simply to identify it (Wait - what is that arrow pointing to? Just looks like a wad of tissue to me...); other times we had to describe something more detailed, like the path it took from point A to point B in the body, or its physiologic role, or some key molecular mechanism involved in its function or in diseases that marred its function.

Radiology we learned during clinical rotations if we didn't take the formal class. It's amazing to me how much we can infer about people just from the ghostly markings of a chest x-ray - their disease process, their body type, sometimes particular stories about their lives. And yes, there are some astonishing x-rays - foreign objects in places you wouldn't expect them to be...

I like tasks that require me to look at something carefully and perhaps differently from the way I ordinarily see things. For this reason I enjoy "spot the object" illusions, and I've learned a little something about the way I see things. With the ones that require noticing a "big picture" or wide-angle image (take a look at the can-you-see-the-baby image on Dr. Deb's blog), I often find myself saying, "Oh, that's EASY, surely people can see THAT!" But when required to find a smaller object embedded or hidden in a larger picture (see the coffee bean one), I scour and scour and scour and mutter to myself, "Where IS that thing?"

I really liked this mother-and-child-praying one from a gallery of spot-the-object illusions at moilllusions.com:

But one of my favorite images is not so much an illusion as a startling fusion - "Fluffy Infiltrates" by Day, a Health Volunteers Overseas photo contest winner :

Whether it's a great photograph, an ultrasound, an x-ray, a painting, or a scene in daily life, something that makes us take a moment to look and see in a way that creates new understanding is not only valuable but also in many cases a source of intellectual pleasure. Something about moments of recognition must trigger satisfaction neurotransmitters in our brains. There's nothing like a great "Aha!" moment (especially in the middle of an exam!). Perhaps that pleasure in making sense of something, of things clicking into place, of solving a mystery or deepening comprehension, is more primal than we realize, with roots in our ancient histories. In people looking at the sky and making sense of the stars. In babies, brand new to the world, recognizing their parents' faces at last.

What is Music?

If you care about music...

If you care about composing and creativity...

If you care about people having access to music and to participation in music, regardless of background, "ability," "disability," etc....

If you know someone with cerebral palsy, or have it, or know someone who has a condition usually perceived as a severe limitation, or have one yourself...

THEN PLEASE WATCH THIS VIDEO CLIP. (You can also click on the screen below.)

It's twenty minutes of the most mind-blowing footage of the combined scientific and artistic work of Tod Machover, who also happens to be a friend.

PLEASE DO NOT MISS THE SECOND HALF (minute 11 onwards).