Sirens

The sirens wailed and we gathered up the children and went into the bomb shelter. The kids are a bit scared but in good spirits. We called my in laws in the city, they heard two explosions. No casualties thank God. Looks like we'll spend the night in the shelter.

Update:

The nursery school in Be'er Sheva that was hit by a missile was the one my eldest daughter attended. It is very close to the apartment we lived in. My in-laws still live in the same neighborhood. Thank God it was at night when the school was empty.

War

I'm on call here in Tel Aviv in the delivery room. And my family is down south, where war is being waged against the evil that is Hamas. Thankfully, my village is out of range of the rockets. What I feel is mostly frustration, and also outrage.

Frustration. That I'm not with my family.

Frustration. That the world still doesn't see our enemies for what they are: Bloodthirsty barbarians who sanctify death.

Outrage. The world criticizes us for defending our country against the constant barrage of rockets and mortars that have been directed towards Southern Israel for the last 8 (!) years. And FYI, the rockets were fired usually around 8 AM and 4 PM, the time when children go to school and come home.

Frustration. Because the Arabs are too infantile and primitive to accept peace.

Outrage. At the thinly veiled anti-semitism of the world community. Their criticism is directed to the wrong party. It's Hamas who should be condemned.

Yes, yes, I'm not politically correct. Screw PC. The European left, the Israeli left and the hypocritical Arab "intelligenstia" are simply wrong. And immoral.

No Israeli Jew has ever rejoiced at the death of an enemy or at the death of civilians. No Jew has ever murdered a mother and her daughters in the own beds. No Jew has ever smashed the head of a 4 year old child against a rock. No Jew has ever knowingly or purposefully sought out women and children for massacre. (Sabra and Shatila you say? That was payback by Lebanese Christians for years of atrocities commited against them by Muslims. And the bitter irony is that the Jews were blamed.) This is the Arab way and I despise them for it.

There may be moderates in the Arab world but their voice is not heard. And that is too bad.

SurgeXperiences Blog Carnival #212

Welcome to the the 12 edition of SurgeXperiences Blog Carnival season 2! This is my second time hosting. Enjoy!

Since there is no theme, for better or for worse I've sort of catagorized the posts. This time I'll be starting with posts from patients (after all, we do all we do for them, right?)

Patient Blogs

Raymond, a personal finance expert, posts about his experience with laser eye surgery. It is a concise and comprehensive review of the pros and cons.

A doc at M.D.O.D tells us what it is like to be in a medical emergency from the patient's point of view in: Tamponade, or if it weren't for bad luck...

Every one of us should read this woman's account of emergency surgery for an ectopic pregnancy. Her pre op anxiety was not addressed, and her post op pain relief came too late, for shame!

Kyle Shewfelt shows us some of the hardware that was removed from his leg.

These parents share the frustration of canceled surgery.

Student Blogs

Ben Bryner describes the process of applying to a residency program in: Surgery, Interviews and Rock'n'Roll. He writes: "Actually, nobody's really asked me what I would to if I couldn't be a surgeon. But my predetermined answer is: A sushi chef (like surgery, but more delicious) or a reporter."

Unprotected Text, relates the difference of teaching styles in anatomy class in this post .

Sharps Container wants to scream as she recalls the suffering of a child with burns after child abuse. I urge her to remain a sensitive soul, as she writes: "But now--with nearly a semester of medical school behind me--I think my reaction to the case would be changed...But I would still want to scream. I hope I never lose that impulse."


Resident Blogs

Dr. Alice worries about her upcoming pediatric rotation, but is relieved to find that it's not as bad as she expected. And she even finds time to go to the Library!


Surgeon Blogs

The Prairie Pooch gives us a glimpse of the future of robotic surgery in A Surgeon You Can Swallow.

On the other hand, Paul Levy opines that perhaps there is no added benefit to robotic laparoscopic surgery, but was forced to buy such technology in order to be competitive.

Becky and DrWes both found this interesting story that gives new meaning to surgery at a distance.

Aggravated Doc Surg details the art of "The Bump" (bumping another surgeon's cases for an urgent one.) He also gives thanks that he didn't suffer this nasty fracture.

RL Bates posts an informative post about skin cancer.

Self Mutilation was never so bizarre as Your ER Doc posts in this weird case.

The ever witty Bongi tells us that Out of Benoni he emerged, despite the negative prognostication of an evil headmaster. In words, even the ever cool Bongi loses his composure (justifiably I might add).

In Transplant Gone Wild, Buckeye Surgeon reports the story of an immoral doctor who ran amok, completely unchecked. Shocking.

Medical Imagery

For those who like pretty pictures, KevinMD sent us this gem. Warning to those with a weak stomach: Not for viewing before a meal.

Ron Miguel RN sends this hi res photograph of a surgeon's hand.

Oystein sends two posts: Lego Eye - can you spot the mistakes?, and Inner Sights - illustrates what a little bit of annotating can do to a picture. He also found this delightful music-video celebrating the heart.

Other Stuff (for lack of a better name)

Archeology and Surgery fans will enjoy this find brought to us by Dolce Vita.

Erica Collins posts this site listing 50 awsome video games for Physical Therapy and Rehab.

Anesthesiologist Blogs

Guess what? No posts from anesthesiologists were submitted. Hey wake up people!!

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SurgeXperiences is a blog carnival about surgical blogs, wherein surgical experiences are shared. It is open to all (surgeon, nurse, anesthesia, patient, radiologist, pathologist, etc) who have a surgical blog or article to submit. The next edition of SurgeXperiences (213) will be hosted by surgical first assistant Make Mine Trauma at "IntraopOrate" on 21 Dec, 2 weeks from now. Be sure to submit your post via this form.

Memes, aren't they annoying?

Darn, I've been tagged.
Gila, the only reason I'm doing this is because you're such a sweetheart. I usually ignore memes. So let's get this over with. To those whom I am about to tag, please forgive me.

5 Things I was doing 10 years ago:
1) Began my residency.
2) Amazed everytime a patient woke up at the end of anesthesia.
3) Oldest child in the planning stages.
4) Did my first reserve duty as a military doctor.
5) Had the cat castrated. (No, I didn't do it myself.)

5 Things on my to-do list today:
1) Make sure the patient wakes up at the end of anesthesia.
2) Be more patient with the children, even after being on call.
3) Be more patient with my wife, even after being on call.
4) Enjoy a really good cup of coffee.
5) Study some Gemarra.

5 snacks I love:
1) Poptarts.
2) Chocolate.
3) Olives (yep, I pop down those suckers like extasy pills).
4) Pizza (the kind they make in South Philly).
5) Beer (snacks can be liquid too ya know!)

5 Things I'd do if I were a millionaire:
1) Take the family on a trip around the world.
2) Attain a PhD in Philosophy.
3) Attend 50 Jazz festivals in one year.
4) Establish a college fund for disadvanted youth.
5) Bribe a prominent politician.

5 places I have lived:
1) Jerusalem, Israel.
2) Bloomington, Indiana.
3) Cheltenham, Pennsylvania.
4) Ithaca, New York.
5) Be'er Sheva, Israel.

