Monday, December 31, 2007
My personal dilemma is always the same. Where can I better serve the country? Obviously, my experience treating trauma victims both in the OR and intensive care would bear fruition on the front lines. On the other hand, I couldn't possibly be in more than one place at one time. So perhaps imparting my knowledge and experience to doctors who will be called up anyway to serve at the front is more effective. I don't know if there is a correct answer.
The last two weeks we gave intensive training sessions to as many doctors and medics as possible. Using a very sophisticated simulator we could recreate battle injuries using computerized manikins that respond to treatments and procedures. After each scenario, which was video taped, we reviewed the teams' performance and offered constructive criticism. I was struck by one thing: None of the doctors or medics exhibited any misgivings about joining the combat troops (at least not outwardly). The only misgivings that were expressed were those of non-trauma doctors as to their own level of experience: was it enough to help the wounded they were about to treat? Except for one cardiothoracic surgeon with an over inflated ego, all the doctors and medics were very appreciative of any wisdom I could impart to them.
This dedication to professionalism was shared by both career army physicians and reservists alike. I imagine that the tenaciousness of the combat troops and their dedication to our country will be well served by such doctors. I, like many others, have noticed that the combat units are populated disproportionately by soldier/citizens from the periphery. The Tel-Aviv Yuppies, the high tech sector (aka technoweenies), the economic elite are all under-represented in these units. I despise them and their religious pursuit of money. I find their lack of communal consciousness pathetic. I served as a tank commander during my compulsory service and in the reserves until I was transferred to the medical corps during med school. As an armored battalion physician, I addressed my medics with the claim that those who serve in the reserves are not "suckers" but the country's real elite, and they should be proud of serving. I don't know that I ever convinced any of the soldiers under my command of anything but that I truly believe in this credo.
It may be too early for pointing fingers; however at the very least I feel that the soldiers and officers that do all the hard work have been betrayed by the top brass and the self serving politicians. I think Olmert ( the Prime Minister) should take his spineless politics elsewhere, and Halutz (former Chief of Staff) is invited to spread his wings and fly away, they are both utter failures at what they do and don't deserve to lead the fine men an women who are the salt of the earth in this country. Peretz (former Defense Minister) is just pathetic. If I have insulted anyone, so be it.
Wednesday, December 26, 2007
I'm on call in the OR. The list of urgent and emergent surgeries gets longer and longer. As the day wears on, the anesthesiologists and the OR nurses become weary.
I don't even remember the first operation of the day. At 2:45 AM we finish the last operation. I write out orders to the recovery room nurse for pain medication and send the junior resident to get some rest. I stay to write out the log of the cases that were done on call. At 3 AM my beeper jars my senses. The supervising nurse in the OR informs me that the surgeons are rushing up with a trauma victim from
I call the junior resident and tell him to prepare OR 5 for an emergency operation. The surgeons burst in with the patient. It is a Palestinian with a gunshot wound to the abdomen. He underwent an initial emergency surgery in
We often get referrals from
We transferred the young man to the operating table, he was barely conscious, he was cold, and his pulse was barely palpable: all hallmarks of severe hemorrhagic shock.
As the surgeons opened up the abdomen the extent of his injuries was appalling. The bullet entered the right lung, passed through the diaphragm shredding the liver, part of the small bowel and the right kidney finally lodging in the pelvis. Our surgeons admired the Gazan surgeons’ work. They had resected most of the liver, the small bowel and removed the damaged kidney. They anastomosed (connected) the stomach to the stump of the bowel. The sutures were perfect. These guys definitely know how to sew.
Unfortunately, their post-op treatment is less optimal and the patient continued to bleed because of consumption of clotting factors. Although the surgeons urged me to infuse blood, I started with plasma in order to replenish the clotting factors. The only documentation we received described the surgical procedure performed. There was no information as to which blood products the victim received. My instincts were right, the oozing stopped and then I started to infuse blood. The patient’s blood pressure stabilized but remained low. We transferred the patient to the Intensive Care Unit. By the time we were finished, it was 7 AM. Time to sign out.
These “on calls” are killing me. They are becoming harder and harder. Operating through the night has become the rule rather than the exception. Maybe it's the caseload which has become endless, or maybe I'm getting older, or maybe it's both. I go home feeling like I'm observing the world from inside an aquarium.
At the bus stop someone asks me a question, his voice sounds like it's emanating from a tape recorder with low batteries. I haven't the foggiest idea what he wants from me. He points to his wrist. Assuming he wants to know what time it is, I say "7:20."
Apparently I was right because he turns away. I hook up my ears to my MP3 player and try my best to ignore the world. At home, I shower and collapse in bed.
A few days later, I'm assigned to the ICU. Amazing, the patient is still alive, barely. How he survived to the initial surgery is a mystery. How he made it this far is unfathomable. He is sedated, mechanically ventilated, and since his remaining kidney has shut down, is on hemofiltration (a machine that replaces the kidney temporarily). His blood pressure is still low. The doctor finishing his on-call rattles off the vital stats and relates that the patient underwent a "second look" operation to make sure he didn't rebleed.
One of the doctors is a Gazan who tells us the circumstances surrounding the injury. It turns out that the patient was at a wedding. As is customary, shots were fired in the air in celebration. Either someone missed the air in the sky and hit the air in the young man's lung, or it was a bullet finishing its steep trajectory that fell on the unsuspecting victim. Not that it matters to him, but it seems a pretty stupid reason for getting shot.
Ruminating on the case, I became enlightened as to how the "new math" is done in
Post Script: Unfortunately, the patient succumbed to his wounds. This is not only tragic, but frustrating because of all the effort expended to try to save him.
Friday, December 14, 2007
It started when I was on call in the OR. Close to midnight, we were alerted that a helicopter was evacuating a seriously injured soldier who was unconscious and mechanically ventilated. It was a tragic accident. The soldier serving in the armored corps had his head crushed between the breech of the cannon and the roof of the turret. Having served as a tank commander during my compulsory service I knew that this was a rare but terrible consequence of mechanical malfunction, human error, or both. Getting a limb caught in the cannon mechanism was not a rare accident in older tanks. The newer tanks have a failsafe system to prevent this from happening. Something must have gone terribly wrong.
