Wednesday, November 28, 2007
Monday, November 26, 2007
I never thought that as an anesthesiologist that I'd qualify as a country doctor!
My daughter and I have recently gotten into the old Dr. Quinn, Medicine Woman series starring Jane Seymour. Talk about a country doctor. I never really got into the show while it was on the air but now I find it's great, escapist fun. We're suckers for period pieces!
While I find a lot of the surgical scenarios and outcomes totally implausible, I'm enjoying the portrayal of frontier village life and the peek into 19th century medicine - chloroform for asthma in the absence of albuterol, stramonium leaves instead of Atrovent, but also drugs we still use today, like digitalis, and aspirin in the form of willow bark tea.
Depictions of childbirth in these period pieces always make me shake my head with disbelief and a sense of unworthiness. I admire women who are able to endure labor pain without anesthesia. I kneel in spirit and place my brow to the earth in homage. I know that by the time I got to my fourth centimeter of cervical dilation I couldn't imagine wanting to (or being able to) live a moment longer with the contractions I had. So to the millions of women out there who give birth repeatedly without doctors like me easing the pain, I say: you are made of stronger and more heroic material than I.
I saw quite a few babies come into the world on my call these past four days, and though I've given birth myself more than once and seen it countless times after some years in practice, I can't get used to the whole process. I am still somewhat aghast every time I stand by, ready to help (but usually not needed), while a woman's body somehow stretches and pushes and tears and toils to squeeze a little person the size of a melon through a canal of tissue only a few centimeters wide. I'm aghast, and also awed.
Yet while many people exclaim at moments like these, "Isn't it a miracle?" it's precisely at these very moments that I find myself at my most agnostic. I gaze at the almost feral process, with its primal cries, bloody chaos, and torn tissue, its swirl of individual instinct and human social support, and I have the distinct feeling of being lost, a bundle of muscles, fluid, vulnerable tissue, and jumbled thoughts among many others, an anonymous organism caught up in multiple interconnected cycles of birth and death. I think to myself, "This is it. Humanity. A bunch of cells and physiologic systems generating more cells and physiologic systems. Natural processes repeating themselves generation after generation, keeping the species going." Physical reality is all of reality - so many feel this is the whole truth.
Perhaps there's more meaning behind it all, an intangible but real spirit flowing through, but it's at moments of birth that I find that idea hardest to grasp, ironically. Even at the birth of my own children, I had moments of feeling totally aspiritual. The moment was all there was, their petal-soft hands in mine, there breathing bodies resting on my beating heart.
Perhaps that is the the whole truth, but there's another possibility, of course - the possibility that meaning does exist and that we can put our hope and trust in it. Advent is coming up, when Christians traditionally reflect on the ancient belief of the divine incarnate. I like to think the divine might be present - perhaps we even generate it, give birth to it by defining it, a little Christmas in every life - in those very earth-bound moments during which we enter fully into human experience, feeling the amniotic fluid gush out of us, the flesh stretching and yielding, our breath and blood moving through us with unimaginable power. For all that is energy, and matter, neither of which is created or destroyed - ultimately a thought full of hope.
Sunday, November 25, 2007
Thursday, November 22, 2007
The place? St. Augustine, Florida.
The date? September 8, 1565, 54 years before the arrival of settlers to Berkley Hundred, Virginia ad 56 years before the Pilgrims supped with the Wampanoag.
The activity? Catholic Mass, followed by a meal of bean soup with the Timucua Indians.
The guy? Pedro Menéndez de Avilés, of Asturias, Spain.
Here's an interesting article on the subject from USA Today.
A friend just returned from a trip to Jordan with her daughter. They enjoyed the camel rides and the visit to Petra, but they had to sideline their side visit to Saudi Arabia because a) women are not allowed to travel alone there and b) they needed a man to represent them for their visa application at the consulate, and things didn't work out in time.
So, on the top of my list of reasons to say "Happy Thanksgiving" today is FREEDOM.