5 jobs I have had:
1) Truck driver.
2) Short order cook.
3) Dairy Farm worker (cows are some of the nicest

people I know).
4) English teacher.
5) Cashier.

I tag: Baila, Zahava (aka Mrs. Bogner), Jameel, T, Bongi.

Here I set, But elsewhere I rise

Several years ago, one of my favorite artists, Ehud Banai (singer/songwriter/musician), was interviewed on television. He recounted a short vignette that appeared in his book that was published that same year called, "Remembering Almost Everything".
(זוכר כמעט הכל).

Yuval Glick was only 19 when his airforce plane went down into the Sea of Galilee (in Hebrew - Kinneret). His mother had immigrated from Bulgaria as a teenager and had a difficult period of adjustment. But one day she was taken on a trip to the Kinneret and the sight of the sea that greeted her, made her feel as if she had come home. Every year she would travel to the same spot where she had first seen the Kinneret. She contacted Banai and told him all about her son who had been a fan of Banai's.

After her son died she no longer traveled to the Kinneret, she felt anger towards the lake for taking her son.

Four years later, she called Banai again to tell him of a life changing event. She finally decided to go back to the Kinneret, for reconciliation. During the long journey from the south, she had a tape of Banai's music playing over and over. She would drive, then stop, cry and then continue driving. As she reached the very spot where she had first seen the Kinneret, she heard Banai's voice emanate from the speakers:

"What can I say,
What can I say,
Here I set,
But elsewhere I rise."

מה יש לדבר,
מה יש לדבר,
אני שוקע כאן,
אבל זורח במקום אחר

The recent tragedy in Mumbai has affected everyone here in some way or another. I was on call in the delivery room on the Sabbath providing epidurals for women in labor as the depressing news came in, but I packed it away. After all, babies being born is a joyous occasion.

By all accounts, Rabbi Holzberg and his wife Rivka H"YD, were exceptional people. I didn't know them, but their murder shook me. We all know why they and others in the Chabad House were murdered, because they were Jews. While they were brutally murdered in Mumbai, here, in Tel Aviv, Jewish babies were being born.

Perhaps the sun that set in Mumbai rose elsewhere.

The Incident

It was bound to happen. I stepped on someone's toes. This someone just happened to be the teacher's pet. And it happened when I was only a couple of weeks on the new job. Great way to make an impression.

One evening I was in charge of the recovery room. The end of the morning shift and the beginning of the call is always a chaotic period. Recovery is full of patients and as the operations finish more are brought in. For the most part the nurses are very independent and recovery runs quite smoothly. But at this crucial time of day a physician is needed to help out.

A patient after a long operation was brought to recovery. The anesthesiologist briefed me on the patient's history and the operation. A few moments later, the nurse called me over to examine the patient who was not breathing well. In fact the patient was in respiratory distress and need to be intubated and ventilated. The anesthesiologist was still around and she didn't want the patient to be reintubated. A rather vocal argument erupted between the nurse and the doctor. I told the doctor that I'm working in recovery and she might as well go home for a well earned rest. She didn't take the hint and stayed. Against my better judgement I went to tend to other patients. But moments later, the nurse, this time more agitated than before, called me again to see the patient who was not doing better. At this point I told the anesthesiologist that I believe that this patient needs to be ventilated. She said that she wants to check the ABG (arterial blood gas). This blood test shows the oxygenation, ventilation and metabolic status of the patient. I said that the patient is clearly in respiratory distress and that even if the ABG is normal, she still needs to be ventilated. The nurse, again added her vociferous opinion and was very rude. To diffuse the situation I again suggested that the anesthesiologist go home that I would take care of the situation. Again, she did not take the hint, drew blood for the ABG and went to place the sample in the machine. While she was absent, I asked the nurse for the intubation tray.

The ABG showed normal oxygenation but PCO2 (a measure of ventilation) of 45 mmHg. This is the borderline normal, but a person with respiratory distress should be hyperventilating and one would expect the PCO2 to be much lower. This result shows that the patient is tiring and will eventually stop breathing. Even though the text books mention a PCO2 of 55 as the indication for ventilation, I never wait for the patient to breath so poorly before intubating, it's just plain cruel. I said as much to the anesthesiologist but she remained unconvinced. Again, the nurse rudely voiced her opinion. I was getting tired of this and proceeded with the intubation. Flustered, the anesthesiologist said she was going to tell the boss. I felt like I was in kindergarten.

With the patient safely intubated and ventilated, I was called to the phone, the boss was irate. I was raked over the coals for being insubordinate to a more senior physician. She (the boss), asked rhetorically, if I thought I was more familiar with the patient than the anesthesiologist who had spent the entire day with the patient in the OR.

Flashback to kindergarten, no, nursery school. The teacher asks why did you break the window?
Oh, I dunno, I decided to evolve into a teenage punk a bit early and vandalize. Holy crap, is there any right answer to such a stupid question?!!!

The next morning, I apologized to the other anesthesiologist, that I had no intention of insulting her, but I felt that the patient's condition warranted immediate action. She, surprisingly, thanked me! Holy cognitive dissonance Batman! Yes, she actually thanked me for distancing her from the rude nurse!

(BTW, I actually have great respect for the rude nurse's vast clinical experience. She was, well, just rude.)

Then we were called to the boss' office where again I was raked over the coals, albeit very charmingly (did I mention that the boss is normally a very charming woman?). The important thing was not the clinical question of whether to ventilate or not (silly me, I thought that was the point), but that we maintain a good working relationship among the staff. This was starting to play out like a Fellini film. (Did I mention that I'm a great fan of Fellini?)

After a long beautifully crafted speech, I said, "Boss, you've burst through an open door, because we've already kissed and made up, the wedding is in three months." For a moment she had no idea what I was talking about, then, the light bulb lit up. "So why did you let me go on and on?"
I said, "it was such a nice speech, and you obviously spent some time thinking about what you wanted to say, I just didn't have the heart to stop you."

I figure, if one is to be raked over the coals, do it with style.

Post Script #1: Since then, my reputation has only improved.
Post Script #2: A month later, I serendipitously anesthetized the same patient for a tracheostomy because she still hadn't been weaned off the ventilator.
Post Script #3: I want to announce to all involved: "I told you so!!!". But I won't, because I was brought up to know better. (Thanks Mom and Dad).

Happy UnBlogoversary

With my usual impeccable sense of timing, I've completely missed my 1st blogoversary by one full day. So, on this inauspicious occasion, I wish to wish myself a very Happy UnBlogoversary to me.

Upcoming Surgical Blog Carnival

I will be hosting the next SurgeXperiences BlogCarnival on Dec. 7 (a day that will live in infamy). There will be no theme this time. All relevant subjects will be considered. So, surgical bloggers, get your creative juices flowing! Submit your posts here.

