Sweet Vitriol: Thoughts on Ether Day

Happy Ether Day... though I have to admit, Ether Day always makes me a little sad. It makes me think of how merciless the academic world can be, and of poor Horace Wells. But I'm skipping ahead.

On this day, October 16, in 1846, William T.G. Morton used a sponge soaked with ether to anesthetize Gilbert Abbott, a Boston printer. Surgeon John Collins Warren removed a tumor from below Abbott's jaw. When Abbott emerged from the anesthetic and reported having felt no pain during the procedure, Warren turned to the audience and said, "Gentlemen, this is no humbug." This was a reference to the awful Horace Wells incident. But again, I'm ahead of myself.

Ether Day was the most famous public demonstration of a general anesthetic but by no means the first, nor was it the first use of general anesthesia for surgery or the first medicinal use of ether. In March of 1842 Crawford Long used ether as an anesthetic to remove a sebaceous cyst from the neck of his patient, James Venable but did not publish his work until 1848 in The Southern Medical and Surgical Journal.

Nitrous oxide, or laughing gas, too, had already been publicly demonstrated in circus sideshows before the demonstration at Mass General took place. On December 10, 1844, a travelling lecturer and former medical student named Gardner Quincy Colton, who had already earned $535 with his nitrous oxide demonstrations, gave a show in Hartford, CT during which a volunteer from the audience felt no pain from an injured leg. Dentist Horace Wells was there. His interest in developing an anesthetic technique for dental practice inspired him to procure a supply of the gas from Colton. He began to administer nitrous oxide to his dental patients.

Before Morton demonstrated ether anesthesia at Mass General on Ether Day, Horace Wells had tried a similar demonstration in Boston over a year before, using nitrous oxide. It was a disaster.

I have always had a soft spot for Horace Wells because of this, because I know what it's like to be on the spot publicly, in front of a bunch of academics who are not necessarily on your side and seem to be just waiting for you to screw up. I've observed on many occasions that, in many instances, academics are people for whom making intelligent remarks about something consists of pointing out what's wrong with the thing, often with great relish and self-satisfaction. Of course, I've also known truly great academics, those who are knowledgeable and can communicate their knowledge with a sense of joy and excitement rather than superiority, who are creative and open-minded, capable of enjoying a piece of music or theater without nitpicking, willing to admit they have more to learn, and in fact able to learn from others. I have a feeling this was not the type of academic Horace Wells was up against when he tried to demonstrate that nitrous oxide could be used as an anesthetic. In January of 1845, before a critical and demanding audience of medical students at Mass General, apparently something went wrong with the way the gas was administered, and the patient cried out in pain. Wells was publicly humiliated, with the students jeering "Humbug! Humbug!" as he left the auditiorium, and he lost his credibility within the medical community. After this miserable failure he became a traveling salesman and sold canaries, shower baths, and other household goods for the next two years.

I think it's interesting that William T.G. Morton had been Wells' student and then business partner in the early 1840's, when Wells first set up his practice in Hartford. They went their separate ways after only a couple of years in dental practice together. In 1847, after Morton's success and notoriety as a result of Ether Day, Wells ended up working for his former student: he went to Paris to sell anesthesia for Morton, who tried for years to get royalties for his "discovery" of ether anesthesia. Wells became addicted to chloroform while in Europe, in a state of delirium assaulted two women with sulfuric acid, got committed to Tombs Prison in New York, and committed suicide by slitting an artery in his leg with a razor. He was only 33.

An article by A.J. Wright from the 1999 newsletter of the American Society of Anesthesiologists acknowledges, "Recent work by Stephen D. Small, M.D., has demonstrated that Wells was a deeply religious young man concerned 'with a reality that transcended intoxication, a dangerous idea without scientific proof that the inhalation of nitrous oxide could be pushed to levels heretofore unknown, with great benefit.' Here then is Wells' main contribution - 'to push the inhalation much farther than for a mere exhibition for fun.' Wells' motivation seems to have truly been the discovery of surgical pain relief, not an exotic experiment performed a few times and abandoned, as with Dr. Long, or a process to be patented for profit, as Morton tried to do."

