Thursday, November 29, 2007

Time and Money

I know, I'm awful. I just couldn't resist passing this on:










We knew this empirically but now we have mathematical proof!


Thanks to Yariv

The Rabbi

Faithful (If I may be so bold) readers: The following incident was originally posted on a-to-remain-nameless-site a year and a half ago when my 3rd child was born. I haven't changed a word:

After 41 weeks my wife (finally!) gave birth to a strapping 3.9 kg (8.5 lbs.) baby boy.

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 Tunisia). But the prayer was delayed because Uncle Yosef was late. Finally, he arrived with news that the rabbi of his moshav (an agricultural settlement) is planning to surprise me and come to the Zohar. Filled with emotion, I tearfully recall my first meeting with the rabbi...

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).

2. The sharpest readers will note that this post is, in fact, a triple flashback (flashback
of a flashback of a flashback). A personal record.


Sunday, November 25, 2007

A sneaky way to get a cup of coffee

There is an ulterior motive for this post. No, I have no shame, none whatsoever. Yes I have some self respect. Besides, I really like good coffee.

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).

A word of explanation

Some readers may have noticed that I posted 9 posts in one day. This is not because I'm a particularly prolific blogger. Rather, I had my blog on a site managed by the online version of a newspaper. That site was quite limited and made no allowances for personal preferences in format. In addition there was no way to gauge traffic to the site except by the number of comments which were always in the single digits. This latter concern bothered me for two reasons:

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

The Ordeal

I am posting this blog about passing the Oral Bored Exam in Anesthesiology. This was my personal crossing of the Rubicon, a cross that I bore or any of the infinite myriad of any tiresome metaphor of your choosing for subjecting oneself willingly to torture.


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.

oxy- and other morons

At the risk of insulting someone of the nursing persuasion, I must say that some of the nurses in the ICU are total idiots. To be sure, and I will mention this in order to deflect any insinuation that I am a misogynist, we have some equally wonderful nurses. And to tell you the truth, I couldn't possibly do what the nurses do.

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.