That Really Bugs Me

The hours are long, the commute is long, but I'm very pleased with this hospital. The work load is tremendous, almost impossible. But there is a very positive atmosphere. Although there are things that I prefer about my previous hospital, there are things here which make the work much more enjoyable. There is much support in the the small tasks in the OR that together add up to more than the sum of their parts. In general the running of the OR is much more efficient. In my previous place of employment, besides anesthetizing the patient, at the end of surgery I would bring the patient to the PACU (Post Anesthesia Care Unit aka recovery) and have to personally inject all the iv meds that I ordered for the patient. Then, run back to the OR and prepare the equipment for the next case.

In this OR, the PACU nurses perform all the tasks ordered by the anesthesiologist without the anesthesiologist being physically present. During this time there is the support staff that prepare the OR for the next case. This means that I have more time to be a doctor and just be with the patients. I actually have the time to talk to them. In addition to medical history and physical examination, I have the time to actually get to know the patients, even superficially. Surprisingly, I've discovered that most patients have jobs! Last week I anesthetized a dancer with a broken leg. Today I anesthetized a composer. We had a lengthy and fascinating conversation about the Israeli jazz scene (jazz is one of my passions).

Not surprisingly, these short exchanges calm the patients as much as, if not more than, iv anxiolytics. One can't feign interest, the patients respond to someone who sees them as people and not as "cases". Even the brief interaction between a patient and the anesthesiologist can be meaningful. This is all the more intense when the patient is faced with life altering events...

...The operation should have been scheduled for the morning when everyone is fresh. But all the rooms were booked which means that the operation would be postponed for another day. The parents were red-eyed from crying. They brought their young child to the hospital because of generalized weakness. The diagnosis: a brain tumor in the posterior fossa, which involves a particularly difficult operation fraught with danger. The most senior anesthesiologist on call took the case while the rest of us continued with the "regular" emergency operations. Working through the night, at 7 AM the child was transported to the pediatric ICU. I can only imagine the turmoil the parents went through. Their previously healthy child was diagnosed with a life threatening tumor and within hours underwent uneventful surgery.

This story will most probably never be reported in the newspapers. There is a "journalist" in one of Israel's dailies who has made a career of "exposing" malpractice. Obviously, I don't condone malpractice. But this evil man, by twisting the truth has ruined careers, all to sell a few rags. His vitriolic articles spew hatred for doctors and the medical system. Perhaps he or a family member were victims of malpractice. Some say he has a chip on his shoulder because he wasn't accepted into medical school. Whatever the reason, he writes negative articles exclusively. To be sure, there is malpractice, most often it can be attributed to the insane pressure of an impossibly overworked system. He will never write about the good things we do on a daily basis. That really bugs me.

Pilot of the Soul

I've been working in my new job now for a couple of weeks. It's been exhausting. The commute has only a minor part in this. The toughest part is being the "new kid" in the neighborhood: Becoming acquainted with the staff and the various functionaries is the most challenging part. Learning the local customs, less so. Basically anesthesia is anesthesia. The difference in technique and approach is really one of nuances. What doesn't change is one's attitude and professionalism.


This recent article in the online version of the Jerusalem Post describes the current shortage of anesthesiologists in Israel. But the article also reviews a fascinating book by my former boss and mentor Prof. Gabriel Gurman. The book is unique in that it is bilingual. That is, it was written in Hebrew, translated to English and both versions appear in the same volume. The book is called "Visionaries and Dreamers - The story of the founding fathers of Anesthesiology in Israel". Far from being a dreary history lesson, it is a portrait of the pioneers of the field in this country, who almost always worked in the most difficult of conditions.

Today's Israeli anesthesiologists have a great legacy to follow. Although it is a rather young specialty in medicine, it is also the oldest:

ויפל יהוה אלהים תרדמה על האדם ויישן ויקח אחת מצלעותיו ויסגור בשר תחתננה

"And the Lord God caused a deep sleep to fall upon Adam and he slept; and He took one of his ribs, and closed up the flesh instead thereof (Genesis 2:21)."

One of my colleagues describes anesthesia in the following way: It's a situation where one (the anesthesiologist) is standing with the patient at the edge of an abyss, then pushes the patient over, and then, at the last moment grabs the patient's hand and pulls him back. Although there is some truth to this dramatic notion, I prefer the interpretation of A.B. Yehoshua a prominent Israeli writer in his book "Open Heart". The following is a short review of the book by Lior Granot, Prof. Gurman's co-author in a personal note. She quotes:

"...The most important part of anesthesiology is not abandoning the patient. Think of the patient's soul, not just of his breathing. During surgery, while the surgeon is completely focused on one small part of the patient, the anesthesiologist is the only one thinking of the patient as a whole, not just parts put together. The anesthesiologist is the real internal doctor..."

Granot continues:

This is a quote of what Dr. Nakash, the anesthesiologist in Yehoshua's Open Heart says to Benji, the young resident... Dr. Nakash, a calm man with inner peace, calls the anesthesiologist "the pilot of the soul". He compares anesthetization to a plane taking off and the safe awakening of the patient to landing. "Think of yourself as the pilot of the soul, who has to insure that it glides painlessly through the void of sleep without being jolted or shocked, without falling. But also make sure it doesn't soar too high and slip inadvertently into the next world."

I rather like this spiritual approach. It provides a deeper meaning to what the anesthesiologist does, and reminds us that the crux of the profession is it's humanity.

A Blog Award

It's official, I received the:





For this post.

You can read the review here.

Shana Tova

Most Jbloggers end their posts with Shana Tova - Happy (Jewish) New Year. I'm a Woody Allen type of guy: He prefers to start off a first date with The Goodnight Kiss, it breaks the tension right off the bat. So to all my fellow Jews - Shana Tova. And to the rest of my loyal readers ( all 15 of you ;P ) - there are only 91 shopping days until Christmas.

I'm currently unemployed. Well, that's a bit melodramatic. I'm in between jobs. I handed in my hospital ID and I'm starting my next job after the holiday. This period has been marked by emotional ups and downs, and has been punctuated by finding a used car. (After prolonged exposure to used car salesmen - I doused myself with chlorhexidine.)

Despite my rugged exterior (hah!) I've found myself becoming more emotional and even sentimental lately. For example, I was recently promoted. Rank means very little in the IDF reserves. There is no monetary reward for higher rank. And really the best man for the job is the one who does it even if he doesn't wear the formal rank. Often a private or a corporal will do the job strictly done by an officer according to merit. So I've never really put much emphasis on rank per se. The ceremony was a very informal affair attended by my commanding officer, his commanding officer and a few others, some in civilian attire. The most important guests were my parents. My CO said a few words, and before the changing of my insignia, I asked to say something. I explained to the small assembly that I enlisted 23 years ago as a "lone soldier". In the IDF, that usually means a soldier whose immediate family lives overseas. Here, family follow their children's milestones and attend the various ceremonies. In my case, the end of basic training when the recruits swear allegiance to the state, the end of tank commander's school, and officers school. I was physically apart from my family during all these ceremonies, although I never felt alone or deprived. I never felt sad, probably because I was young and suffered from that eternal malady of youth - the illusion of complete self-sufficiency and self-importance.