On the ASA website people can order Crawford Long, Horace Wells, or William Morton T-shirts to cast their vote as to "who was first." I think they need to get Gardner Quincy Colton up there, a med school drop-out with no academic credentials. Actually, what I really think, banter aside, is that each Ether Day, what we need to reflect on is the way in which academic cruelty can destroy a person and rob us of his or her gifts. If those med students who were watching Horace Wells had replaced their jeers of contempt with supportive actions and educational questions, the result might have been much more productive use of everyone's work and perhaps much less unnecessary tragedy.

ADDENDUM FROM WIKIPEDIA:
"Twelve days before his death, the Parisian Medical Society had voted and honored [Horace Wells] as the first to discover and perform surgical operations without pain. In addition, he was elected an honorary member and awarded an honorary MD degree. However, Wells died unaware of these decisions."

***

Speaking of academe, I spent Ether Day enjoying the beautiful fall weather in Harvard Square on a rare day off with my husband. We had lunch at Finale, which is known for its terrific desserts but deserves accolades for its delectable gourmet sandwiches too.

"What did we used to talk about when we hung out here when we were younger?" I asked him as we ate our sandwiches. The places around Harvard Square were our old stomping grounds.

Chomp, chomp, sip. "I dunno. Why?"

"Well, what on earth could have brought us together at that age?" I wondered aloud. He and I have nothing in common, with the exception of some core spiritual values / ways of looking at the world. Nothing at all.

"Pheromones," he replied. Munch, sip, munch, munch. "Good sandwich."

I think our being totally different, like two puzzle pieces with completely different shapes, helps our marriage. That, and we find each other funny.

"Do you want my raspberry garnish?" The berries on my dessert were a little tart, but the crème brûlée was rhapsodic.

"Sure. Want my chocolate triangle?" He said, handing over the little wedge of dark chocolate from beside a delicious frangipane tart.

"Of course."

Ah, a marriage that works. Gotta love it.


***

Here's an Ether Timeline (by no means complete) for any who might be interested. I found a lot of the info here at bookrags and also compiled by Thomas J. Evans, CRNA, at the Anesthesia Nursing and Medicine Website:

1275: Spanish chemist Raymond Lullius discovers ether, calling it "sweet vitriol."

1540: Valerius Cordus describes the synthesis of ether. Paracelsus discovers it has hypnotic properties.

1730: Frobenius changes the name of sweet vitriol to ether.

1788: Matthew Turner writes An Account of the Extraordinary Medicinal Fluid, called Aether, now available for perusal through Project Gutenberg.

1794: Pearson and Beddoes use ether to treat scurvy, bladder stones, & catarrhal fever.

1800: Sir Humphry Davy described the effects of nitrous oxide.

1804: Japanese physician Hanaoka Seishu used a bunch of scary plants to produce general anesthesia in a patient in need of surgery for breast cancer.

1805: American docs use ether to treat pulmonary inflammation.

1818: Faraday, Davy's student, notes that like nitrous oxide, ether can produce analgesia and euphoria when inhaled.

1820's: "Ether frolics" became a popular way for U.S. chemistry students to amuse themselves.

1842 - January: probably inspired by a frolic, chemistry student William Clark of Rochester, NY administered ether to a Miss Hobbie while dentist Elijah Pope pulled her tooth.

1842 - March: Crawford Long uses ether to remove a sebaceous cyst.

1844: Gardner Colton demostrates nitrous oxide in Hartford. Horace Wells starts to use nitrous oxide in his dental practice.

1846: Ex-physician Charles T. Jackson suggests that Morton use ether for dental extractions. Morton does so and performs painless tooth extraction on Eben Frost in September. Ether Day in October.

1848: Death of a salesman: Wells commits suicide.

1850's and 60's: Big fight between Morton and Jackson as to who "discovered" ether anesthesia. Long and Wells also with claims, though Long never tried to patent his use of ether for personal profit.

1868: Morton dies in poverty, from a stroke.

1873: Jackson goes insane, dies in 1880.

1944: Gregory Peck's character anesthetizes a boy with some drops in the film Keys of the Kingdom.

1952: Bugs Bunny episode "Water Water Every Hare" features a slow-motion chase between a mad scientist and Bugs who are in a semi-anesthetized stupor due to a broken ether bottle.

Barn Raising II: the follow-up

Yesterday evening we had the chance to drop in on our friends in Gilmanton, NH whose barn-raising we attended last June. My husband had a wonderful time helping with the construction, so it was a pleasure to see the finished product and say hello to the herd of 8 alpacas that now make their home there.