When the helicopter landed I asked my colleagues in the ICU to send someone down to the trauma room because I couldn't leave the OR. I was supervising an inexperienced junior resident who couldn't be left alone. The doctor sent down is a woman we call "the chicken" because she's afraid of her own shadow. It never ceases to amaze me that some doctors don't know their own limitations. She should never have been an anesthesiologist. Sure, she can anesthetize any routine case, but when things get complicated or the patient's condition deteriorates she loses her head. As soon as she got to the trauma room she called me to help intubate. I asked her why intubation was necessary since the patient received an emergency tracheotomy in the field. I asked her what the soldier's condition was, she couldn't tell me. She hadn't even examined the patient herself! I told her that I couldn't come down there myself but I would send her another anesthesiologist from the delivery room to help her. She apparently was not satisfied with this solution and complained to the senior on call in the ICU. The senior was dragged into the general hysteria and she immediately began to shout at me and insult me that I was irresponsible. She also threatened to file a complaint with the chief of the department. I told her she could go right ahead, I was standing by my decision. The doctor I was sending to help is very competent and has even more experience than me in airway management. Besides, if anything adverse happens to the patient currently in the OR, the question will not be IF they fry my testicles, but whether they will be fried in olive oil or butter. Anyway, after lots of frantic telephone conversations and shouting and histrionics and soap opera antics, the doctor in the trauma room finally checked the patient herself and found that he was adequately ventilated and stable. In other words false alarm! A few moments later the senior in the ICU called to tell me that the patient was stable and that there was no need to send another doctor to help out. God forbid she should apologize.
The arguments, mostly stupid, and I remind you that I was justified in all of them, despite being very tired and cranky, just kept happening.
The best and final argument occurred when I was on call in the ICU. I managed to insult a professor of pediatric infectious diseases who is also the director of the bacteriology lab. For some silly reason, any time we need the lab services while on call we need his permission to call the lab tech in. The lab tech, incidentally, is paid to come in when necessary during on calls. So his esteemed highness needed to know all the details of the sample that was sent to the lab. The sample was taken a day before in the OR so I hadn't actually seen it. He insisted on knowing if the sample was obtained on a swab or stored in a sterile cup. I just couldn't figure out why this was so important to him. He chewed me out for not having that critical information. (Later I realized that he just HAD to know because: if the sample is on a swab, then it must first be cultured and then gram stained the next day and viewed in a microscope. If the sample is in a cup then it can be stained and viewed the same day. In other words he wanted to determine if he had to come in the same day or the next day to look into the microscope.) I was getting flustered with his incessant interrogation and I was needed on the ward. I finally told him that I didn't need any favors and hung up.
Well, his royal highness, the Grand Poopah of all Professordom was mortally insulted. He called back VERY angry. I would like to mention that I have a history of insulting higher ups. Even during my compulsory service in the army I somehow had a knack of insulting full colonels and brigadier generals. That I was never punished shows that I have more luck than brains. I tried to apologize, but his holiness wouldn't let me get a word in edgewise. He was adamant that he should educate me in how to be polite to jerks with over inflated egos. He kept telling me not to hang up, that he had just a little more to tell me. Finally, his tirade ended and I could get back to treating the patients in the ICU. For about one millionth of a nanosecond, I entertained the odd idea of actually apologizing face to face. But in a calmer moment, I realized that the one who behaved badly was the esteemed professor of poor etiquette. He's not the first professor I've encountered who causes Emily Post to rotate in her grave. I guess the title inflates the ego and ablates the etiquette gland.
It'll be a cold day in hell before I give that jack-of-all-asses the satisfaction.
It's the sunspot activity I tell ya, it just has to be.
Tuesday, December 11, 2007
Some patients just surprise in many ways. On call in the ICU, again. The surgeons call to ask that I admit one of their patients. The gentleman, an elderly Russian immigrant, was suffering from rapid atrial fibrillation (a chaotic rhythm where the atria beat quickly and the ventricles do what they can to keep up) that wasn't responding to treatment. He was originally admitted for an emergency operation due to a perforation of the colon, which complicated a routine colonoscopy (that's where a gastroenterologist views the inside of one's guts with a fiber-optic scope looking for polyps, tumors and the like). The odd thing was that the man was walking around with this perforation for three days before going to the ER. This must be a tough guy. I have observed that people who ate the soles of shoes in
Our opinion was that the rhythm disturbance was a stress response to the intrabdominal infection (which is what happens when intestinal contents leak out and slosh around freely in the abdominal cavity). So before transfer to the ICU, we requested (we meaning my boss, the ICU chief and I) that the surgeons take another look in the abdomen to make sure that there were no remnants of colonic contents still around. After the operation we received him in stable condition but with ongoing atrial fibrillation.
I started a drip of an anti-arrhythmic and asked the other doctor on call to put in a central venous line while I went up to surgery to see another patient. When I left, the patient's blood pressure was 140/70, pretty good considering.
When I returned, the blood pressure was 80/60. In response to my query, the other doctor explained that the patient began to wake up from the anesthetic, so she administered a small amount of an IV anesthetic so that he wouldn't suffer during the procedure. This caused his blood pressure to drop. I quickly injected phenylephrine to boost the blood pressure but it continued to drop. I called for the defibrillator; in the several seconds it took to reach the patient's beside, the pressure had dropped to 40/15 - this is considered incompatible with life.
But then again, life is full of surprises.
Grabbing the paddles, I give the order to set the defibrillator at 100 Joules synchronized. Shouting "clear," I administered the electrical shock to the patient's chest and the rhythm converted to normal sinus rhythm. Yes, sports fans, we have a save! Except, that the blood pressure remained low. So we infused a vasopressor to get the pressure up. A few hours later our patient was weaned from both the vasopressor and mechanical ventilation. However, he had one more surprise up his sleeve.