I explained to the officers present that this small unassuming ceremony had special importance to my family because it was compensation for all that my parents had missed. At this point I got all choked up. I seem to be developing into a sentimental fool in my old age. Usually one's commanders place the new insignia on one's shoulders. In this case it was my parents who performed the honors.

This past weekend I was privileged to meet the parents of a former patient who are neighbors of the Treppenwitz's, with whom the Sandmen spent a wonderful weekend. Again I became pretty emotional. Their son was injured while serving as an officer in the IDF. Treppenwitz wrote about him and I recognized the description and wrote to him. Thus began a beautiful friendship (Sorry Bogart!) .

I'm not sure why I've been getting so choked up lately. I suspect that my move to another hospital, the end of an era, as it were, has opened up a Pandora's box of pent up tension and feelings.

Reserve me a room at the Loony-Bin Hilton

I am currently dealing with 3, yup, count 'em, THREE bureaucracies:
1. My current employer.
2. My future employer.
3. The scientific council of the Israel Medical Association.
The first is to terminate my employment. The second is to start working in a new hospital. And the third is to obtain my consultants licence. The paperwork is daunting. I have single handedly deforested half of the Amazon basin.
And I'm looking for a car. Have I mentioned that used car salesmen make my skin crawl with their clammy slimeyness?
If you hear about me being commited to an asylum, you'll understand why.

"Lasts"

This is a month of "lasts". Last call in the ICU, last call in the ambulances, last call in the OR, the last presentation before the department. I've been in Be'er Sheva for 19 (!) years. So it is with mixed feelings that I'm leaving. Next month I'll be starting my new job in Tel Aviv.

On one hand, Soroka Medical Center has been like a second home (it is entirely possible that I've spent more time there than at home). I'm leaving all that is familiar, even the most annoying people have their own quirky charm. At the most practical level, I'll have to learn who the key players are, where do they put everything, how do I get from here to there and back? (Where's the mask and bag for heaven's sake??!)
On the other, I've become weary of the same old, same old. It's a new start, a chance to develop and grow and that is what makes the move exciting.

So as I look forward, I also reflect on the past. I look in the mirror and see a stranger. Who the hell is that distinguished looking gentleman? (I should probably smash that cursed mirror into a thousand shards.) Inside, I still feel as young as that med student from almost two decades ago. When did this imposter arrive on the scene? But there is some weariness in those eyes. Weary of the same old arguments, the politics, the gossip, the general obsession with crap. And if I hear another fellow worker say, "but it's not my job." I will be put away for homicide (by reason of insanity).

The last call in the ICU. It was a mess: Motor vehicle accidents, ruptured aorta's, blood everywhere galore. When one of the nurses asked if we were going to draw bloods for some tests, I asked her to do it because of the work load. Her answer, "it's not my job" (even though most of the nurses do draw bloods when the doctors are busy). For a moment, I entertained the notion of dragging her by her hair and throwing her off the roof.

The worst case, a 33 year old mother of 5 involved in a car accident. The children were arguing in the back, she turned to yell at them and the car drifted into a lamp post. The entire family injured, a 2 month old infant fataly. The infant wasn't strapped into her car seat. I've posted this before. Please use safety belts. I really don't need the extra work. Ironically, a friend from med school called to tell me that she knew the family, and on numerous occasions lectured them on their laxity regarding buckling up.

The last call in Mada. It was gruesome.
**Warning**Not for those with weak constitutions**
*To those who proceed beyond this point: I bear no responsibility for anyone who faints, vomits or feels like crap!*














Three bodies.

The first was the worst. An elderly woman (maybe) with dementia went missing on Thursday. She was found in a mechanics shop on Sunday when he opened for business. The guys from Zaka had already wrapped her in a body bag. Of course the head was at the closed end. To be able to fill out the death certificate I have to personally look at the body. I decided the cut open the bag from that end. Even before cutting the bag the stench was overwhelming. I exposed the face, she was not alone. She was covered with maggots. Why do I have to deal with this? This country doesn't have medical examiners who go out into the field, so the doctors in Mada have to. This is not why I became an anesthesiologist. This is a reason why pathologists exist, they like this stuff (I think).

The second was an 82 year old woman who collapsed while her daughter was giving her lunch. By the time we got there, there was nothing to be done. I informed the daughter, an only child, that her mother was dead. She burst into tears. As she cried she kept apologizing, that she is usually strong. As I filled out the death certificate, I noticed that the mother's ID number was short, meaning that she had been in Israel for a long time. The daughter told me that she was indeed a Sabra, native born, and that she had been an educator, a writer and a poet. She was from the generation of the Nephilim, that legendary generation that reestablished the Jewish State. She still was apologizing for crying. I told her that she has every right to cry and grieve for her mother. I said that she seemed to me the anchor of her family and that everyone relied on her. She replied that I had hit the nail on the head. Well, now it's time for you to rely on them, let your family support you for a change. She seemed relieved, as if a burden had been lifted from her shoulders.
The last body, a young man who commited suicide by hanging himself. Another lost soul, another young widow, another small child who will never know her father.

After three bodies, I had enough. I did the only thing that I could do, I joked. I told the ambulance driver to take me to the nearest Rabbi, no not the nearest, the heaviest hitter, the guy wielding the most clout with the Lord. The body count stops here.
No, we didn't actually go to a Rabbi. We went to eat felafel. But perhaps my surreptitious, inadvertant little prayer worked. The rest of the call was just nuts and bolts.

This Saturday is my last call in the OR. I'm hoping I climb the walls with boredom.

But I won't bet my life on it.

The Burned Girl - continued

Several weeks ago, I provided anesthesia for the daily dressing change of a child who was severely burned. In the weeks that have passed, her condition has improved, the skin grafts are looking fine. I was sent again to anesthetize her. But the plastic surgeon said that at this point in her recovery there is no need for anesthesia. She had already begun walking with the aid of a walker. However, she continues to scream and cry anytime the nurses touch her, or even approach her with scissors. Since pain is a subjective experience, it is difficult, especially in children, to determine if the behavior is because of pain, anxiety or both.
As the nurses began to remove her bandages, I observed her behavior. My gut feeling was that her screams were more from stress and anxiety than from pain. Surely she had good reason to be anxious. This little girl has experienced more than her share of suffering. I tried to engage her in conversation to try to divert her attention from what the nurses were doing. I had little success, the nurses were concentrated on what they were doing and didn't realize what I was doing and so there was no cooperation on their part. The girl had fasted in anticipation of the anesthesia which probably added to the stress. I made my mind up, I won't anesthetize her. I gave her a cup of water. While she was drinking, she didn't notice what the nurses were doing, which confirmed my instincts. A therapist also joined in the proceedings. She took measurements for a pressure suit that the girl will have to wear to improve the healing of the skin. Even the measuring tape frightened her.
At this point it was futile to try to calm her. So many people were talking at the same time to try to sooth her and it was having the opposite effect.
Truth be told, I was becoming irritated at the staff who prevented me from doing what I do best, induce relaxation. I don't necessarily need drugs for that, just the right attitude. I refrained from reprimanding the staff in front of the girl and her father. I didn't want to embarass them or add to the level of stress in the room.
After the bandages had been changed, the nurses were about to put a fresh diaper on the girl. I said, "No diaper!" Amazing, they listened, and dressed her in hospital pajamas. I took the father aside and told him that this is an important step in her rehabilitation. For three months she has been serviced by the staff and her family, justifiably, but now is the time for her to become an active participant in her recovery. So let's start with this. She is old enough to tell you if she needs to use the toilet. If so, then she can use the walker, a wheel chair or even be carried there. This is the beginning to restoring her autonomy.