(Before:)

(Now:)

Tomorrow I am on call, away from my family. Years of doing this and I still haven't gotten used to it.

Bad Friday

Warning: Though I usually try not to be a "downer," the following post isn't super-cheerful and will strike many as an example of wallowing in whiny self-pity. Please refrain from pointing that out - I already know it - and skip it if that sort of thing annoys you. This blog often serves as a venting journal for me, and I definitely needed an outlet yesterday where I could let it all hang out! :)

***

"Happiness is a how, not a what, a talent, not an object." -Herman Hesse

I have this cute little book by David Niven entitled 100 Simple Secrets of Happy People, which outlines a number of ways that essentially happy people approach life. It suggests things like laugh often, get enough sleep, enjoy a hobby, make time for friendships, etc. and backs up each suggestion with an anecdote and a relevant research finding. One of its suggestions is not to take failure personally.

I consider myself a happy person. I find life filled with blessings, and I enjoy it. But I also tend to take failure personally, and I ascribe this to a kind of perfectionistic temperament that leads me to be hard on myself and demand the best work I can do.

Yesterday I was asked to help one of the docs on the 2nd floor with a spinal tap. He had tried that morning and found it difficult. I went up and gave it a try, and I found it difficult. I wasn't able to get it either, and I'm supposed to be an expert at this procedure. Everywhere I inserted the needle, I found a wall of bone, bone, bone. I tried different positions, angles, and techniques, but nothing worked, and after putting the poor patient through discomfort for a while, we decided to give her a rest and reconsider our options.

To make matters worse, this was a patient I had cared for before. She was the same patient in whom I had heard a murmur a couple of weeks ago in the area of the mitral valve. At that time the combination of her extremely low blood count and her family's description of a 30-pound weight loss over a relatively short period of time had made me extremely suspicious for cancer. I called her primary care physician from the recovery room to discuss this as well as her surgical course with him, and what I had observed from her history and physical exam, but that was the last contact I'd had with this patient, until yesterday. She lay back down on the hospital bed after our failed attempts at obtaining spinal fluid to assess it for cancer cells and said, "I'm gonna die." When patients say this, and it's not because they have a martyr complex or have a tendency toward melodrama, but rather because they really feel it "in their gut," I listen, because it's like a prophecy, almost always fulfilled in the months that follow. I was sad.


Happy people don't let rough moments define them, personally or professionally. But I've been trained to look at everything as evidence, to exalt the importance of proof and observable reality. Wanting to be a good physician doesn't make me one. Yet hundreds of well-cared for patients and expertly-managed airways and other procedures all seem to disappear in my memory every time a difficulty disappoints me. I know there's more to being a good doc than being slick at lines and needle sticks. My husband blames my training experience for the way I take all these setbacks to heart and don't acknowledge the good I supposedly do. I think it's just me, the way I respond to things and the demands I impose on myself. A lot of my so-called "bad days" are "all in my head," but that knowledge doesn't help much.

Imperfection wasn't tolerated in the ballet studio when I was young or on the medical wards when I was older, and with good reason for the latter. I do recognize that it's easy for ego to be all wrapped up in our good intentions for our patients. Of course I want to do my best, be at my best, for them, but I also don't want to fail because of how important it is to me to be a good physician. The motivation's neither completely selfish nor completely unselfish. There are those who judge altruism harshly, saying that doing good for others is all about the do-gooder wanting to feel good. I say it's never only one thing or another. I do believe many people sincerely care for and want to help others but also want to feel good about their own work.

That's certainly how I feel about it. Which is why I feel bad, on both counts, right now.

***

While I'm giving vent to my frustrations, let me go ahead and get off my chest all the other things that made yesterday not-my-favorite day at work.

-Neither electroconvulsive therapy session for which I provided anesthesia was straight-forward; my first patient desaturated sharply during the induced seizure and was difficult to mask ventilate;

-I almost had a medically unnecessary C-section added on to my schedule which was going to be done because the mother didn't want to push the baby out vaginally - a practice to which I strongly object because of the increased risks, present and future, to both mother and baby (as in, the baby is 3 times more likely to die) as a result of "electing" to have the abdomen sliced open for major surgery;

-I had a spat with my boss over my objections to something I felt endangered patients and compromised my standards for delivering good patient care.

Is mercury in retrograde or something?! Thank goodness it's the weekend!