While the nurses were changing his position (in order to prevent pressure sores which can develop only after 2 hours of immobility), the patient complained of pain, so we gave a couple of milligrams of morphine. A few minutes later, the patient became obtunded, with slow labored breathing. The fairly small dose of morphine had depressed his respiratory center. We had to reintubate and ventilate him, again. I administered a different anesthetic this time for the intubation (putting a breathing tube into the trachea). This anesthetic is known for preserving blood pressure, yet, again, his pressure dropped.
Again we gave him a drip of a vasopressor. A couple of hours later he was fully awake and alert with a stable blood pressure and mechanically ventilated through the tube. And, get this, he was actually flirting with the nurses! He must have been a real ladies' man in his youth.Eventually we weaned him from mechanical ventilation. He looked and acted as if he had just returned from a stroll in the park. This guy is indestructible.
Tuesday, December 4, 2007
Lately I've treated patients who were severely injured. That's nothing new. The common denominator of these patients was that the cause of their injuries was, for lack of a better term: stupid mistakes.
The first two I call the copper robbers (bear with me). They also might be called tweedle dum and tweedle dumber. These two numbskulls steal copper wire. Not that they need the money: they live in a moshav - one is a soldier and the other just finished his service. They are cousins. They are probably bored and were looking for some excitement. So, they went out looking for copper wire to steal. They found some. However, to their discomfort, the wire just happened to be connected to electricity, of the high voltage variety. The result: 40% and 60% burns. The treatment: multiple operations for skin grafts and a lot of pain.
The next victim: Legs of steel. An army doctor, a friend and student of mine. He was to provide medical support for some mission. This means hours of boredom sitting in the ambulance waiting for the signal to return to base if there are no wounded to treat. I imagine he got out to stretch his legs and take a breather. Unfortunately, he was on the main route in that particular area (just a wide dirt road) on a moonless night, when a Hummer with the headlights off for some reason, came round the bend and struck him. Why was he on the road, why was the Hummer hurtling down with the headlights off? Who knows? The result: head trauma, fractured ribs, legs, lung contusion, lots of pain. Probably a long period of rehabilitation, and maybe permanent disability. And for what? For a stupid mistake.
The last victim rattled me the most. A multi-car pile up. Three cars, 9 injured. 7 adults with mild injuries. But two children severely injured. A two year old girl who died of her injuries. A 12 year old whose scarred face will greet him in the mirror for the rest of his life. I was on call in Magen David Adom. The first ambulance on the scene evacuated him to my team in the mobile ICU. The sight was gruesome, deep gashes in his scalp and left cheek. The left side of the upper jaw was missing - it just wasn't there. Blood everywhere. He was semi conscious. Fearing aspiration of blood and gastric contents into the lungs, I sedated the boy and attempted intubation of the trachea (placing a breathing tube into the windpipe). This was plan A. Even with a suction catheter evacuating the blood from the airway, I couldn't visualize the vocal cords. Ventilating him with a mask and bag was just barely adequate, lots of air was escaping through the laceration in his left cheek. I decided to perform an emergency cricothyroidotomy. This was plan B. A relatively simple procedure in adults, it is trickier in children because the surface anatomy is less obvious. I added more sedation and made the incision in his neck to expose the cricothyroid membrane through which I might introduce a breathing tube. I wasn't able to pass the guide through. With his oxygen saturation dropping fast, I needed a plan C immediately, if not sooner! I instructed one medic to obstruct the hole I made in the trachea with a finger. I took a thick gauze pad and held the boy's cheek closed and with the same hand pressed the mask to his mouth and nose. I emptied the breathing bag into his lungs. A lot of air was leaking out, but I was able to improve his oxygenation. We loaded the stretcher onto the ambulance and raced to the ER. There, the anesthesiologists took over for me, my hands were tired at this point, and were able to intubate. After hours of surgery, the boy was transferred to the pediatric ICU in stable condition. The result of this accident: terrible damage to the bones and skin of the face requiring multiple operations in the future. No plastic surgery will ever erase the physical and emotional scars. All could have been avoided had the children been properly restrained with seat belts. (The children were the only passengers not wearing seat belts, and I remind you that all the adults emerged with only minor injuries because they were wearing seat belts). The parents will forever be burdened with guilt. Such a seemingly minor oversight, yet such catastrophic consequences.
The last few nights I fall asleep with the images of that accident. I replay the scenario over and over, this time I succeed in the intubation, another time I succeed in performing the cricothyroidotomy. Every time I scream at the parents, "why didn't you fasten their seatbelts?"
I've been staring at the screen for the past hour. I have no pithy summation. What can I write? Some stupid cliche like: "an ounce of prevention..."? I just feel drained. Darn it! I implore anyone reading this to drive carefully, and fasten everybody's seat belt, and don't talk on the cell phone while driving and stop making stupid thoughtless mistakes! I really don't need the aggravation.
Thursday, November 29, 2007
After 41 weeks my wife (finally!) gave birth to a strapping
I've had this ear-to-ear grin plastered to my face for the past week. I asked not to be on call the last few weeks so that I could be with my wife at a moments notice. Bad for the bank account, good for my family. Finally I can play with the children and actually stay awake at the same time; what a novel concept!
The evening before the Brit (the circumcision ceremony) we conducted "the Zohar," a tradition among Tunisian Jews (my mom-in-law came from
I had heard of him before I ever met him. Uncle Yosef once remarked that the rabbi's house burned down. Then one day, I was assigned to the ICU. The doctor presenting the cases mentioned that the quadriplegic in the bed in front of us was a rabbi.
Looking down at the chart, I saw on the admission sticker that the patient was from Uncle Yosef's moshav. After morning rounds I introduce myself to the patient and mention that I know Uncle Yosef, that he is my wife's uncle. He seemed relieved that there was a connection between us other than the patient/doctor relationship. He was indeed the rabbi of the moshav of whom I had heard.
Communication was limited: The rabbi had been severely injured in a motor vehicle accident and was paralyzed from the neck down. He was mechanically ventilated through a tracheotomy tube and unable to utter sounds. He "spoke" in croaked whispers and required some lip reading (which is not my forte). The rabbi was a rarity in the ICU. Since he did not suffer any brain injury he was fully conscious much of the time. Only when complications arose did we sedate him to allay any suffering. Every time I was on call in the ICU, I would make a point of greeting him and exchange a few words. I would always tell him what day it was and the time.