The Scotsman

I don't know how coherent this post will be since I was on call yesterday and my wife is on a trip up north just for the ladies paid for by her boss (The Ministry for Environmental Protection). So it's just me and the kids. Well, I do have the help of the most fantastic babysitter ever invented, ever! She is wonderful with the children and our youngest, (all of 2.5 yrs of age) is completely smitten with her. And best of all, she has a black belt in karate. Anyway I'm very tired, but still feel the need to write.

The month of Elul, the last month of the year, is traditionally, a month of reflection. This year, Elul happens to coincide perfectly with the Gregorian month of September. The last day of September is Rosh Hashannah, the New Year. After which, on the 1st of October, I will begin my job in Tel Aviv. It is so coincidental that it's eerie.

There is a common practice in academic hospitals to conduct a journal club. This is where doctors present the latest professional literature to their colleagues so that everyone keeps up to date. In our department, it is called (in Hebrew): Pinat hashekef. Which, roughly translated, is "The Overhead Slide Corner". That makes no sense whatsoever. It actually sounds like a really tricky baseball pitch. (Maybe I'll invent that some day.) Remember towards the end of the previous millenium, before Powerpoint? We used to prepare presentations on plastic pages to be projected by an overhead projector onto a screen. These were generally handwritten! So that's where the name came from. Now, of course, we use powerpoint presentations, but the name stuck.

This Sunday, I'll be presenting my very last pinat hashekef ever in Soroka MC. I decided to depart from the normal procedure and offer a reflective presentation of my observations over the past 19(!) years. Most of it will be humourous (I do have a reputation to maintain). It will be mostly inside jokes and I'll be making jabs at some of the staff.

But I will also present some of the wisdom I've accumulated over the years and will thank my mentors, one of whom I will mention here:

Dr. Alan Fisher z"l passed away suddenly several years ago. He was found slumped over a workbench in his workshop, he was an amateur carpenter. Dr. Fisher came from Scotland in the 1970's and was a pioneer in establishing the ICU in Soroka. He also was involved in medical ethics, surely a novel field at the time. True to the stereotype, he was thrifty and drove the same automobile for 30 years, well, actually, to save money he rode a bicycle to work. His work ethic was legendary and he kept us residents on our toes. He also had a fantastic sense of humour. Being the only other English speaker in the department, I was privileged to hear him tell jokes in a Scottish accent that couldn't possibly be translated into Hebrew. There was only one minor problem. His timing was terrible and he ruined most of the jokes. Nonetheless, I laughed, may I be forgiven, because of that fabulous Scottish accent. Truth be told, he was the source of much of my early material. I was able to translate some of the jokes into Hebrew, often to a raucous reception. From what I've written here, one might get the impression that I spend most of my time engaged in jocularity. There are situations in medicine that are often pregnant with tension, especially when the staff is tired and working hard in the middle of the night. Sometimes, just the right turn of phrase diffuses such a situation. And many times, a patient, anxious to the point of tears facing emergency surgery, will relax after a kind word, a smile and yes, even a lousy pun helps.

Dr. Fisher taught me many things. He taught me anesthesiology and critical care. He taught me about diligence and attention to detail. But most of all, he taught me to be a human and humane in inhuman situations.

No Stranger to Pain

It's no secret that August is a tough month for parents. No summer camp, no day camp, no activities. Just me and the missus versus three little indians climbing the walls waiting for someone to entertain them. I'm on vacation now which means that I'm actually conscious most of the time. We were up north for a few days near the Sea of Galilee. It was hot and humid and sticky but we found lot's of water based activities for the kids so that they had a great time. So did I actually. But it was a relief to be back home where we have "normal" weather - just hot.
This prelude explains why I've actually had time to blog. Here are a couple of cases that have been stewing in my overheated brain for a bit.


I had the privilege of being on call in the ICU on the day that the Chief decided that two patients should be woken up from anesthesia and weaned from the ventilator.
The first patient was a 50 something gentleman who fell off a ladder while painting his home in preparation for his son's wedding. He had a brain contusion and rib fractures which caused a pneumothorax thus necessitating the insertion of a chest drain. As I reviewed the chest film before waking him up I noticed that there were old rib fractures on the opposite side.

In an epiphany of free association, I recalled two of the greatest movies of all time: Rambo - First Blood Part II, and Hot Shots! part Deux. I remember a line that is uttered in both movies. It must be mentioned that the second movie is a parody of the first. In Rambo II, our intrepid hero is strapped to a device to be tortured by electric shocks. The device actually looks like an old bed frame from a 5th rate motel. So much for Hollywood production values. Rambo has his shirt ripped off, conveniently showcasing Stallone's muscular physique. The torturer sees the multiple scars that adorn Rambo's torso and says, "I see you're no stranger to pain". Rambo then just grunts a reply. In Hot Shots! the scene is recreated with Charlie Sheen as our intrepid hero. His reply to "I see you're no stranger to pain" is: "Yeah, I've been married...twice."

Anyhoo.

Ladder man was obviously no stranger to pain. I began the weaning process. At one point the patient was fully conscious and extubated. I informed him that he was in the ICU after falling off a ladder and enumerated his injuries. He said, "what are you talking about? I fell off a ladder two years ago!". Which explained the old rib fractures. He had absolutely no recall of his most recent fall. Attaining the full measure of sarcasm that I could muster, I suggested he sell his ladder. Unfortunately, the patient develped severe pneumonia necessitating reintubation and another week of mechanical ventilation. Needless to say, he missed his son's wedding.

The second patient was a young bedouin who was suffering from hydrogen sulfide intoxication. That's the gas that makes rotten eggs rotten, and flatulence, well, just stink. But is is also toxic in high concentrations. He was working in the sewer when he was overcome by the gas and lost consciousness. A fellow worker tried to drag him out but felt the effects himself and had to abandon his co-worker. A rescue team from the fire dept. finally extracted him after half an hour. In addition to the effects of the gas he had aspirated raw sewage into his lungs. This patient actually recovered quite quickly with treatment. When he awoke I told him where he was. He also had no recall of the events. It turned out that it was his first day on the job with a contractor. The contractor didn't tell him that the work was potentially dangerous. I told him that he should give thanks to the Almighty because he had come within a hair's breadth of giving up the ghost. I also suggested that he contact a lawyer. It felt good to sick the hounds of hell on a non-physician.

I just love giving good advice.

