How Many Buttons Can They Push...? (And, a meme to get my mind off them)

Let's see if the on-call gods can push every possible button until I die of exasperation.

Button #1: Beeper goes off as I'm driving to work.

I'm coming, y'all, what could possibly be the problem this early in the day?

I make the call-back. The nurse says, "It's about the first patient..."

Button #2: NPO violation

"...He drank coffee with cream and orange juice with pulp and came in chewing gum. What do you want to do?"

I want to turn the car around, crawl back into bed with my loving spouse, and sleep and sleep until my call weekend is over.

"Bump him to the end of the line, please. Next?"

Button #3: Having to explain a clinical decision to uphold safety guidelines to a patient who has violated them.

"That counts?!" He says when I explain. Yup, it counts. That's why they tell you when you're the first patient of the day, please, sir, taking NOTHING. BY. MOUTH. before your surgery.

"But why?" he asks, as if I were an irrational despot about to exile him from fair Verona. So I go into my spiel about the risk of aspiration, increased gastric acidity and fluid volume, etc., etc. and how it's my job to protect his safety during the procedure, etc., etc., etc.

Button #4: Ignorant tactlessness.

The wife or girlfriend pipes up, "Is this the doctor who's going to be working on you?"

And the patient says, "Oh, no - this is just the anesthesiologist..."

That could be interpreted innocently. But he doesn't stop there. He explains. "...All she does is knock me out."

A plague on both your houses. Why don't you just call me "Missy," too, while you're at it?

Button #5: Poor listening and inconsistent discipline among folks who are supposed to be part of your medical team. Don't get me wrong, I appreciate a relaxed atmostphere and overall friendliness in the workplace, but that doesn't mean the O.R. can turn into a social gathering.

Button #6: Add-ons. Endless add-ons. Add-ons after the add-ons. Add-ons at other hospitals, even, that I can't possibly make because I'm stuck at THIS one.

Button #7: The "too tired" state. Finally home after yet another 13-hour day but too tired to enjoy the company of my loving family and dreading the infernal beeper going off again. Exhausted but in that awful "too tired to sleep" state, when your body feels like a truck ran over it but your mind is racing with all the buttons that got pushed today. At least there weren't any mendacious drug-seekers or bellicose aggressors (like a patient from this past week who practically assaulted one of my colleagues because, surprise surprise, she had made a clinical decision to keep him in the hospital based on our profession's safety guidelines...)

***

Here's what I'm gonna do to try to unwind and relax a little bit. I'm gonna play. I think adults should make play a priority. My game tonight will be a meme Patty from Oboeinsight has tagged me with: to share six personal things that readers might not necessarily know about me.

Hmm...Let's see...

-I played Little Miss Muffet in a school pageant in kindergarten.

-Like Kathleen (see #76 on her list of 100 things), I secretly love Martha Stewart's skills and ideas but you'd NEVER believe it looking at my house...

-It bothers me when the roll of toilet paper is hung so the end of it comes out from UNDER the roll instead of over the top of the roll. Apparently this is a pet peeve I share with Lea Salonga.

-As a child when I really liked a movie I'd watch the video over and over and over and over again. One movie that got this kind of wear (so to speak) was The Red Shoes. I am STILL addicted to movie quoting and probably have a random movie quote for almost anything...

Hmm...TWO more? Thinking...thinking...

-I don't like to call up restaurants and place take-out orders. I have a mental block about making phone calls like that. I don't know why.

-Through Anali's blog I got inspired by this question from writer/blogger/photographer Karen Walrond: "What are some of the things you own that you think are pretty iconic representations of who you are?" I'd have to say, probably my Christmas music collection, my books, and a home-made candle my friend Sheila gave me that's decorated with a cross and an unfolded manuscript.

I don't know if I can tag six more people (Ramona? Oystein? Wanna play? Katy came up with TEN things - how'd you do that?!). I'll just send it out to anyone who might be reading this; consider yourselves all "tagged!"