If I could make a true list of all the things for which I'm thankful, it would (or should) be practically endless. But here's a short ad hoc list, one I limited to any 10 items that came to mind within the first hour of getting out of bed:
-food, shelter, and clothing: our basic needs in abundance
-my husband's patience and affection
-my children's health and happiness
-the option to take a warm shower any time I feel the need to clean up
-reliable indoor plumbing
-a quiet beeper (for now)
-friends and family who accept me as is
-books (and the literacy and education to be able to enjoy them)
HAPPY THANKSGIVING TO ALL - AND MAY THE SEASONS TO COME ALWAYS BE FILLED WITH THANKFULNESS AND THE FREEDOM TO ENJOY EVERY BLESSING.
Sunday, November 18, 2007
I'm still working on that, but in the meantime, inspired by one of my coworkers, I made my first sweet potato pie ever today, and people seemed pleased with the results. So here's my handiwork, adapted from various internet recipes. If anyone has suggestions/recipes for a favorite holiday side dish, please help me out!
1 1/3 c flour
1 ½ t sugar
¼ t salt
4 ginger snaps, crushed
½ c butter
ice water to bind together
2 sweet potatoes, baked, peeled, & mashed
5 T butter
1 c + 2 T sugar
1 ¼ c evaporated milk
½ t cinnamon
½ t nutmeg
1 t vanilla
1 T rum (optional, of course)
¼ t salt
Bake at 350 degrees for about an hour.
Saturday, November 17, 2007
This week my husband and I met with our children's teachers for parent-teacher conferences, and we sat across from two very bright, talented, attractive, wonderful individuals thinking, "Wow, they are so young."
It's official. We're middle-aged suburban parents, mom-of and dad-of. We have arrived.
Well, ok, maybe we're not quite middle-aged yet, but as my husband sat enthralled at "perky" Ms. W's assessment of our son's abilities, I thought to myself, "This is it. We're getting old together. How nice!"
I'll say this for the lovely Ms. W: she "gets" our son. She laughs at his quirky jokes. She appreciates his precocity and channels it to the aid of others. She encourages him to teach, and guides him to do so with respect and patience. In other words, she brings out the best in our son: a sign of a good teacher.
Then there's Mr. W, our daughter's teacher. I've often joked that we should get Ms. W and Mr. W together - she wouldn't even have to change her name. Mr. W "gets" our daughter too ("She seems to be the class expert on Wicked!"). In the end that's really what makes a teacher really effective: the ability to understand, appreciate, and adapt to each individual student's gifts and needs, and to guide those in the right direction. We've got two winners this year.
We've been reflecting on our own educational highlights, and I was shocked to learn my husband and father-in-law hardly remember their earlier school days. Parts of mine are still so vivid in my mind! I got inspired to make a "Signficant Educational Experience Timeline," a follow-up to my significant reading timeline from several weeks ago. It's been an interesting way to reflect on "how I got here from there."
Toddlerhood: my parents spoke only Spanish to me at home; my grandmother, English; and I was surrounded by Tagalog-speakers. I think growing up trilingual did something to my brain.
Age 4: my mother and grandmother taught me to read.
Age 5: I started piano and ballet.
Age 7: I learned my times tables by heart, a practice which seems to have disappeared from the landscape of American math education, which my husband and I find appalling and which we think will be a huge disadvantage to kids later in life when they just have to know things quickly without having to "think about the concepts." But hey, we're just parents, what do we know.
Age 9: moved to the U.S. Books everywhere, easily available. Mrs. R, the Lower School librarian, introduced us to Tuck Everlasting. Lower School Headmistress helped us create our own poetry anthologies, with art and binding. Sister H. did a unit on the life of St. Peter and encouraged us to do creative final projects - mine was authorship of St. Peter's "diary."
Throughout subsequent years: my mom's "reward" for good report cards would be a trip to The Cheshire Cat, a children's book store. My mom and dad took me traveling every summer - an education in itself.
Age 10: had to dissect a chicken leg in bio and almost barfed. Still picky about chicken dishes. The giant earthworm dissection was a bummer too...
Grades 6 & 7: Had a strict and superb social studies teacher, Mr. O, who insisted we keep up with current events. He spoke to us like adults and expected us to have some opinions and be able to articulate them intelligently, whether the topic was Savonarola's burning of the vanities or Reagan's latest Cold War projects. Had a great English teacher in 7th grade who likewise didn't "talk down" to us. In science I did an oral presentation on mitochondria. We learned about physiologic systems in organisms - respiratory, digestive, locomotive, etc. and had to design our own organism with its own physiology. Mine was boring - basically a cactus parasite.