The Discussion

My wife's Uncle Yosef recently celebrated his 75th birthday. For such an auspicious occasion, the family organized a feast in his honor in their yard. As the family, friends and guests began to drift into the venue, I spied the Rabbi of the moshav (an agricultural community) being wheeled in his wheelchair. I immediately went to greet him. The Rabbi is a former patient from the ICU. To better appreciate the relationship, I direct the reader to a previous post about the Rabbi. He is a young man (anyone younger than me is young. Period.). Yet he has a certain aura about him, and despite his age he commands the respect and even fondness of the members of the moshav.
After the usual pleasantries, we immediately began discussing religion, medicine and more or less everything under the sun. I suffer from an affliction that compels me to seek out and engage the worthy for such philosophical discussions. Some may find such intercourse tedious, I find it rivetting. I have few friends and acqaintances who are of the same ilk. Among these are a few that though we may not speak for months or years, it feels as if we never parted. I have the same feeling whenever I meet the Rabbi. At one point food was served and I asked the Rabbi if he wanted to take a break from our discourse to break bread. To my surprise and even embarassment, he declined, and said that this (our discussion) was more important. To be held in such high esteem by such a remarkable man is very flattering.
I don't know how long we spoke, but as the discussion became more intense we became oblivious to what was going on around us.
Our concentration was shattered by my cell phone. Drats! It was my wife. After a few moments I whispered into the phone, "Yes dear."
I turned to the Rabbi and said, "If we don't eat something, the women will be insulted."
"Your right" he said.
As we partook of the victuals, we both ruminated over the last words of our conversation. And then we joined the party.

Jbloggers Conference

Just a few thoughts on last night's NBN Jbloggers conference.
At first I felt somewhat fish-out-of-waterness. I didn't really "fit the profile" of the conference. On one hand, I don't blog on "jewish" subjects. On the other, I believe my jewishness informs my outlook on life, work, the universe etc... So, I guess I'm just as jewish as the next blogger...well, jewish blogger.
I was somewhat annoyed with the political undertones of the conference, as there was a perceived majority of a certain demographic, but that was to be expected I suppose.
Former prime-minister Bibi Netanyahu made a grand enterance. He is a very knowledgable and engaging speaker. Unfortunately, he spoke for over an hour which detracted from the time alotted to other bloggers and presentations. And, again, I was annoyed with his campaigning (once a politician...)
Little known fact about me:
I grew up in the same Philadelphia suburb where the Netanyahu's lived when the patriarch (Ben-Tzion) was a professor at Dropsie College. We didn't live there at the same time. I mention this not as a claim to fame, but as a prelude to the next bit of personal information:
My decision to return to Israel, after having grown up in the USA, was crystallized after reading a book called "Yoni's Letters". Yoni, Jonathan Netanyahu (z"l), was the older brother of Bibi and was the commander of the operation to free Israeli hostages from a hijacked plane in Entebbe in 1976 (oddly enough the year of my Bar Mitzvah). Yoni was killed in action during the operation and is probably the best known of Israel's military heroes. After his death, letters he sent to his family during his army service were published as a serial in an Israeli newspaper and eventually compiled and published in book form. BTW the book was translated into English.
As I read the book, I was surprised to discover some of the parallels in our lives. Yoni went to the same high school as I did, and his impression of American culture was identical to mine. Reading his letters mirroring thoughts and feelings of mine served to galvanize my decision. Despite having grown up in the US, I never felt that I completely belonged, a fish out of water as it were. So after finishing my undergraduate degree, I packed up and came back home, albeit a home I barely knew.
23 years later I'm at a conference of Jbloggers meeting many others who have come home. Some very very recently and others like myself, not so recently. Strange fish, strange water. Everyone was looking at everyone else's name tag. Some actually recognize my blog's title and even like the blog.
I was able to exchange a few words with Treppenwitz and his charming wife Zehava whom I had the pleasure of inviting to a hike in my neck of the desert a couple of months ago. David was his usual witty self and in my opinion was the star of the evening (despite Bibi's fabulous enterance in the middle of David's words).
I also had the great pleasure of meeting one of my favorite bloggers Gila, who writes My Shrapnel. And I must mention a delightful conversation with Baila.
Because of the diversity of the bloggers in attendance (200!) and those watching online (1300!), I agree with one of the speakers, that the Jblogosphere is a conglomerate of people with the same hobby (OK some do this professionaly). It made for an interesting evening.

Update

Just a bit of news.
In the previous post, I described the odd case of a John Doe who was severely beaten. He recovered quickly and was transferred to the surgical ward. This morning while talking to a social worker, he lost consciousness. The code team was called and rescusitation performed. He didn't make it.
The next bit of news has been percolating for sometime: I'm leaving Soroka. After 19 years (including med school, internship and residency). I was offered much better terms in a hospital in Tel Aviv. For various reasons, I won't be uprooting the family. So I will be commuting everyday by train. Despite the shortage of anesthesiologists, no one from management really made an effort to find out why I am leaving. On the other hand, once the rumor had spread, I received a wide range reactions, all positive. This is especially gratifying to hear from the surgeons, among whom, I believe, I managed to win respect. The reactions ranged from, what a shame, good luck, to actual rage (how could they let someone like you go? Immediately followed by an irate SMS to the deputy chief of the hospital) This, of course, is very good for my otherwise fragile ego. Hopefully it portends equal success in the next phase of my career.
Before I made the final decision, I consulted the former chief of the department, my mentor, to absorb some words of wisdom and put things in perspective. This morning I met with him again. He rhetorically asked me how one defines success. I attempted to reply, but he cut me short. He said that he has been wrestling with the question for some time and that the best answer that he could find is this:
One is successful if one has left the world in a better condition, even by a small measure, than when one came into the world.
I hope I have done this and will continue to do so.