On the up side, my kids are adorable, my husband is wonderful, I'm looking at a gorgeous view of Lake Winnipesaukee right now with fall foliage just beginning to color the landscape in the foreground and the White Mountains clearly visible in the distance, I have oboe goals, and I am safely ensconced in a cozy cabin writing to my heart's content. For all this happiness I am deeply thankful.

Oboe Confession

I had SOOOOOO much fun at my oboe lesson today! Kyoko can turn every little gaff or setback into a huge laughing moment. We spent the 2nd half of the lesson doing a kind of sight-reading marathon, with her accompanying me on piano. I felt like someone who's not quite reading at grade level, but she actually seemed pleased with how I did, and also with how, despite the LOOOONG summer hiatus and my recent stressful schedule, I had managed to keep up some of what I had gained with the instrument. What a relief! I thought it was going to be a bad lesson.

She's gently trying to get me to consider a recital and put Gordon Jacob's lovely "Ten Little Etudes" under my nose, carrot-to-Bugs-Bunny style, to tempt me. When I started taking lessons I had told her up front that I would never, ever, ever, ever do an oboe recital. Now I'm enjoying the instrument so much that I'm not so sure I hate the recital idea the way I did before...except that being gazed at publicly is still such a horrifying thing for me to imagine. Play in a group? That I would do. In fact, I'd LOVE to be in an ensemble, if I could be just one of many voices, contributing my part but not alone in the limelight. She mentioned there might actually be just the group for me in a neighboring town; her friend conducts an ensemble of adult beginner musicians. But a recital? No way. The very word recital gives me the creeps. I suffer from physically incapacitating, stomach-gnawing, horribly terrifying, emotionally crippling stage fright. (There's a great article here at Mandolin Magazine that sums up the experience and possible ways to deal with it.) If it was bad during my dancing years, when I was at least performing in something I was good at, how can I possibly bring myself to do publicly something I'm barely tolerable at? I'd almost rather be coding someone in the O.R. ...

Meanwhile, my son's loving violin. He was practicing in the living room while I was in the kitchen and I overheard him talking to himself, saying "That was fun!" after a couple of the things he was practicing. I think I had about as happy a feeling for him as I could possibly have. I love the fact that we can now enjoy my violin mix together. We're suckers for Neville Mariner's cut of Vivaldi's Winter, and Gil Shaham playing Sarasate.

Kyoko's in concert next week with the Philharmonic at Sanders Theater, my old stomping grounds, where I struggled to stay awake through many an undergraduate lecture. They're playing a new work for violin and tabla as well as some Ginasteras and Mussorgsky. I think I'll bring the kids to hear Pictures.

Books That Made a Difference

A month ago, Madeleine L'Engle, one of my favorite authors, died. It's been hard to contemplate the passing of someone who was such a significant presence and influence in my childhood, through her marvelous books. There have been many blog posts about Madeleine L'Engle. Many of the recent ones are outpourings of how important her work was to the blogger's life and character formation. My own thoughts would only echo what they have stated about the power of the written word to transform one's world, one's very identity.

So I'm going to do my daughter's friend's homework here instead. She was asked to come up with a "Signficant Reading Timeline." I notice as I create it that there's a lot of L'Engle on there, and a lot of what's considered "children's literature." If anyone out there feels like sharing a significant reading / educational experience / movie / influential event timeline or a "books that made a difference" list (blogged about mine last July), please do!

Early childhood:

Where the Wild Things Are by Maurice Sendak;

Where the Sidewalk Ends by Shel Silverstein;

various fairy tale anthologies;

a children's bible;

a comic book of the life of St. Bernadette; and

some works by E. Nesbit and Enid Blyton

Age 8:

Harriet the Spy by Louise Fitzhugh;

Little Witch by Elizabeth Bennett;

various works by Ruth Chew, Betty MacDonald, Beverly Cleary

Age 9: Tuck Everlasting by Natalie Babbitt.

This was HUGE. I realized that you could make language beautiful on purpose as well as tell a meaningful story with it, thanks to Dolores Roberson, the librarian and teacher who guided us through this book in school.