And if any one has an "EASY BUTTON" out there for me, I'll take that over these other ones! :)

Morale Issues

What happens when our energies flag?

We've all had those days - those moments when, despite having chosen our work out of genuine dedication, we think to ourselves, "What am I DOING here? Should I be doing this any more?"

The other day I walked into an O.R. to borrow a piece of equipment and came upon one of my colleagues being playful with her five-year-old patient. Later in the recovery room I saw her little patient snoozing, calm, comfortable, safely swaddled in some warm blankets. When I saw my colleague in the conference room, I said in passing, "Hey, nice job with that pediatric case."

"Thanks," she said with about as much enthusiasm as I've been responding to compliments about my work lately. There was something in her voice that made me wonder if she was having a "blue period" of her own - a lot of us seemed to be.

"Does it give you satisfaction? I mean, getting patients safely through surgery, so they're comfortable afterward, and relatively happy?" I asked.

Our eyes met and we both smiled knowing what her answer would be.

"No," we both said at the same time, with a chuckle of resignation.

"But it should, shouldn't it?" I continued. "Logically speaking. We should get a lot of satisfaction from successfully keeping people safe, easing their pain and anxiety, and doing right by them. Right?"

"Yeah..."

"So how come we're feeling like this?"

Truth be told, my "blue period" has persisted. And I think it's because there's been a lot of non-clinical as well as clinical stress at work lately. A LOT. Morale has been abysmal, so even the things that should brighten our day, or remind us of why we love our work, don't any more.

The training program I came from would sneer at the prioritization of morale as an influential component to productivity and work satisfaction. I felt while I was there that the only important thing was for the work - and there was plenty of it - to get done, and done fast. How we felt was irrelevant. We just had to get the work done.

I think this kind of atmosphere can be very damaging over time. I have no doubt they would see my "take" on that as way too soft. But I think I'm right.

I try to believe in the transcendent as well as the practical value of my work. That is, for me the practice of medicine, though grueling and at times discouraging, is intrinsically beautiful and meaningful because I see it as more than just helping patients get through some difficult physiologic and emotional events. I see the connections formed during those events, temporary though they may be, as spiritually significant - ways of extending invisible grace into the world through tangible means.

So although workplace morale has taken a dive lately and we haven't been able to feel much satisfaction from even the good work we do day to day, I try to tell myself to look beyond all that, rise above the pessimism and discouragement, and try to live in hope. Not frivolous, superficial hope, like, "I hope the situation gets better," but rather the deeper hope of people of faith that says, Know that even in the desert you are not alone, and even in darkness there is good, there is always good.

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Photo: U.S. Army Capt. Cristal Horsch uses a stethoscope to listen as she examines an Afghan child during a Cooperative Medical Assistance mission in the Kunar Province of Afghanistan on Aug. 18, 2004. Task Force 325, Task Force Victory and the Asadabad Provincial Reconstruction Team provided people and animals with medical care. DoD photo by Staff Sgt. Vernell Hall, U.S. Army.

One of the Ones That Stay With You

"You're thinking of putting an epidural in a quadriplegic? Whatever for? It's not like he'll feel any pain."

I looked up from the chart in front of me. I had forgotten that the idea might be foreign to a non-anesthesiologist.

"Oh, it's not because of pain," I explained. "It's because I don't want him to have autonomic dysreflexia."

"Never heard of it," the preop nurse replied. "Will you explain it to me?"

At the time of this conversaton I'm scheduled to provide anesthesia for a man only slightly younger than I who broke his neck in an accident years ago.

For a patient with a spinal cord injury, I prepare for the worst. There are all sorts of challenges - maintaining a good airway and adequate oxygenation and ventilation; moving and positioning; and last but not least, the dreaded phenomenon of autonomic dysreflexia, in which surgical stimulation can produce out-of-control blood pressures and cardiac disturbances that can be life-threatening.