The Burned Girl

A couple of night ago I was on call in the OR. I got a call from the shock/trauma room that they needed my assistance. A fifty something John Doe was brought in after being beaten in his own home. One look was enough to see this was an odd case. This man had been literally tortured. The odd thing was that all his bruises were several days old. From the shape of the bruising, we deduced that he had been forced to remain on all fours while he was whipped with what we assumed was a belt (some of the bruises had the shape of a buckle). He had massive subcutaneous emphysema (air under the skin) from his neck to his groin. This indicated that there was a puncture of the airway. Because he was agitated and was unable to cooperate I anesthetized and ventilated him. After a total body CT we transferred him to the ICU. A bronchoscopy and esophagoscopy were performed with no findings. Odd.
Later that night, the ENT doctor called with a bit of panic in her voice. A year old infant with post tonsillectomy bleeding was being rushed to the OR. This did not sound good. We prepared the pediatric equipment and received the child at the entrance to the OR. He was completely pale including his lips. He was unconscious and his fontanelle was sunken. All this indicated that he was in severe shock because of massive blood loss.
Post tonsillectomy bleeding is not an uncommon complication and is considered one of the classic problems of anesthesia and is almost always included in the oral board exam. The dilemma is how to induce anesthesia to optimally prevent aspiration of blood into the lungs. Like many problems in anesthesia there is no right answer. The individual technique is probably less important (even though the discussions of proper technique sometimes deteriorate to the verge of fisticuffs) than the overall approach to an emergency situation. I agree with Dr. Keamy, who blogs on The Ether Way who writes:
"Judgment in anesthesia, as in all of life, takes unusual forms. While you might think that drug selection/technique are the essence of anesthesia judgment, I believe after thirty years that these choices matter rather less than we think. I am reminded of old studies of psychotherapy that concluded that good therapeutic outcomes correlated with individual therapists more than theoretical "schools" of therapy; that talk therapy is personal. So, perhaps surprisingly, is anesthesia."
We rushed the baby into OR 7. Luckily the pediatricians had put in an IV line. We induced anesthesia. I put the laryngoscope in the mouth and for a split second glimpsed the vocal cords and then everything went red. The oral cavity filled with blood. I asked for large bore suction (which we had prepared beforehand) to be put into the mouth. The blood was flowing freely, but I could see the vocal cords. I pushed the endotracheal tube through and moved aside so that the ENT could get in there and stop the bleed with electrical cautery. We gave blood through the IV and put in a central venous line in the femoral vein. Color returned to the baby's lips although he was still quite pale. Still asleep and mechanically ventilated I transferred the child to the Pediatric ICU.
Yesterday I had a chance to do a good-deed-for-the-day. I went to pediatrics to anesthetize a 4 year old girl for a change of bandages. This poor child had played with matches and her dress had caught fire causing severe burns from her ears to her ankles. She had been hospitalized for close to two months, much of that time in intensive care. Dressing changes are done almost every day and are excruciatingly painful, hence necessitating anesthesia. Thus, I had anesthetized her often in the ICU. This was the first time I saw her on the Peds ward. For the first time I noticed that her hair was matted, and her fingernails had grown quite long. I asked the nurses about this and they said that the mother refused to shampoo her hair and trim her nails and had demanded that it be done under anesthesia. They went on to describe how the family had raised the ire of the staff by complaining about everything and everyone. I could understand, the staff works very hard under difficult conditions to provide the best care possible and it is frustrating to hear nothing but complaints from the family. I pointed out that the parents probably don't know how to deal with the guilt about what had happened and vented their frustration on the staff. This is unfortunate, I told them, but the bottom line is that we are here for the girl and we won't "cure" the parents of their guilt and their poor manners. Besides, I continued, you work so hard to keep her bandages fresh and clean, but all is for naught with such grimy fingernails. The microbial garden growing there is a constant source of infection. I'll give you another 10 minutes of anesthesia and you make her pretty. Such rapier sharp logic apparently made sense. At the end of the procedure, the little girl had nice clean bandages, an expert manicure and clean scented hair. While I was writing the anesthesia note in the chart, the nurses came and told me that the mother thanked them. I thought to myself, "perhaps there is a cure for poor manners"

For Gilbert and Sullivan Fans.

Those with delicate sensibilites be warned, contains explicit language.
This is another ditty from the Amateur Transplants team (both MD's by the way).

Unnecessary Tests

Recently, I was asked to examine a patient who was scheduled for an emergency amputation of her leg because of gangrene. I went over her chart and discovered that one of the junior residents had seen her the night before and had requested two consults: 1) A cardiology consult because the patient was complaining of unstable angina (chest pain at rest). and 2) A vascular surgery consult because of a history of CVA (cerebral vascular accident aka - stroke). I cancelled the consults because they were unnecessary. The patient had bypass surgery 4 months prior. The most recent echocardiogram showed that the patient suffers from congestive heart failure. Even if a workup were done, no surgeon in his right mind would do bypass surgery on a patient with an active infection. The same goes for the CVA. Since the stroke the neurological status of the patient has been stable. Again, even if vascular surgery were indicated, this is not the time.
Bossman, the chief of anesthesiology, raked me over the coals for cancelling the consults saying that it was irresponsible. I told him that consultants opinions would change nothing in the anesthetic management of this patient and were, therefore, superfluous. Having painted himself in a corner, Bossman nonetheless found a pretext to delay surgery. The patients's hemoglobin was 9.7, just a hair below the threshold of 10 for a cardiac patient. The patient would have to receive a unit of blood and wait another day.
The next day, I ran into the resident who requested the consults. In an attempt to educate and not just criticize, I asked him why he asked for the consults. His reply made me see red. It is the reply of the imbecile, of the doctor who is afraid to think and make decisions, and it drives me to distraction: "To spread around the responsibility". To be fair, it is not all his fault, he learned this "defensive medicine" posture from Bossman.
I told him that even if he really believes in that philosophy, he should never actually say it out loud, it's just plain embarrasing. I proceeded to impart two pearls of wisdom that I believe are universal:
1) If you ask the consultant a stupid question, you will, invariably, get a stupid answer. Don't just ask for a "cardiology consult". One must ask the consult a specific (and hopefully intelligent) question. For example, "Does this patient need further workup and/or intervention for her chest pain?"
2) You better have a damn good justification for delaying surgery if the delay endangers the patient. In this case, delaying the amputation exposed the patient to another day of infection that could have developed into full blown sepsis with septic shock. This complication can be fatal. This is not speculation, this is experience. We've all anesthetized patients with septic shock, it's challenging to say the least. Had such a complication occurred, the first question the judge will ask is: "What did you gain from the consults that justified delaying surgery and endangering the patient".
The fear of "missing" something exists. In this era of defensive medicine and zealous over-litigation, it is in the back of all our minds. No physician wants to miss a diagnosis that might endanger the patient and/or expose us to a lawsuit. But if we order every and any test under the sun are we really serving our patients well?
I believe in this guiding principle: Any investigation, whether a consultation or a blood test should be done only if the results will affect patient management. Not only is an unnecessary test a waste of money, it may even endanger the patient.
P.S. - The patient had surgery with no complications.

What Do Anesthesiologists Do?

And the answer is:

Well, sort of.

The "eyes" have it.