Preteen years:

Mrs. Frisby and the Rats of NIMH by Robert C. O'Brien

Meet the Austins, A Wrinkle in Time, and A Wind in the Door by L'Engle;

Jennifer, Hecate, Macbeth, William McKinley, and Me, Elizabeth by E.L. Konigsburg;

The Ordinary Princess by M.M. Kaye;

A Gathering of Days by Joan M. Blos;

The Lion, the Witch, and the Wardrobe by C.S. Lewis;

Little Flower by Mary Fabean Windeatt (a bio for children of St. Therese of Lisieux)

The Velvet Room and The Egypt Game by Zilpha Keatley Snyder

Homecoming and Dicey's Song by Cynthia Voigt

various works by L.M. Boston, Helen Pearce Jacobs, Lois Lowry, John Bellairs, Katherine Paterson

Age 13:

A Ring of Endless Light by L'Engle;

To Kill a Mockingbird by Harper Lee

Age 15:

Many Waters by L'Engle;

Lives of a Cell by Lewis Thomas;

Two from Galilee by Marjorie Holmes;

Ethan Frome by Edith Wharton;

The Agony and the Ecstasy by Irving Stone

Age 16: Le Petit Prince by Antoine de St.-Exupéry

Age 17: Two Part Invention by L'Engle

Age 18: Winter's Tale, A Dove of the East and Other Stories, and Ellis Island and Other Stories by Mark Helprin

20's:

Catherine, Called Birdy by Karen Cushman;

Wild Swans by Jung Chang;

By the River Piedra I Sat and I Wept by Paulo Coelho;

The Christmas Miracle of Jonathan Toomey by Susan Wojciekowski;

Holes by Louis Sachar

30's:

The Fourth Wise Man by Diane Summers;

"The Expert on God" by John L'Heureux;

Lying Awake by Mark Salzman;

Bird by Bird by Anne Lamott;

The Sparrow by Mary Doria Russell

The Swallows of Kabul by Yasmina Khadra

Vipers' Tangle by Francois Mauriac;

Wicked by Gregory Maguire;

The Painted Veil by W. Somerset Maugham

***

My son's review last month of Robert Munsch’s Purple, Green, and Yellow:

“Brigid asked her mom for colouring markers and got 500 of them!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Brigid got permanent markers and drew on pictures and paper and herself.

Brigid tried to wash off the marker and it didn’t work so she colored herself back to normal. Mom called the doctor and Brigid took a bath and turned invisible. In the end Brigid was ok but dad was not.”

It pleased me to no end to find him curled up in bed reading the anthology Poetry Speaks to Children and to learn that one of his favorite poems in the book was "hist whist" by e.e. cummings. I'm thrilled that he devoured Born with a Bang, From Lava to Life, and Mammals Who Morph by Jennifer Morgan in the space of a weekend. I delight, too, in my daughter's discoveries - Sharon Creech, William Sleator, Louis Sachar. Everyone should have a significant reading timeline. I am enjoying watching my children's unfold.

"Hot" Topics of the Day

I love it when brilliant, creative scientists take the latest medical break-throughs straight from nature's gift closet. Aspirin from willow bark. Hirudin from leech saliva. Protamine from salmon sperm. And now capsaicin from red hot chili peppers, which may be useful as a gate-opening molecule to let QX-314, a derivative of the local anesthetic lidocaine, do its job as a pain blocker. Looks like we anesthesia folks are going to have to learn some new tricks yet again! Thanks go to my mother-in-law, who alerted me to the article in today's Globe about the research on this substance, already known to riot police (it's the active ingredient in pepper spray), arthritis sufferers (who might use capsaicin-containing creams), and purveyors of hot sauce.

***

On the season premier of Desperate Housewives Teri Hatcher's character asks someone during a medical consultation to check "those diplomas because I want to make sure that they're not from some med school in the Philippines."

The producers had this to say to the Philippine government's outcry against the insult: "The producers of 'Desperate Housewives' and ABC Studios offer our sincere apologies for any offense caused by the brief reference in the season premiere...There was no intent to disparage the integrity of any aspect of the medical community in the Philippines."

What possible intent could there have been, then?

Considering that some of the best doctors in the world come from OUTSIDE the U.S., that some of the best nurses in the U.S. are from the Philippines, and some of the worst health care in the world can be found in the U.S. system, I have to agree with those who have characterized the line as an ignorant and offensive slur.

***

Happy Feast of St. Francis!