Options for prevention include trying to place an epidural or having the patient be under really, really deep - deeper-than-usual - anesthesia. I opt for the latter in the end, when the day of surgery actually arrives and I've had a chance to talk to surgeon, patient, and family. Though I am a little tense during the procedure, anticipating with each blood-pressure reading that it will be sky-high and I'll have to administer a blood-vessel-dilating drug from my pre-prepared arsenal of syringes and drips, everything goes just fine.

Such a patient can be medically challenging; but there are emotional challenges too, especially when the patient is so young. I think of all the experiences he has lost, that he must long for. I think of how unfair it must seem to see me walking toward him on my imperfect yet fully functional legs, breathing on my own, able to write in the chart, hold a phone receiver, hug my family. When I touch him to connect physically while speaking to him from the top of the bed as I wheel it into the O.R., I touch his head rather than his shoulder, because I know he can't feel my reassurance otherwise...and then I wonder if touch is reassuring or not for him. He doesn't seem to mind.

He is a pleasant-looking man with a nice demeanor, and if he had not been injured I can tell he would probably have had an athletic physique. In other words, a regular, healthy life. When we shift the blankets over his body I notice how thin he is, how atrophied his muscles, how stiff his limbs. He has a ventilator to help him breathe, but he has trouble breathing when he lies flat, so we raise his head. I don't want this man to have any discomfort.

The procedure is brief, and he does well. When I leave the hospital for the day he is smiling and talking with his family and his nurse. I admire his courage, feel a little shame at what I tend to take for granted, and am sad for what he has lost. The thought haunts me: he'll never be able to move. Maybe there are those who would be offended by this sadness, who don't want to hear me express it or don't think I should even have it. Americans seem to recoil with horror and resentment from anything that smacks of pity, whereas Filipinos see it as a virtue and a loving sentiment, synonymous with compassion. It doesn't matter how the sentiment is judged: I am sad. I won't forget him.

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Illustration: a painting found in 1921 on a wall of the baptismal chamber of the house-church at Dura-Europos, on the Euphrates River in modern Syria. Dating c. 235, it is the oldest known representation of Jesus and depicts him healing a paralyzed man and and telling the man to rise, pick up his mat, and go home.

The Joy of Browsing: an anesthesioboist's quiet Saturday

Mm, browsing. It's one of my favorite things to do. I'll admit it: it's even better than wrapping Christmas presents. My "perfect date" would consist of terrific conversation, a delicious meal, and at least an hour in a wonderful book store BROWSING. I don't know why I find it so soothing, but I do. I love it. Calms my soul like nothing else.

No book store here, unfortunately - just rain, fog, a warm drink, and blissful seclusion in a cozy cabin for the weekend, but I have put my third Philippa Gregory novel down for a bit - a hard task - and indulged in a little cyber-browsing. Not as good as real-life browsing, but comforting in its own way.

I just had to share this delightful piece of stitching by a surgeon/fellow-blogger. I stumbled upon her blog when I checked to see if there were other people on Blogger who list Tuck Everlasting as a favorite book on their profiles:

Am I geeky to find this so adorably cute?!

Here's another picture I found on the enjoyable medical blog EverythingHealth, authored by Toni Brayer, M.D., which tells this story of a transplant surgeon who used a ping-pong ball (thinking outside the box!) to save his patient. As the Happy Hospitalist commented, that takes b... er, guts! If you're into medicine, Dr. Brayer's blog is a great one for interesting medical stories and news. I'll be eating more pistachios from now on... :)

One last picture, a sample from my daughter's birthday loot. I was reminded of it as I was browsing for ambigrams. Like me, my daughter absolutely loves notebooks and journals. She picked out this one the last time we browsed in a book store together. Turn the image upside down and you're still reading the same word. We couldn't resist!

It's still raining. I think I'll go generate some more ambigrams, or read some more of my book, or practice some oboe, or watch the rest of the Rock Hudson movie we were watching, or make some cookies...

*Sigh.* I love quiet weekends!

Anargyroi (a mini-excursion in medical history/legend)

Happy Feast of Saints Cosmas and Damian.