Students

This is an expanded version of a previous blog. I hope you are not disappointed:Among the many duties of a physician in a university hospital, is teaching. The main task is to teach medical students in their clinical rotation. I'm reminded of the old television series based on the movie, "The Paper Chase". The crusty old professor declares that the first year law students "come in with minds full of mush, and go out thinking like lawyers" (this is said in a very dramatic Boston Brahmin inflection). During the anesthesia rotation of two weeks, we try to make sense out of the tremendous amount of pre-clinical knowledge regarding physiology, disease processes, pharmacology etc which creates a very thick muck in the gray matter of a typical student's brain. This muck we then turn into clinically relevant information. Often, the students comment, surprised, that they didn't know that anesthesiology was such a complex field.In addition to medical students from the Israeli medical school here at Ben-Gurion U., we also teach students from the Medical School of International Health which is a joint program of BGU and Columbia U. Since these students are fluent in English, I am always tapped to instruct them. But this is only the tip of the iceberg. We also instruct paramedics from the Emergency Medicine Program, nurses in an intensive care nursing course, and pharmacology students (future pharmacists). Moreover, I give formal lectures in various courses including ACLS (Advanced Cardiac Life Support – CPR to the layman). This means that about six months out of the year we perform clinical instruction during office hours. Bottom line, while I'm providing anesthesia I'm also explaining, teaching, grilling the students on their knowledge. This takes great concentration and frankly, is very draining. For all the effort, I enjoy teaching and from the feedback I receive I am a good teacher. (The slapping sound you just heard is me patting myself on the back).I usually try to inject some humor during a lecture, to prevent the listeners from going comatose. This tendency to somnolence is especially apparent when the lecture is scheduled after lunch. The students' blood supply is preferentially directed to the gastro-intestinal tract and almost no blood goes to the brain at that hour. I've found that humor also serves me well during clinical instruction in the OR. I've been surprised when a former student, years later, quotes my clinical "pearls of wisdom". For example, I maintain that the best way to monitor a patient is to use all six senses. Only five senses you say? Nay, six, here they are with their clinical uses:1. Sight – to see the fountains of blood when the surgeon makes a hole in a "small" artery like the aorta. It's also good for judging the effectiveness of a patient's breathing.2. Hearing – to hear the "beep, beep, beeeeeeeeeeep" of the pulse oximeter (measures oxygen saturation in the blood). Also good for auscultation of breath sounds and heart sounds using a stethoscope. A stethoscope is a low tech instrument used for listening to informative noises that originate in the body. However, this piece of equipment works only if there is a minimum of one neuron connecting the ears of the auscultator to each other.3. Smell – to detect fecal contamination of the surgical field when the surgeon makes a hole in the bowel. Also good for judging how long that piece of fish in the cafeteria has been out of water.4. Touch – to feel a patient's pulse. And sometimes to hold a patient's hand in comfort (a radical idea, I know).5. Taste – many years ago, diabetes was diagnosed by tasting the patient's urine. This is no longer in vogue. Also, may be used to confirm that that piece of fish in the cafeteria has been out of water too long.6. Sixth – this self named sense is the one that tells us it's time to consult a lawyer (preferably one with a mushless brain).Imparting such pearls of wisdom is an important part of clinical instruction, and sometimes some of the really important stuff gets lodged in the students' minds along with them. This becomes apparent when, at the end of the rotation, an oral exam is administered to the students.Recently, I took part in such an exam. A few days later, I was on call in the ICU. A senior surgeon came in to check up on the patients from his department that were admitted to the CU. He asked me if I had tested his son. I said "I guess so, but we (there were two other examiners also) didn't ask if he was the son of… to avoid any hint of favoritism." The surgeon told me that he asked his son who tested him. He remembered the names of the other two examiners but not mine. But he described me as "soft spoken, gentlemanly and looks like Richard Gere". Ok, that's a compliment but I have no illusions concerning my outward appearance. Immediately I did two things:1. I told the surgeon to take his son to have his eyesight examined STAT!2. I called my wife to tell her: "Madam, you must thank the Lord that you married a soft spoken gentleman who bears a striking resemblance to Richard Gere.My wife's reply: "what are you talking about, I married YOU!That is a perfect example of a reality check.

And another thing...

I still do quite a bit of reserve duty as military physician. And I noticed something interesting and somewhat disturbing.
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.

Good for my ego...I think

Don't get you're hopes up, this will be a very short blog.
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.
Yeah, right

The Rules

It's 5:55 AM. I check the kids to see that they are still covered by the blankets. The next time I see my children will be in another 36 hours, I'm on call today. Locking the door behind me, I take a deep breath of the morning air. It's cool and damp with some light fog beginning to disperse.

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

The routine of the OR is sometimes broken when I am assigned to the pre-op clinic. The main purpose of the clinic is to prevent last minute cancellations of operations. These cancellations usually occur when a patient with a chronic illness, such as heart disease, arrives on the day of the operation in less than optimal condition. An example of this might be uncontrolled blood pressure on the day of the operation. Such a patient's surgery is cancelled and the patient is usually referred to the family physician to reassess the patient. This results in inefficient utilization of the OR and causes frustration for the patient who may have waited quite a long time for his/her surgery. Such a patient would be identified in the pre-op clinic and sent to the appropriate referral.
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 fa├žade. 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.

scratch your head

Last January was the worst month ever. This time I won't tell you about this or that patient. This is mostly family related. January came in like a lion and wrought havoc. I'm talking about the flu. At any given point in time, 2 or more of the family were with flu. Not that we were any different from any other family, but add to this on-calls, well, you get the picture.
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.

Psychiatry Day

Here in Beersheba, the department of anesthesiology has a contract with Magen David Adom. We provide them with 24-hour coverage in the mobile intensive care ambulance. It's a win-win situation. We get to work outside of the hospital, which is a nice change of pace, and the public gets doctors who have experience in both trauma and acute coronary care management. There are few specialties that combine both fields. Even ER doctors (in Israel) usually stay within their respective fields, either surgical (trauma) or internal medicine.
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
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