Many parishes hold a "blessing of the animals" event in honor of Saint Francis of Assisi. This year it's a little delayed at our parish, probably due to the holiday weekend, but we'll be there! For our kids, who don't have pets, it's always a blessing of the stuffed animals. I'll never forget young Fr. John at our church laying a hand on my son's teddy bear and saying, "God bless SuperBlueBear." The Jesuits are great.

But back to the Franciscans - I want to say hi with a big hug to my favorite Franciscans / Franciscan affiliates: James Stewart, one of the most talented spiritual teachers I've had the privilege to hear and learn from, and Fr. Matthew Pravetz, O.F.M., who taught me the anatomy of the human body without letting me forget about the human spirit.

Finally, although St. Francis probably did NOT write the "Prayer of St. Francis," I'd like to jot it down here because it's my favorite prayer ever. With its meditative rhythm, expressive humility, and beautiful ideas, it says it all. The oldest known version was found in the December 1912 issue of a French magazine La Clochette; that version (which contains a few lines the popular English-language one tends to omit) is reproduced here too.

Prayer for Peace

Lord, make me an instrument of your peace.
Where there is hatred, let me sow love;
Where there is injury, pardon;
Where there is doubt, faith;
Where there is despair, hope;
Where there is darkness, light;
And where there is sadness, joy.
O Divine Master,
Grant that I may not seek so much
To be consoled as to console,
To be understood as to understand,
To be loved as to love;
For it is in giving that we receive,
It is pardoning that we are pardoned, and

It is in dying that we are born to eternal life.

Belle prière à faire pendant la Messe (original version):
Seigneur, faites de moi un instrument de votre paix.
Là où il y a de la haine, que je mette l’amour.
Là où il y a l’offense, que je mette le pardon.
Là où il y a la discorde, que je mette l’union.
Là où il y a l’erreur, que je mette la vérité.
Là où il y a le doute, que je mette la foi.
Là où il y a le désespoir, que je mette l’espérance.
Là où il y a les ténèbres, que je mette votre lumière.
Là où il y a la tristesse, que je mette la joie.
Ô Maître, que je ne cherche pas tant à être consolé qu’à consoler,
À être compris qu’à comprendre,
À être aimé qu’à aimer,
Car c’est en donnant qu’on reçoit,
C’est en s’oubliant qu’on trouve,
C’est en pardonnant qu’on est pardonné,
C’est en mourant qu’on ressuscite à l’éternelle vie.

Heart Room

(illustration by Patrick J. Lynch, medical illustrator)

When I was examining a patient in the preop holding area over the weekend I noticed a soft murmur with the early part of each heart beat, with a little vibrato or buzz to it, in the area of the mitral valve. "I think she's got mitral regurgitation. Is it in there?" I asked the nurse, who was leafing through the chart next to me. I didn't recall any mention of the condition on any documented history or physical exam when I was going through the chart, but I might have missed it.

"Nothing in here about that. What exactly do you hear? Can I listen?"

I held the end of the stethoscope down to what I thought was the best spot and gave her the ear pieces. "Just sounds like a regular heart beat to me," she said.

I listened again. The murmur was there, a blowing sound in the background. "It's about a Grade II," I said.

"I don't know what that is. What does it sound like?"

I thought for a moment about how to describe it. Then I put the thumb-side of my fist up to my lips and said, "It sounds like someone's doing this in the background with each beat." I blew into my fist with a recurrent foo-foo-foo sound.

She listened again. "Oh my gosh...now I hear it!" she said. "I would never have picked that up if you hadn't told me what to listen for!"

Heart murmurs have been cropping up everywhere at work lately. I think I've asked patients three times in the last week, "Has anyone ever mentioned to you that you have a murmur?" Part of the reason, I think, is that long-standing murmurs are inadequately described and documented in the preop clinic, while new ones are getting blown-off (so to speak) and inadequately pursued in terms of work-up. Then there was the day the surgeon announced during our seventh of eight cases, "By the way, about the emergency add-on after this? The patient has severe aortic stenosis. Just thought I'd let you know." Gee, thanks. Now that I know the valve through which her heart's trying to pump blood to the rest of her body is practically closed off, and if she goes into cardiac arrest on the table CPR won't do jack for her, I can't wait to do the case.