Factual details about their lives are largely lost to us, but according to legend Cosmas and Damian were twin physicians born in Arabia and brutally martyred in Syria (c. 287) under the persecutions of Diocletian.

One "miracle story" associated with them tells of transplant surgery: they grafted a leg from a recently-deceased Ethiopian onto a fair-skinned deacon named Justinian who had an ulcerated leg. This part of the legend is interesting to me for a couple of reasons - the idea of this kind of surgery even being contemplated in the third century, and the striking (and, to me, unexpected) juxtaposition of races in the story.

It was said that they were nicknamed Anargyroi, "The Silverless," because they didn't charge a fee for their services. In the Eastern Orthodox Church the term Hagioi Anargyroi, or Holy Unmercernaries, describes a special category of saints who perform labors solely out of love for God and humanity.

Cosmas and Damian are regarded as patron saints of physicians and surgeons as well as chemical manufacturers, pharmacists, hair dressers, hernia patients, and people desiring relief from pestilence. In Brazil they are also regarded as protectors of children and their feast is celebrated on its original date of September 27. They have been popular subjects in medieval and Renaissance art.

Not My Best Moment II: The O.R. as a Cultural Anthropology Lab

I have friends who are nurses.

I have friends who are surgeons.

I have friends on the housekeeping team.

I have friends who are physicians in other departments.

When we are acting in our professional capacity, we sometimes have to assume certain roles according to our expertise, with some roles more directive than others. In the lunch room, though, we're all Red Sox fans together.

Or I should say, almost all.

I've heard some disillusioning things about some of the nurses' attitudes to members of the housekeeping staff. Some of the nurses have told the night crew to stay away from the leftover coffee in the coffee pot. Others have warned the night cleaning staff not to trespass into the area behind the main O.R. desk, which begs the question, how then are they supposed to do their work and empty the waste paper baskets or sweep the floor in that area?

It sounds very much like the housekeepers have been spoken to as if they were children or chattel. I am sick at heart to hear about these things. One of the reasons I prefer life in America to life in the Philippines is that here, people aren't supposed to expect "lording it over others" to be acceptable, as it often is in countries like mine. Here the people we serve are not supposed to be our "betters;" they pay us, we work - it's a contractual rather than a feudal relationship that demands mutual respect of people's rights.

In theory, that is. But the sad truth is that there is classism here. There are people who look down on those who have less education, less income, or more menial work than they have. There are those who would refuse to recognize the intrinsic dignity of another simply because she's holding a mop rather than a scalpel.

One of those is the woman I once rebuked for behaving unacceptably during a crucial moment in the O.R.

This same woman, Nurse X, yelled at my friend on the housekeeping staff, let's call her Z, to get her cleaning supplies cart out of the way while a patient was being wheeled out of the O.R. I saw the incident. The cart was not in the way to begin with. Nurse X took Z by the shoulders and shoved her to the wall, crashing her into the cart in the process, causing the cleaning water to spill into the corridor and Z to nick her shin. Nurse X roughly manhandled Z, who is small, in a way she would never dream of doing to a man "of rank" in the hospital.

It happened so fast. I was so shocked I didn't know what to say, then it was over and people went back to the hustle and bustle of O.R. life, and I got pulled away to take care of some medical thing. Later I kicked myself for not saying something - for being a weak leader, and succumbing to Bystander Effect - then rationalized my shocked silence by telling myself that Nurse X would have made an ugly, unprofessional scene right there in full view of other staff and patients, and it would have been fruitless to allow a scene to be made. But I should have done more. What's that famous line - "All that is necessary for evil to triumph is for good men [and women] to do nothing."

I talked to Z afterward to see if she was ok, and she was not. Later that evening Z's supervisor approached me to ask about the incident and I spewed my guts out, not just about the horrifying incident but also about the stupid coffee pot thing and the behind-the-desk rule. But I don't think that "testimony" will do enough, and I went to bed that night knowing that in a very real way I had failed a friend.