ICU patients who are conscious lose their sense of time since the fluorescent lights are on 24 hours a day. Telling them the day and time gives some sort of anchor. Despite his condition, he always seemed to be in good spirits. He always asked me about my family. Finally, after several weeks he was discharged to a rehabilitation facility.
A year later, at a the Bar Mitzva celebration of one of the cousins from the moshav, Uncle Yosef mentioned that the rabbi was there. I approached the rabbi. He was sitting in a motorized wheelchair. Dressed in a perfectly tailored suit. This was the first time I had ever met a former ICU patient outside of the hospital. I asked him if he remembered me. He said yes and thanked me for all the attention I paid him during his hospitalization. He inquired as to my family, I asked him about rehab. He said that it was a long difficult process.
This was the first time I'd heard his normal voice. He was breathing unassisted, and thanks to rehabilitation had regained partial function of his hands. He was able to feed himself, which is very important for one's quality of life (an important indication of a patient’s well being). I noticed that despite the din of the music he was reading the Gemarra that discusses thorny theological questions. I asked him how he could possibly concentrate. His answer: The Lord gave him the strength to recover from a horrendous car accident and the strength to ignore the noise around him and deal with higher matters.
Over the years, we met, mainly at such family functions. He never failed to show his appreciation for my concern. I told him that I felt blessed to have known him.
Whenever I think of the rabbi, I recall an incident which never fails to evoke a shiver.
One evening on call, I believe it was Sabbath eve, the patient in the bed next to the rabbi coded, necessitating resuscitation. During our resuscitation efforts, I heard the rabbi trying to call our attention. Being ventilated through a tube in his neck and quadriplegic, the only way he could grab our attention was to make a "tsk, tsk" noise with his tongue, which sounds sort of like the sprinkler jets for lawns. It is admittedly a grating sound. I saw on his monitor that all his vital signs were normal. Annoyed, I called to him that we were in the middle of resuscitation and that I would get to him as soon as possible. After a lengthy resuscitation, the patient improved. I approached the rabbi's bed. Somewhat winded from the effort, I tersely asked him if something was wrong. He asked if the woman in the adjacent bed was OK. I was embarassed by my lack of patience with him.
I was amazed, despite his own suffering, he was concerned with the patients around him. I'm not religious, and I claim no knowledge of what a saint is. But I think that this man is the closest I'll ever be to meet such a being.
The rabbi never made it to the ceremony. He wasn't able to secure the special vehicle he needs from the local council office at such short notice. I talked to him on the phone and told him that I was very moved by his intention to surprise me. I promised to visit him at the first chance. To have such a man bless my new baby is a special privilege indeed.
post script: 1. I still haven't been able to visit the Rabbi (shame on me).
of a flashback of a flashback). A personal record.
Sunday, November 25, 2007
Look over to the right. I recommend Treppenwitz, a fine blog it is.
One of Trepp's posts was about a neighbor of his, an army officer, who was wounded in the line of duty. I posted a comment that I had treated the officer. Trepp offered me a cup of java. I have yet to imbibe of the glorious black nectar from the hand of a great blogger (and gentleman I might add).
We both work in the same city. So, how about it Trepp? Will we do coffee? Or how about this?: I make you a cup. I have a sparkling new espresso machine (thanks Mom and Dad).
1. I have an ego, just like everyone else, so I want to know how "popular" I am.
2. And just to justify, at least to myself, that the time I spend blogging (which is limited to say the least) is not time wasted.
It's likely too early to make any grandiose claims, but it seems that I actually have a readership out there in the blogosphere. I dare not call them faithful readers just yet. If someone actually likes reading this exercise in self-indulgence then at least two of us are enjoying ourselves (and probably even one more (hi Mom!)).
The previous site has agreed to republish my old posts so that I can download them. I will be posting them here because they held some interest for a time and some might find them entertaining. Ideally, I would prefer that they appear in the chronological order that they were originally posted. This is mainly because some of the posts dealt with the current events at the time (e.g. the war in Lebanon last summer). I haven't figured out how to do that. If anyone has a solution please let me know.
My original reasons for blogging were, and for the most part are still, two: First, to get it all out. Anesthesiology is a very high pressure job. I am a classic adrenaline junky, but even I get OD'ed once in a while. It is helpful to have a place to vent without having the wife and kids suffer my insufferable personality after 36 hours straight on the job. Secondly, I have a sneaking suspicion that most of the public has little or no idea about what an anesthesiologist actually does and how one does it. So, call it a public service.
That is my humble excuse to offer you a peek into my world.
Friday, November 23, 2007
Oral exams have always been my bane. I hated them all through med school. Written exams were never a problem. When confronted by live examiners, I would black out, forget everything I ever knew, including my name. The residency, for those who don't know, lasts for several years during which time one must pass a written test (known here in Israel as "stage A"), and an oral test ("stage B").
This was not my first attempt. In the past I have become almost catatonic during the exam, making the impression on the examiner that I am a total idiot (in the best case) that should not be unleased upon an unsuspecting public. The worst case scenario, is the examiner who has an orgasm if he/she can show the examinee that he/she/it possesses the intellectual capacity of an underdevelped amoeba. These sadistic characters are of the most odious kind and provoked quite a few vivid fantasies of examiner-cide. More than once I entertained the thought of showing up for the exam armed to the teeth with high powered rifles, a main battle tank, a couple of ballistic missles, or, conversely, some particularly cruel instrument of torture. The fact that I am not now serving a life sentence for muder in the first degree is proof that none of these plans were carried to fruition (despite the fact that I might have become a folk-hero on the order of Robin Hood).
The frustrating aspect of this exam, is that I rarely get flustered in emergency situations (which more or less occur every day). I can give a lecture to a hundred professors, treat 4 trauma victims simultaneously (supervising junior residents of course) and prepare my reserve unit for war without batting an eyelash. Put me in front of an examiner and I instantly become invertebrate.
The explanation is, as should be expected, psychological. All the aforementioned situations are normal for me. I have been extensively trained for such scenarii. But the exam is different. I am out of my element like a fish out of water.