Despite the challenges presented by heart valve problems, I have to admit they've always held a kind of mystique for me. I loved learning the physiologic implications of each lesion, and in medical school, getting a handle on the different sound for each type of murmur. Learning to recognize and differentiate among the different murmurs felt to me like decoding a cipher, and gaining access to certain mysteries, the secrets of the body, and of medicine. It was a lot of med student euphoria, of course, because the truth is, heart disease can be inscrutable at times, and its management tricky, requiring a lot more than just a nice stethoscope and a few textbook facts. But how I treasured that first stethoscope in med school, a beautiful navy blue Littmann Cardiology III! It was my portal to a connection with others, through the sounds of their breath and their heart valves closing against each other, beating time to the rhythm of their lives, every moment, as they ate and slept and worked and rested.

***

The "heart room" or cardiac surgery suite had a certain mystique about it too. During residency I never lost the sense of awe over what we tried to do for people in there. On the anesthesia team work began long before the surgeons ever got in the room. Our responsibilities included placing monitors, central lines, arterial lines, and breathing tubes (here I am going for the jugular at the start of one of these cases).

We were also responsible for designing and executing an anesthetic that wouldn't make the patient crash, that would take into account the individual problems his or her particular heart condition presented (they weren't all the same), and that would allow the patient to survive having his or her heart stopped, body practically frozen, lungs deflated, chest cracked open, heart restarted, heart contractions assisted by drug infusions we had prepared if necessary, and vital signs hurled from one extreme to another. I never got over the tension of looking over the drape to watch for those first contractions after coming off bypass, and I felt like exclaiming hallelujah every time the heart muscle began to move in a recognizable way. Often the fun was just about to begin, as we scrambled to assess quickly how well those contractions were doing, how much we needed to interfere chemically or electrically to help them along.

It's ironic to me that one of the most memorable surgeons I ever encountered during my training was a cardiac surgeon whose verbal aggression in the O.R. had become legendary. Some of the details may have morphed into legend too by now, but I relate them to the best of my recollection. When I heard about this man's reputation I was terrified of working with him as the lowly anesthesia resident behind the drape. One of the "legends" was that he once yelled at the cardiothoracic fellow at the top of his lungs, "This is all f___d up, you f___ing f___, now unf___ it!" Another anesthesia resident a year or so ahead of me said he had once asked this surgeon if he lived on a farm, because the conversation had somehow gotten onto the subject of wild turkey sightings in his yard, and the surgeon turned to the hapless anesthesia resident and replied, "No, you little sh___, I live in Brookline!" And I witnessed some very similar statements from this surgeon, so these stories were entirely believable to me. Once when I had my hands full and couldn't raise the O.R. table up immediately after he asked, he started to do his thing with, "What does it take to get this g__d___ table up and over, g__d___ it?!" I peered over the drape at him and gave him a little lip back, and ever since then if we ran into each other seeing patients preoperatively he'd actually give a nod in greeting, and once even patted me on the shoulder (eew, eew, cooties from Satan!) on his way out of the room. I hated the way he spoke to his residents and fellows, but he was an amazing surgeon; if my loved ones needed valves replaced, I'd want his hands sewing them in. What to do with that?

***

Several days ago a 6-year-old girl from my son's school ran into her father's arms after playing in a soccer game, collapsed, and died. The press alluded vaguely to known pre-existing heart problems. Our community is stunned and deeply saddened. Yet, to my horror, I've already seen nasty, prejudiced, hateful judgments from people eager to assign blame without knowing the facts. Why are people like that? I have to include a quote here on the subject, from some experts (Oded Bar-Or & Thomas W. Rowland, authors of Pediatric Exercise Medicine: From Physiologic Principles to Health Care Application): “It is important that children with congenital heart defects be encouraged to participate in physical activities to the safe limits of their capabilities. The need is not simply to optimize physical and psychosocial development but also to provide the long-term benefits of regular activity in preventing adult cardiovascular disease.”

We can learn how to hear, and sometimes repair, hearts that are physically broken. But we stumble over the human heart shattered by unbearable loss. I've seen it: people react to other people's pain with fear, blame, or avoidance. I did the same during a simulator exercise in medical school: confronted with an actor's make-believe suffering, I practically bolted out of the room as fast as I could. I got very depressed thinking, what kind of doctor would I make if I couldn't look a pained person in the eye, hold his hand, stick by him long enough to be of real help? I think I still have to face this tightrope every day, the one that leads across to the bedside of a suffering human being, and though it can still be a little scary, I hope my balance has improved over the years...