8th grade: Algebra was terrible for me that year, but English was fantastic. My nostalgia has a Proustian side to it: I still remember the way the pages of my copy of Warriner's English Grammar and Composition smelled when I opened the book - a pleasant, "booky" aroma. Our English teacher had us write in a journal, introduced us to To Kill a Mockingbird and A Midsummernight's Dream, and actually went over the rules of English grammar - again, now lost to the American school age population. There IS a point to diagramming sentences, but no, now anything goes...and it's obvious from the egregious grammar errors and terrible use of language in American spoken and written media. (Perhaps I sound a bit curmudgeonly...)
High school: I really learned to write. Higher math and science not my strong points, though I loved bio and actually won a prize in a school science fair because the judges thought I wrote so well - talk about an unexpected turn of events. Took 3 years of French - which I use now, having married into a French family. Hit my peak as well as my decline in ballet. Scripture class in 9th grade was eye-opening, a course which influenced my formation both academically and personally for years to come. It really trained us to think critically about faith in the context of history, and to consider the various literary genres in the Bible (which really upset the students who took everything in the Bible as fact). I loved it. It made me sign up to take Ancient Greek the following summer at Stanford so I could read the New Testament in the original koine - talk about a super-geek! I am so grateful to my parents for letting me be me, and supporting all these interests, and now to my husband, children, and in-laws, who do the same.
College: I HAD SO MUCH FUN! Took a memorable course in Irish poetry from the great Seamus Heaney. It was inspiring to learn from an academic who could actually produce stellar work in the very subject he was picking apart!
Grad school: got a master's degree in child development while pregnant with our first. Really influenced my thinking - i.e., made me feel more relaxed about letting my own children grow and discover their own lessons and loves.
Med school: too many significant experiences to mention. Anatomy and pathophysiology courses and teachers highly formative. Clinical years make you grow up and face reality a little better, though still in a very sheltered way.
Residency: The picture of me with the fiberoptic scope up on the sidebar at right is only a partial one; the complete picture, above, shows that I had an attentive teacher at my side, in this case a very good one, ready to offer help if I needed it. So it wasn't all bad...but there was plenty of bad to go around. For the first time in my life I had a plethora of negative educational experiences, some quite signficant. There was not only plenty of bad teaching but also an abundance of bad attitudes to teaching/learning/education. I learned that being insulted really sets me back emotionally and worsens my learning ability/process. I learned that my friends and I can prepare for and pass any medical boards, written and oral, ENTIRELY on our own. Some positives included learning how to manage difficult airways, how to prepare for individual patients' challenges, how to manage crises, and how to define my own worth (an ongoing process).
I'd like to quote something Paul Levy wrote so eloquently on his blog: “Soccer is a thinking person's game, and it is hard for a player to think if an authority figure is yelling at you as the ball comes your way. Kids who are trained to think learn how to make the right decisions in the split-second action of a game. Kids who are trained to listen to their coaches learn to wait to be told what to do.” That about sums up how I feel about my residency education.
Now: CHAMBER MUSIC! OBOE LESSONS! Talk about a signficant learning experience! And one that's a real pleasure...thanks, Orlando and Kyoko! :) (That's the two of them below, flutist and oboist, in a photo off the Anemoi Quintet website.)
Wednesday, November 14, 2007
The double reed instruments - the oboe, English horn, basson, and contrabassoon -
are really, really hard to play. The mouthpiece consists of two tiny pieces of cane that are bound together in such as way as to leave an extremely small space between them. In order to get the two reeds to vibrate together, you must grasp this tiny mouthpiece tightly between your lips and blow for all you're worth. You blow until your eyes begin to bulge, until your nasal passages inflate like balloons and your brain gets pushed back against your skull case...
...Pain: it's a word often associated with the personalities of oboe players in particular, no disrespect intended. It is, however, one of those chicken or egg questions. Are overly-fastidious, anal-retentive people attracted to the oboe because of its technical difficulty and its nasal, arguably whiny sound, or do the technical demands and the sound of the oboe turn oboists into overly-fastidious anal-retentives?