This time I treated the cause and not the symptoms. Since the problem was psychological, I approached the preparation for the exam from that angle. First of all, a friend in the department (to whom I am indebted) helped me prepare. Whether knowingly or not, he used a method which is accepted in the treatment of phobia called: desensitization. Briefly, the patient suffering from a phobia is gradually exposed to the offending stimulus until the phobia disappears. For example, a person who is afraid of flying will be shown photographs of airplanes at first. Then, perhaps a tape of airplane sounds will be played. Eventually, the person will board a plane that will not take off, and the final step will be to fly. There are even flights scheduled that don't go anywhere especially for the treatment of this phobia. The patients will just take off and land at the same airport ( I don't know if access to the duty free is included in the treatment).
So thus we simulated cases discussed in an exam format. At first, we would discuss the cases at length for 1-2 hours picking apart the most minute detail of HOW to answer questions. This would be done in a very friendly atmosphere. Eventually after several months, my friend would play the "mean" examiner and the time for discussion would be identical to the time allotted a case in the exam itself.
In addition, I went to a hypnotist who used hypnotic suggestion to convert the uncomfortable situation of the exam to one where I feel like a fish back in water, i.e. the general feeling would be as if I were at work and not in an exam. Since I took a course in medical hypnosis, I easily enter an auto-hypnotic state which made this process quite effective.
The exam itself was still somewhat stressful but nothing like what I went through in the past. And, in fact, I now realize that I know more than most of the examiners. When the exam ended, the examiners entered a room to discuss the performance of the examinees. This is done especially for those who were borderline. In other words, an examinee may have performed badly in one or two stations making a poor impression. But if the rest of the examiners were impressed with the cantidate, then a vote is taken whether or not to pass the examinee. At the end of this process, which lasts for about an hour, the director of the exam invites the examinees one by one to be given the results.
This process is nervewracking. The exam itself is 4 hours. Another hour waiting for the examiners to finish their deliberations. And then, we each enter the holy of holies. I can only compare the feeling to what I imagine a condemned man feels when being lead to the gallows. Of the 7 condemned, I was the last to go in. The first went in, and came out with a smile - pass! The second went in - fail. How I know that terrible feeling. The enormous effort to prepare, all for naught. Not only the examinee suffers, the entire family suffers as well. For months my children saw only my photograph taped to the refrigerator door. My wife was a "stage B widow". The third entered the shrine - fail. My heart races, beads of sweat form on my brow. The fourth enters - a smile - pass! The fifth enters - pass! The sixth enters - fail. My turn. Suddenly the world is transformed into a universe of quantum mechanics, as I travel close to the speed of light, the universe around me slows down (what the heck, I was never very good at physics). I tread the hallowed ground. The lord of the known universe begins to utter the following words: I have good news and I have bad news. I feel my head swim, my knees feel weak. "The good news is that you passed all 8 stations. The bad news is that you did not pass with honors."
I replied that I will live with the calumny juuuuuuuuuuust fine. His holiness smiles and shakes my hand. Time returns to it's normal speed. As I exit the room, I hold out my fist with the thumb extended as Caeser did when deciding the fate of a defeated gladiatior. Thumb down - death. Thumb up - life. Maintaining a poker face I see the anxiety on my friends' faces. Slowly, and simultaneously I point my thumb to the sky and smile. Even now, just recalling the moment, I am overwhelmed with emotion. And then, a shout of triumph mysteriously is emitted from my throat. It sounds like the jubilant war cry of a Mohican.
The first person I call is my wife. I hear my daughter in the backround screaming with joy. Finally we can go north for the vacation I denied the kids for so long. Then I call my parents. Mom says that it was easier giving birth to me than watch me go through this. The rest of that evening raced by like a tornado. Needless to say, I didn't sleep much from the exitement. The weight of the world has lifted from my shoulders. It's time to start living again.
However, I was completely traumatized the last time I was on call, not by the patients, but by the nurses. Because of a last minute no show by the shift nurse in charge, another nurse was asked to fill in. The that night shift was staffed by the "vampire nurses from hell". They did their best to drain all the blood out of me. Some of them were just plain stupid, and others were stupid AND lazy (a very endearing combination). Their collective IQ did not reach 100. Among other things they managed to let a patient fall (or perhaps jump to safety) out of his bed. This was a drug addict who had undergone CPR including defibrillation (electric shock) when he suffered a cardiac arrest after a drug overdose. After a very dramatic scene in which each nurse pulled on a different extremity to try to pull him back into the bed, I tried to calm everyone down, but to no avail. How the patient was returned to bed with everyone pulling in opposite directions shouting and yelling is still a mystery to me. It was a real soap opera, but a few minutes later, the patient was back in bed no worse for the wear, having suffered no injury. I requested that the nurses fill out an incident report, which is standard practise. One of the nurses sort of casually mentioned that this was unnecessary since no one would tell about an incident that happened in the middle of the night. This incensed me, because there are some nurses who never hesitate to tell the ICU director about any mistakes (no matter how small) I make.
Now during all this was the nurse in charge running around hysterically like the proverbial chicken without a head. Except, that she really has no head. OK, actually, she has a head but it is filled with vacuum (is that an oxymoron?) She has no concept of filtering out the amount of stimuli that spews forth from her mouth. She never shuts up. She always makes lot of fuss and actually gets very little done. She constantly updates the doctors with very "important" information that we can easily see on the monitors or extract from the electronic charts. (All the patients' vital signs and even latest lab results are accessible on a computer screen). The straw that broke the camel's back came at 5 am when my ear had just settled comfortably onto my pillow. She jarred me awake to inform me that the patient's cardiac enzymes were elevated. I asked her what, exactly, she thought I should do with that information. I told her that a patient that underwent CPR with diffibrillation is supposed to have elevated enzymes, so no one should be surprised. She must have noticed the exasperation in my voice because she answered, "I'm only doing my job and informing you of abnormal lab results". I am resigned to the fact that she is beyong rehabilitation. She is, and I mean this in the most mean spirited way possible, an incorrigable moron.
OK. enough therapy.