Mark 4:39

Today is my daughter's birthday.

She is eleven. If she had been a rich Tudor girl, as in the impossible-to-put-down books I am reading now by Philippa Gregory, we'd be gearing up for a wedding next year or the year after, to some faraway nobleman who would spend his life treating her like property and cheating on her with countless mistresses.

As I brushed her hair this past weekend - we were on Martha's Vineyard with family friends - I thought of generations of women who have been brushing their daughters' hair for hundreds of years before me. The brush almost tugs her closer to me with each stroke - a wistful rhythm. It's an act that seems to expresses this tender, almost plaintive thought: stop a moment, my lovely girl; don't grow up too fast; enjoy this time to yourself, this untroubled time without complications or worries or major responsibilities, this fledgling time to be you and be entirely lovable and free.

I talked to her of our good fortune: we are women in a society in which we are free to choose to be wives or not, mothers or not, with opportunities to educate ourselves, vote for our leaders, work at professions of our own choosing. She would not be riding off to some stranger's court next year to be wedded and bedded at a horribly young age.

Yet centuries of disregard for women don't fade all that fast. Just today I had to draw a thoughtless nurse aside for speaking to me in front of a patient in a way I truly believe she wouldn't have with a male physician.

Then I had to let it go, fast. I had a patient who was afraid to the point of tears. With her I was gentle, I hope, and reassuring. She nodded as I described things, showed relief when I explained things, clung to my hand when I rested it on her arm.

I was pulled away again for some other unpleasant business, and I had to put the harder face on, the one that has to take charge and get things done right. Then back to the patient, and more reassuring murmurings, more of what I hoped were kind words that built trust, and soothing moments. Then the procedure began, and again, there was a need for firmness - my more business-like side, as I tried to convey important directives and elicit competent, efficient work from the team I was working with. Then it was time: the patient awoke, surprised it was all over, refreshed. Again a hand on the shoulder. Everything's all right. You're just waking up. Procedure's all done. You did great. Tears of relief. A smile. A squeeze of my hand.

Hard. Soft. Hard. Soft. So it goes all day, every day. Compassion in the interstices, between moments where I have to take a stand, or take charge of something, or direct someone, or all the above.

We're tugged in so many directions. I think of trees pulled about by storm winds or rain. How can I teach my daughter to stand firm in this whirlwind world, to bend but not to break, to be firmly rooted but pliant, and most important of all, to use her health and her gifts to bear good fruit? I want her to be happy and safe. I want her to stay energetic and free. I want her to feel satisfied with her work but not to get too physically and emotionally exhausted. All day at work as I travel from patient to patient, task to task, she is in my thoughts, like a song in the background of everything I do and try to be.

What can I teach her about how to cope with wave after wave of demands on her attention, her time, her energy?

It comes to me: I will have to teach her, by example if not by word, to reach for stillness, again and again. When I return to it, sometimes it's for just a millisecond. A pause before inserting an I.V. A putting aside of annoyance at a fellow-doctor's lack of consideration or a nurse's thoughtlessness, in order to lay a hand on a patient and hold still for a second. I hold still. My daughter and me brushing hair during a weekend retreat: another moment of stillness. It's a rhythm, a habit, but one that takes practice, one easily forgotten. I flutter around, busy, sometimes frenetic. But I have to go back to that stillness, even draw other people into it if I can, or I absolutely cannot cope with all the tugging. I have to "rebuke the waves," and try to tell myself, "Peace! Be still!"

Be still. Young people so often underestimate the value of that, the gift of that. Everything now has to be high-stim, instant gratification, always on-the-move. My kids are no different. They are sucked in along with all their friends, into the maelstrom of entertainment and activity that their generation craves. But there is something in mindful stillness that none of those delights can match.

Somehow I will have to teach my children this if I can, and hope that it's of use to them as they grow (too fast!) and discover (wonderfully!) who they are.

[Cross-posted in slightly different form at MothersInMedicine.]