I found this sooooooooo funny - especially the way he delivers it. It's a riot!
My orthopod colleague also clued me in to an oboe piece I hadn't heard before but just downloaded from iTunes: Stravinsky's Pastorale. I've been noticing a lot of great oboe parts on the radio lately - in Respighi's Ancient Airs and Dances, Dvorak's Slavonic dances, Schubert's Rosamunde overture, The Farmyard by Elgar, Saint-Saens' Rhapsodie d'Auvergne, Albinoni's Concerto a Cinque, Butterworth's English Idylls, even the overture to Die Fledermaus. Last weekend Kyoko and Orlando, the flutist who conducts the chamber orchestra I joined, played in a wind quintet concert and introduced me to some other wonderful wind pieces - the Caprice on Danish and Russian Airs by Saint-Saens and the Trio for Oboe, Horn, and Piano by Reinecke. But my latest "dream piece" is There is No Rose by Z. Randall Stroope (Youtube clip below) - an added bonus being that it's Christmas music, my favorite! Maybe someday...
Saturday, November 10, 2007
After receiving a dose of a valium-like drug that would have rendered the average person totally unconscious, Job was still talking to us as we wheeled his bed toward the O.R., but he was also calm. I placed monitors on him and gave him oxygen, talking to him as gently as I could about what I was doing at every step. I injected the anesthetic into his IV and watched as his eyelids fluttered closed and remained motionless when I brushed my fingertips against his eyelashes. I placed the breathing tube, put a warming blanket on him, relaxed his abdominal muscles, measured his temperature, and gave him anti-nausea medication as well as a large dose of long-acting narcotic to blunt his response to painful stimuli. Throughout the surgery I watched over his ventilation, heart rate, heart rhythm, and blood pressure, made sure he was receiving what I thought was the right amount of fluid, checked his urine output, made sure his abdomen stayed relaxed enough to allow Caroline to do what she needed to do, and gave more pain and anti-nausea medicine.
Thursday, November 8, 2007
The MerriamWebster online dictionary defines a "paragon" as "a model of excellence or perfection" [Etymology: Middle French, from Old Italian paragone, literally, touchstone, from paragonare to test on a touchstone, from Greek parakonein to sharpen, from para- + akonē whetstone, from akē point; akin to Greek akmē point...Date: circa 1548].
A couple of days ago on his blog Running a Hospital, Paul Levy, president and CEO of Beth Israel Deaconess Medical Center, invited each reader to reflect on an individual who might come to mind as a "private moral guide" during moments of tension, difficult decision-making, or trying situations - the kind of person who, alive or dead, "serves as a standard against whom we judge our own behavior during a moral test."
Despite my struggles with faith I do often think of stories in the New Testament that give us a hint about Jesus' responses to the world around him. What I understand from most of these stories is that when he saw suffering he tried to heal it, and on more than one occasion when he saw human failure he would say, "Nor do I condemn you; go and sin no more." To me these responses on his part signify that we are not meant for pain but rather for peace, that we are not meant for shame and judgment but rather for acceptance and encouragement, and for the good work of striving to do our best, as people who have the capacity for reason, love, respect, and awe.
But a moral figure such as this, alive or dead, real or fictitious, can seem a little out-of-reach at times. Not so the person who inspired Paul Levy's reflection, the late Rose Finkelstein, a 101-year-old retired nurse who as a dedicated volunteer would often be found singing to the babies in the obstetrics department at BIDMC. A physician in conversation with Levy "said something about Rose along the lines of her being the kind of person who, when you do something in a patient setting that you feel really good about, you think that she would have been pleased."
When the going gets tough I do sometimes still think of my mother's mother (photo above), who died in 1985. I wonder how she might have handled things, or if she would be pleased at my handling of things. As I reflected on this question of moral guides I realized I do imagine a number of "spirit guides" looking over my shoulder for a variety of situations. Most of these "guides" are acquaintances from past chapters of my life who wouldn't even realize I still look to their example for guidance, and one of them is a fictional character! I thought I'd make it my list of the month: some of the exemplars against whose imaginary words of guidance I measure different aspects of myself.