This week I took the two older kids to their swimming lesson and put the youngest in a inflatable float with me in the pool. For an hour he drilled a hole in my head by whining and crying. He kept saying "red" over and over again. By "red" he means anything that is pigmented with any color whatsoever and has caught his fancy. I usually swim without spectacles, making me practically blind. I had no idea what he was looking at. Incidentally today he learned to say "yellow" which is completely interchangable with "red". Very efficient little fellow if you ask me. Since then, I purchased optical swimming goggles. WOW, what a difference. I can now see the scantilly clad babes in the pool. What an eye opening experience (I know, I have no shame.)
Anyway, after an hour of this whining I finally removed him from the water. He immediately mad a bee-line to a purple float which looks like an oversized noodle, and is, in fact, called a "noodle". He took the noodle and showing no fear and equally no sense jumped into the pool (I remind you, he's only 1.5 yrs old). After my heart started beating again, I pushed his head above water and he was laughing. He was laughing! He was having the time of his life. And he didn't want to leave the water. When it was time to go home he threw a tantrum and burst my eardrums. By the time we got to the car the histrionics were over and he reverted to his usual sweet self. He should get an Oscar for that performance.
When I was younger, the female soldiers (who are aged between 18-20) would check me out. Maybe they didn't like what they saw, but at least they looked.
As I get older, I noticed that they don't see me. Literally. I'm as invisible as the air we breath. But, that doesn't bother me so much. What really bothers me, is that now, when I see a woman over 35, I think to myself: "hey not bad at all".
The bar is being raised constantly.
Recently I took part in the oral exam of med students at the end of their anesthesia rotation. One of the students is the son of on of the senior physicians in our hospital. This surgeon, who I've worked with for years, told me the following tale:
He asked his son how the exam went and who the examiners were. His son mentioned the names of the other two examiners who were with me, but didn't recall my name (for some reason). So his father asked him to describe me, and this was his answer:
Quiet, gentle(manly) and looks like Richard Gere.
I suggested that his son have his eyes checked. Being the homophobe that I am, I would prefer that the comparison had come from a female student. But on the other hand, I'll take what I can get.
And you can bet your eye teeth that I immediately called my wife to brag to her and tell her that she should count her blessings that she married such a good looking gentleman.
I've always been a night person. Especially during my bachelor days and while in school, I used to either study and/or party all night and wake up at noon the next day (at the earliest). Now, I'm forced to wake up at 5 AM and be at work by 7:00. The truth is, it's not all that different. I'm still awake at the same hours, just my sleeping schedule has changed. When I would come home at 5 AM after a night of pubbing, I always enjoyed the stillness of that hour, before the world wakes up. It's still the same, except for the opposite direction of travel.
I enjoy observing the "regulars" on the bus ride to Be'er Sheva. There's the pretty young woman with the Barbara Streisand nose, perfect coif (not a hair out of place) and the smart ensemble. Always, black pants: low cut. On this cool morning she wears a thin sweater with one shoulder bare. It looks so spontaneous but I'm sure it's all planned. How does she do it? There are the soldiers; they seem to be immune to the early morning chill. The naval officer, with all sorts of impressive pins and insignia. Just before he steps on the bus, he always looks to his left, warily eyeing the surroundings. He has an expression that says that he is a match for any situation. He is definitely not a navy commando officer. I've known a few of those. They are the most humble and unassuming people I know, yet they lack no self confidence.
There's the security guard and the girl who works at the gas station - they get on the bus at the same stop. There are some people who prepare the bus fare or the prepaid ticket before getting on. There are those who put their bags on the first seat and then rummage around looking for spare change. I like to be prepared; I've never understood people who get on the bus unprepared, I just don't get it. They are the ones who usually get on first and then block the aisle for all those following them.
I get off the bus at the hospital, and another workday begins. Routine operations, mostly. Since my internship I've been expanding a list of rules I invented. They are modeled on the rules set out in a book called "The House of God" by Samuel Shem. Every doctor has read the book, usually in med school. It's a very satirical take on the internship year and the "Rules" have become classics. Some of the humor is very morbid, but sometimes one needs such a release when working day in and day out in a stressful environment. So here are some of the "rules" of Soroka University Medical Center:
1. The intern/resident (depending on your stage of training) is always to blame.
2. If there is work to be done at the end of the day, the intern/resident can do it, even if he/she is not on call.
3. All roads lead to X-ray.
4. The swiftest doctor in the hospital is a rotationer after morning rounds. (Explanation: residents on rotation: these are residents doing a rotation outside of their specialty, for example plastic surgeon rotating through general surgery as part of the syllabus. These residents are usually studying for the board exams and tend to be found in the library 5.5 milliseconds after morning rounds are over.)
5. All patients speak Russian until proven otherwise. This rule is true also of doctors, nurses, nurses' aids, x-ray techs, lab techs, orderlies, landscape crew, housekeeping staff and the laundry workers. It is NOT true of secretaries for some esoteric reason.
6. Each unit of blood ordered involves at least 4 telephone conversations with the blood bank. (Invariably, when one has ordered blood immediately for an emergency operation, the blood bank tech will ALWAYS call and ask: "do you really need that unit NOW?" This is when I wish I had Bugs Bunny's ability to reach through the telephone and strangle the tech with my bare hands).
7. When the noradrenaline drip (for supporting blood presure in unstable patients) is discontinued, the patient's condition immediately improves which means prolonging dying for another three days.
8. If it looks, acts, walks, talks, smells, sounds and feels like septic shock, it's probably septic shock. (This rule resulted from and argument between two senior physicians in the ICU about the cause of a patient's unstable condition. The more senior doc's diagnosis was invariably, wrong.)
The day runs smoothly, routine operations. At 3 PM, the on-call starts. The doctors who are not on call finish their operations and sign out. We start doing the trauma cases that have stacked up during the afternoon, mostly orthopedic cases. I was sent to CT to anesthetize two children who needed emergency scans. Back at the OR, the hours fly by without noticing. It's midnight and the general surgeons bring up an elderly patient with a small bowel obstruction. The patient is stable during the operation. The cause of the obstruction is adhesions due to a previous operation (a common complication). At 2 AM we are done. I send the other anesthesiologists to get some rest and finish up the log of the day's cases.
At 3 AM, I'm woken by the telephone: get to OR 5 quick, a stabbing victim is being rushed in. I wake up another anesthesiologist to help with the case. The patient is a 20-something Bedouin, barely conscious with no palpable pulse. I wonder who the hell gets stabbed at 3 in the morning: was it a drug deal gone sour? A fight among thieves? (Most law-abiding citizens, except bachelors and students, are usually asleep at that hour.) The surgeons cut open the abdomen while we put in some big IV lines, I start infusing warm fluids with a pressure infuser (capable of infusing fluids and blood at 1 liter per minute at body temperature). When the surgeons get to the abdominal cavity the patient's almost non-existent blood pressure is explained: All the blood has spilled out of a cut artery. I ask the surgeon to clamp the aorta (the largest artery which is a conduit to the rest of the arteries in the body). In the meantime, I get blood units hooked up and infuse them. The patient now has a blood pressure, low, but existent.
There may be hope for this patient - providing the heart and brain didn't suffer too much from the lack of perfusion. The surgeons suction out the blood and look for damage made by the knife. They perform what's known as "damage control surgery." The minimum is done to prevent further bleeding, and then the patient will be taken to the ICU for stabilization. The blood pressure is depressing, and the patient dies soon after arriving at the ICU. The vital organs just couldn't overcome.
These kinds of cases always weigh heavily on my mind. I always replay the events, second-guessing myself. Was there something I could have done better, or faster, or just more? Considering the patient's condition upon arrival, it's a wonder he survived that long. But still...
A few hours later, I'm home. Tired? That doesn't quite describe it. I feel like I'm observing the world from inside an aquarium. I glance through the morning paper, and come upon an item that puts everything in perspective. A short article about the stabbing victim. It turns out he was a wife beater, and also used to beat his children. After years of abuse, and very uncharacteristic of Bedouin wives, she took the law into her own hands (she probably never complained to the police before), and stabbed her abusive husband.
She was a murderer. The children were taken in by the victim's family. A tragedy that punctuates years of a family's tragedy. Somehow I felt the failure to save the victim less acutely. I don't condone such violence, but perhaps, in such a brutal environment, brutish justice was served
The clinic is sometimes very hectic with over 40 patients per day. I salute family physicians who deal with this case load on a daily basis. For me, it's enough twice or thrice a month. I guess I need the daily adrenaline rush of an emergency case to keep me on my toes. On the other hand, having an opportunity to interact with patients at eye level (not lying on a stretcher) is a refreshing change.
One might call the clinic a parade of endless variety. Human nature never ceases to amaze me. For example, a pretty young woman came in to the pre-op check-up prior to a gastric banding procedure. This was to be her fifth procedure. The previous four surgeries had been complicated by slippage of the band, perforation of the stomach and more. I was floored when she said that the thought of another anesthetic scared her to death. She was looking for reassurance. I told her that she should rely on her experience; all the complications she suffered were surgery related, none were related to anesthesia. Besides, modern anesthesia is safer than ever (kind of like air travel, isn't that reassuring?).
I'm always surprised by the question: "doc, will I wake up at the end of surgery?" I always think to myself, "and if not, what, you're going to know about it?" No, I don't ever actually say that to a patient, I always reassure them that I have a 100% wake up rate. The fact that someone is planning on cutting into one's flesh is less frightening to some than the anesthetic. Apparently, this fear is really the fear of loss of control over one's body, of one's autonomy. This perhaps, is the only real freedom one is granted by nature. To willingly surrender one's autonomy to a total stranger is a frightening prospect, and this explains why many of the patients ask if I will be their anesthesiologist for the surgery. I humbly submit that this question has less to do with the patient's impression of my professional ability, and more with the simple need to see a familiar face in unfamiliar surroundings.
Despite the case load, I make a point to counsel smokers about the need to quit smoking. It is somewhat of a personal crusade, I admit it. I hate cigarettes, no, not hate, despise. I always have, even as a child, I refused to allow smokers into my room, even if they weren't smoking at the time (because of the accompanying stench). Ironically, I'm an ex smoker myself. I started, like many, before I grew a brain, during my army service. Sometime after the age of 30, my brain grew in. I haven't touched a cigarette in six years. I unabashedly use myself as testament to the fact that it can be done. The counseling only takes 5 minutes, and usually something I say convinces the patient to at least try to quit. The mini-lecture includes the cumulative adverse effects on body function, the connection to systemic diseases such as heart disease, lung disease and high blood pressure. Smoking causes cancer, not one kind, several different kinds. Cigarette smoke just plain stinks, it stinks up the house, the clothes, the hair. Those that smoke in the home endanger their children as well. There was one young woman who didn't seem convinced by any of it. The look on her face was one of utter boredom. I asked her, "doesn't any of this make sense?" She answered, "It all sounds logical, but I just like to smoke. It's as simple as that. I don't want to stop." I told her, "Maybe not now, but every smoker I've ever known reached the point where they wanted to stop, but couldn't." I didn't seem to make any impression on her. But then, I said something which touched a nerve. Everyone has a weakness, a soft underbelly as it were. I said, "If all this doesn't impress you than I want to say one more sentence: It is unaesthetic to smoke. A pretty woman or handsome man who puts the death stick in their mouth is just plain ugly." At this point, she burst out in tears. Of all the logical arguments that I put forth to quit smoking, none made a dent in her façade. Only by appealing to her vanity was I able to get through to her. Yes, human nature at work ladies and gentlemen.
The last patient of the day was a kind grandmother of 12 who was born in Morocco. I mention her birthplace only to explain that Moroccans have a great tradition of hospitality which includes excellent food. While taking her medical history, she suddenly pulled a plastic bag out of her purse. The bag was filled with Moroccan cookies and pastries. "Here", she said, "taste." Along with a proud tradition of hospitality is an equally important ability to be mortally insulted if that hospitality is rejected. Out of politeness, I tasted a cookie, commented on how sweet it was and handed back the bag. "No" she said, "you take the whole bag." Either she had another 12 bags of cookies for each of her grandchildren or she was impressed by my charming personality. I didn't dare refuse.