For how to be a good spouse: my husband.
For writing: novelist and North Dakota poet laureate Larry Woiwode. His 1994 writing workshop at Cambridge University during a summer conference on C.S. Lewis was one of the highlights of my life; I only wish I could have lived up to the high ideals he set before us at the time.
For anesthesia: this is going to sound almost sacrilegious, but the other night when my husband and I were relaxing by watching a re-run of The Hunt for Red October, I realized that the character of Commander Bart Mancuso of the USS Dallas as played by Scott Glenn is the kind of leader I'd want to emulate - intelligent, knowledgeable, cool in a crisis, able to take charge even in unfamiliar territory, respectful of his crew's talents and concerned for their safety.
For medicine in general: Indira Dasgupta, M.D., a mentor from my days in pediatrics. Her knowledge, dignity, humor, and attentive care for her patients accompany me to each bedside as I try to do the best work I can, as she always expected of me.
For teaching: Matthew Pravetz (a great med school professor), James Stewart (not the actor!), and Wilhelm Burmann (one of the best ballet coaches in the world).
These are just a few; I could sit here and think of a few more, but what I find interesting as I enjoy this exercise is the realization that the people who come to mind as my mental "guides" were people I consider to have been my best teachers...
Sunday, November 4, 2007
In my first year out of med school I was an intern at a tertiary care center where the pediatric ward had a large population of children with different kinds of cancer. 3 North was for the younger kids, 3 South for pre-teens and adolescents. These wards no longer exist; the hospital has since expanded and undergone an enormous renovation, and it’s now one of the most physically attractive and impressive pediatric centers I’ve visited. The renovations were just finishing up the last time I dropped in on the hospital with a good friend who stayed in the program after I left to do my anesthesia training, and my friend was able to open the door to those old wards just a crack so I could see them before they disappeared entirely. It was eerie to see them empty, like a ghost town, and a torrent of images appeared in my mind, faces I remembered from my days as an intern there. [Photo: Poa_Pan-milk, private collection, released into public domain by Matthias Sebulke]
One of those faces belonged to a baby girl – I’ll call her Ana – whose parents brought her to us one night after they found that one of her arms had gone completely limp. Just the day before, Ana had been a happy baby, crawling around her home, active, playful, but that day she was completely different, listless and strange, with that alarming arm weakness.
Ana’s parents spoke mostly Spanish, though her father could speak some English as well. By the time they got through the E.R., with interpreters, consulted with a couple of specialists, and came up to the floor for admission, it was 1 or 2 in the morning. I was on call and I had been up since about 5:30 the previous morning. I had been on my feet almost all day with no end to stressful tasks, phone calls, procedures, paper work etc. that I had been working on for hours, between patient visits and admissions. Ana’s parents deserved to have a reliable, kind, sympathetic physician to help them through this unimaginably difficult night, but they got me, and I was at the end of my rapidly fraying rope. I had a mountain of charts in front of me that all needed updating and a floor full of cancer patients who needed their blood drawn before the pre-morning work piled up. All I could think about was sleep.
Ana needed an MRI, and I needed to accompany her to radiology with her parents so she could get one under sedation. For some reason it worked out that between the morning line-up of cases and the things that were going on that night, we could only squeeze her into the schedule at 3 or 4 in the morning. By this time I was crazed with fatigue – the kind that makes little kids cry irritably, but you can’t do that, or scream, either, when you’re a full-grown adult, so my coping mechanism was to speak as little as possible and just get the tasks done.
While Ana was in the MRI suite I set about trying to catch up with the endless amount of work that I just couldn’t seem to make a dent in. My eyes were sore. My whole body was tired. I felt like crying because I just wanted to be allowed to crawl into a bed and sleep. Every once in a while I put my face into the crook of my arm over a desk top but stress over getting through my to-do list would yank my head back up.
As Ana came out of the MRI Ana’s father approached me and politely asked, in English, “Excuse me, do you know what the test shows?” I looked at him incredulously, not processing at first the fact that he had no way of knowing that I would not have the MRI report for hours and wasn’t qualified to read the actual MRI myself. And I was barely processing, though I too was a parent of small children, the fact that this is the first question any loving parent would ask about his baby girl after a procedure like that. I must have stared at him blankly for a moment as these hazy thoughts tried to make it across my sludge-like mind. I could hardly think and felt like dropping to the ground to sleep, right then and there. Or setting my silly pile of charts on fire, one or the other.