The first week was the worst. Our oldest and youngest had the flu. I, of course, left Saturday morning for the hospital. The expression on my wife's face was a combination of pathos, like a kid who had his Nintendo confiscated, and burning jealousy, that I was escaping the wrath of the Devil. I had never seen that expression before. It was unnerving.
The on-call was, as usual, action packed and exhausting. I came home expecting an empty house and a few hours of sleep. My bubble was about to burst. My wife was exhausted, the baby kept her up all night. I told her to get some sleep and I would watch over him for a couple of hours. After some rest, she took him to the pediatrician and I got some sleep. Our ordeal was far from over. Over the next 3 nights neither of us got any substantial rest. The baby demanded to be held in our arms. Furthermore, like a motion detector, he would sound the alarm if, heaven forbid, I tried to sit down.
My wife literally broke down in tears from exhaustion. I am used to being tired all the time, but this was much worse. The last time I felt this degree of fatigue was in basic training in the army when I went 5 days without sleep. I was the only one in the company to get leave for the weekend because during grenade practise I blew the target up into the air. My buddies accredited my grenade-throwing skills to my previous baseball training. (I didn't let on that I never played little league, I played soccer). I didn't really enjoy that weekend because I went to bed on Friday afternoon and woke up on Sunday morning. I vaguely recall getting up to go to the lavatory, but I'm not sure. I didn't eat and I didn't drink, and before I knew it, I was back on base.
OK, enough flashback. My wife bounced back rather quickly, but I didn't feel quite right for several weeks. I was suffering from vertigo and every morning I woke up with a headache, and I had no energy to do anything. And I was still doing on-calls. In the mean time, everyone had at least one more round of the flu in various forms. At this point, I started to imagine all sorts of really nasty diagnoses that might explain my symptoms. What, you say, go to a doctor? Are you nuts? Have a doctor poke and prod me and finally tell me that it's probably viral, yeah, right. I myself have used that line many times. I'd like to remind everyone of a sobering fact: Fifty percent of all doctors finished medical school in the bottom half of their class. With my luck, I'd be examined by the guy/gal who finished last. Do I sound paranoid?
Fear not dear readers, I've fully recovered, the wife and kids are all healthy. Not only that, but the baby started walking this week. Amazingly, he can even talk at the same time. Yep, he walks and talks simultaneously. I must add that both he does like a drunk, but I suspect that he will improve with practise. For those interested I've uploaded a fuzzy video of said achievment. He also managed to break my glasses and my cell phone in the same week. The glasses-breaking annoyed me. The cell phone much less. It gave me an excuse to upgrade to a much sexier phone that does almost everything. Though I can't figure out how to get it to change diapers. I admit it, I love my gadgets. So sue me.
To somehow connect all this to medicine, I relate the following phone conversation while on call. The clerk in the ER called to tell me that there was a trauma victim in the trauma room who fell from a height. She then told me that he was fully concious and that there was no need for the presence of an anesthesiologist in the trauma room. This conversation took place in the evening. I was reminded of a scene from the Three Stooges. (yes, yes, I am not ashamed to admit that I was addicted to the Stooges in my youth). Moe can't sleep so he wakes up the other stooges with a slap in the face. Groggily the other two ask what happened, and Moe says, "Wake up and go to sleep". I asked the clerk "If the victim had come in at 5 in the AM, would you have woken me up to tell me not to come down to the trauma room?"
She had no idea what I wanted from her.
Usually we do three shifts straight (24 hours) while the paramedic and the ambulance driver are relieved every shift. In the ambulance, just as in the hospital, the "rule of three" applies. The rule of three is sort of a Murphy's law of medicine, or, to quote Morton's salt motto: "When it rains, it pours." The idea is that you never encounter just one patient with a heart attack, or just one car accident during those 24 hours, you always get at least three.
And so it was this time. A day of psychiatric cases masquerading as something else. The day started with a "jumper." A woman "fell" four stories out the window...naked. Her son was sleeping (at 9 am!) at the time. He offered no other information. We found her fully conscious with several fractured limbs. She was relatively lucky that her fall was broken by the roof providing shade over the patio below. We carefully evacuated her on a backboard, which probably prevented nerve damage. We later learned that she had severe vertebral fractures and 70% narrowing of the spinal canal. When I called my fellow anesthesiologists on call later that day, I was informed that the woman jumped because she heard voices telling her to do so.
The next case: A young Bedouin who had lost consciousness. When we got to the scene different family members offered different versions of what happened. One claimed that he fell off a horse. Another claimed that he just collapsed during a soccer match. None of these people actually witnessed the event. The young man was unconscious when we put him in the ambulance. Eventually, the true story came out: that he had a vociferous argument with his brother and had lost consciousness immediately afterwards. In other words, he had an attack of "desert rage." He came to in the ambulance, broke a shelf by kicking it, threatened the paramedic and myself. What a nice guy. The psych consult found no psychiatric disorder. They never do.
Then came another unconscious Bedouin. This time a 14-year-old adolescent girl who chewed 4 pieces of her father's nicotine gum. She probably had palpitations because of the nicotine and then had an anxiety attack. She came to in the ER.
Then the last case of the day: We were dispatched to an elderly lady with chest pain which turned out not to be chest pain at all. It was yet another attack of anxiety. The woman had been informed that her dog was very ill. One of the symptoms of her anxiety was a feeling of "pins and needles" in her face and extremities. It happens because of hyperventilation (a fast breathing rate). After the paramedic helped her to calm down she was all smiles and thanked us for all the TLC (tender loving care).
Then she started to analyze her own reaction and thought it was all rather interesting. And then she floored me completely. She said, "Ya know doc? At the same time I had all these weird feelings." Then, dropping down to a whisper, "I felt very warm in my privates." Now, what is the correct response? What I wanted to say was: "OK, ma'am, that was a lot more information than I wanted to hear." But trying to be polite, I mumbled something like, "yeah that happens, I wouldn't worry about it too much."
So much for thinking fast on my feet. These are situations that they never told us about in med school