“I have no idea,” I said finally. Perhaps curtly. I don’t know; I can’t remember. He didn’t ask me any more questions, and I don’t recall being terribly conversational. But I know I wasn’t the calm, helpful, warm, kind, gentle self I try to be for patients who are deeply anxious over something that could change their whole lives. This was, in fact, one of the most terribly important times in Ana’s parents’ lives, and I failed to be totally present to them for it. I wasn’t rude, I hope, or unkind, and I couldn’t help but be affectionate with Ana herself, but I wasn’t particularly supportive or actively kind to her parents. And from one day to the next her parents’ lives had changed forever: Ana had a tumor at the base of her skull that was encroaching on structures in her neck as well as her brain, robbing her of the use of her arm on one side.
Ana received the best care we could provide medically, and during subsequent admissions to the hospital I tried to be more attentive to her parents, but I felt I could never redeem the way I failed to make them feel less alone the night Ana was admitted for the first time. I had been physically present, but spiritually absent. I'm still sorry about it, as I was back then, but it's too late - and it was back then too. Eventually Ana died.
I saw lots of children come and go that first year. Most recovered from their illnesses and did well. Some lingered in their suffering - a little boy whose babysitter had bashed his head into a wall, an adolescent with little or no mental capacity, a number of children with stubborn cancers or metabolic disorders. Some died – a 5-year-old with rhabdomyosarcoma, a nine-year-old girl with an unpleasant attitude, a 13-year-old boy who was looking forward to seeing his grandfather in heaven and whom we sent home to die, a 16-year-old with leukemia and developmental delay whose memorial service I attended, a 2-year-old boy whose death from smoke inhalation was the first I ever had to pronounce officially. And Ana.
Of all those whose death I was somehow connected to, Ana is the one patient whose suffering I felt somewhat responsible for, not because I caused her condition or worsened it medically in any way, but because I wasn’t “there” for her parents when there was literally no one else around to help them. Because I was so tired that all I could think of was going to sleep. It seems weak and silly and selfish now, because now with some distance I can only remember that I felt overwhelmed by the fatigue but not how taxing it actually felt. But there it is – one of my weakest moments as a doctor. There have been others, certainly, but I always go back to this one, maybe because it happened early on, and because it showed me the disappointing truth that all it takes for me to fail to be generous is a minute amount of my own so-called “suffering.”
Saturday, November 3, 2007
Thursday, November 1, 2007
I can't believe just two weeks ago when I first joined, I just sat and stared at the score when the conductor plunked a Corelli concerto down in front of me, but tonight I was actually playing along, with far fewer sit-outs than in that first week or the week after. I was a little annoyed that my favorite reed was beginning to deteriorate. I'm still not at the point of being able to play consistently no matter which reed I use, and it sounds like such a lame excuse when you start to complain about your reed...
Last week, after I played an A and one of the violinists used it to tune, I joked that I could get up and go home, having achieved a life-long dream. This week I got to do it for the whole group because the principal oboist is away on vacation. Little ol' me! Can you believe it? I'm sure we were a little flat, but hey, at least we would all be a little flat together!
Now the question is, given my horror of performing, should I join the group when they do the Corelli, the Pavane, the Pachelbel Canon, and a Mozart piece for a concert in mid-December? Kyoko thinks I should hunker down, practice like mad for a month, and go for it. Despite my self-doubt, I kinda want to! The only problem is I'm on call almost every other day this month...This feels so different from the dread of a piano recital. I'm actually a little excited at the thought of a concert. I guess I just really enjoy a) playing the oboe and b) playing with other people. Plus, since by our own admission we in the group would only be too happy to attain even a shred of mediocrity, there's no pressure - we can all be mediocre together! (Actually, not everyone's technically a beginner...we have a very accomplished flutist who taught herself how to play the violin, so she's a "beginner" violinist but lovely on flute!) Hmmm...Something to think about...