The last on-call was full of action. But there is such a thing as too much of a good thing. The phone rang from the trauma room. In ten minutes a blast injury victim will be brought in. For the third time this month a Bedouin has "encountered" an unexploded shell. These are not citizens innocently exploding. These are criminals who knowingly risk life and limb and enter the army's training fields for one of two reasons: One is to strip old armored vehicles used as targets for their iron and sell it (iron prices have skyrocketed recently). The other is to try to retrieve explosive material from unexploded ordinance to sell to the terror organizations.
A 51 year old semi-conscious man was brought in. Full of shrapnel holes, right leg broken, a finger or two mangled, left eye looks like mush, pools of blood forming around him and most importantly an expanding hematoma in the neck. While the surgeons examine him I ask the nurses to prepare the intubation tray and as an afterthought, "have the emergency tracheotomy tray on standby and page the ENT guy to get here now!" The drugs are in and the patient loses consciousness. Opening the mouth with the laryngoscopy my instincts were right: the hematoma in the neck obliterated the anatomy so I can't see the vocal cords. I try a blind intubation and miss. The ENT guy runs in. "No go, you'll have to perform an emergency tracheotomy." The cricothyroid membrane identified, an incision made and the tracheotomy tube passed into the trachea. The patient is stable, there is no evidence of internal bleeding so we transport the patient to radiology for a total body CT. Except for the bleeding in the neck there is no evidence of additional bleeders. There is shrapnel all over the head and neck including two in the brain with no hematoma or edema, so no need for neurosurgery. In the operating room, two teams work simultaneously. The orthopedic surgeons internally fixate the broken tibia and the ENT surgeons explore the neck. They find lacerated lingual and facial arteries only millimeters from the carotid. A millimeter in the wrong direction and this man would have died even before being evacuated. More luck than brains, that's for sure.
It's midnight, I've been working on this guy for 8 hours. ENT and orthopedics are done. We transfer the patient to the ophthalmology OR (their special operating microscope can't be moved so we must bring Mohamed to the mountain in this case). The policy is to try to repair the eye even if it isn't functional, for aesthetic reasons. It's going to be a really long night. The surgeon begins the tedious process of suturing the eye with ophthamology's Amazing Invisible Sutures (tm). These sutures can't be seen with the naked eye and to tell the truth I don't believe that they are actually there. Oh wait, the TV monitor is hooked up to the microscope. They really are suturing what looks like a bowl of jello.
"That's the eye?" I ask.
"Yup, that's it."
"And it's going to look like an eye?"
"Yup, in about 3 or 4 hours."
(Talkative, aren't they?)
At three AM I literally can't keep my eyes open (ironic isn't it?). I drink some water, walk around look at the mush on the TV screen, hey, it's starting to look like something. Every time I sit down, I fall asleep. OK so I won't sit down.
Four AM, we've been at it for 12 hours. I call up to the general OR where they've been busy too. When we finish the next case, an amputation, we'll send someone to relieve you.
Five AM, hooray, they've finished the eye and my relief walks in. I run down the injuries and surgery that's been done. Now all that's left is to suture the eye lids ("only" 4 more hours of work.) "Good luck, I'm going to get some rest".
The next day is for recovery from the on call.
More or less rested, I come in to work. I've been assigned to urology. The first case: A five year old scheduled for uretheral implant (she has a double system from her left kidney and so she "leaks"). The problem: she was born with Transposition of Great arteries (that's where the main arteries arising from the heart, the aorta and the pulmonary, are reversed). She had corrective surgery, but she still has residual defects that might complicate major surgery. Everything goes well.
The next case is exploration of the retroperitoneum to excise a tumor. These operations are usually accompanied by significant bleeding. After inducing anesthesia I put in a big IV line and an arterial line. The surgeons are having a tough time exposing the tumor (previous operations resulted in adhesions), but finally expose it. There was about a 1.5 liters of bleeding but adequate fluid rescucitation and only one unit of blood later the tumor is out. While closing I administer morphine for post op analgesia. I wake the patient and extubate.
The surgeon (the chief of Urology, no less!) Thanks me. "It's good to have you on board, it gives us peace of mind which is important in such a tricky operation."
Wow! Surgeons are notoriously stingy with compliments, so this is a rare occurance.
It's nice to be appreciated.

No, not that four letter word, the other one

T. from Anesthesioboist submitted an excellent thought provoking post on the 4 letter "F" word, no not that one, the other one. This isn't a spoiler, the post was featured on the latest SurgeXperiences blog carnival on this very site (just scroll down) so I assume most of you have read it. I agree completely with her but would like to add my 2 own shekels worth.
The word is fear. And doctors aren't supposed to fear...anything. But fear is there. Sometimes it's "normal", for example, fear of failure, fear of causing a patient pain, fear of losing a patient (all the more acute in the case of children) etc. But perhaps fear isn't the only emotion we are denied, there is also anxiety. I believe that some fear, especially when faced, is healthy, it spurs us to be better doctors, to increase our knowledge to improve our proficiency. But too much fear and anxiety can be counterproductive and even dangerous - it paralyzes the mind when quick action is warrented, for example, during an emergency.
This can happen during anesthesia, on the ward, on the street, anywhere. At our institution, anesthesiologists are part of the code team which responds to cardiac arrest, and we do on-calls in the mobile intensive care ambulance. So I have quite a few emergencies under my belt. In addition, I am an ACLS (Advanced Cardiac Life Support) course instructor. This is mandatory in many institutions for doctors. One of the most important points that I convey is the the necessity for keeping a cool head when others around you aren't. During an arrest, which is the quintessential emergency, the worst thing to do is to show indecision and fear. It is natural to feel anxiety at such a moment, but, I teach my pupils, the tempest inside should remain there at least during the event. I point out that very few people are actually born with nerves of steel. Fear can be, and should be mastered for such situations. To paraphrase Shakespeare, "Some men are born cool, some achieve cool, and some have cool thrust upon them." Remaining cool during an emergency obviously relies on inborn character traits. But most people can actually learn and perfect cool and this ability improves as one acquires more experience and proficiency.
During a code it is important not to bark orders to the junior members of the team whether doctors or nurses. These may be at various stages of training and experience and an abusive, vain, humiliating team leader may scar them for life (causing them to be useless until pension).
After a code, it is essential, in my opinion to gather the code team and have a short feedback session, and yes, even talk about feelings. I came to this conclusion after a case where I was on call in the ambulance and we were dispatched to take over for EMT's performing CPR on a homeless man in a hostel. The ambulances here also include volunteers, many of whom are high school students. There is some wisdom in teaching the lay public basic life support, but we never take into account that these children are still developing not only physically but also emotionally. Upon arrival at the scene, it was obvious to me that the patient was not responding and that I would soon "call the code" (i.e. cease rescustitation). I allowed both teams to continue for a few more moments so that the younger members could get some valuable experience in rescusitation techniques. While the paramedic was writing up the report, I noticed one of the volunteers crying. I asked the EMT in charge of her what was the matter. He said that she felt that the man died because she didn't perform adequately.
I took her aside and asked her what was wrong. Through a monsoon of tears she let out all of her feelings of failure and inadequacy. When the torrent abated, nose blown and tears wiped, I told her that first of all, she did everything that was expected of her and she did it correctly. Secondly, from my examination, I could tell that the victim was a drug addict. Life had dealt him a lot of bad luck, or he had thrown his life away. Either way it was not her, or our, fault that he died. We just have to do our best. I told her that it was ok to feel bad, it meant that she is sensitive to others' suffering, and that in itself is not a sign of weakness, it is a rare trait. I emphasized that there is no shame in feeling what she feels. Everyone has a niche in this world. And she has quite a few years left to discover hers. I offered her two choices: 1. To accept what happened, to realize that a tragedy happened to that man and to go on. Or, 2. Leave the ambulances and volunteer in some other activity and under no circumstances should she feel less of herself for doing so. My intention was to provide her a way out while maintaining her dignity. I found out a few weeks later that she had left the ambulance service.
Since then, I always gather the team for a feedback session.
Hubris, in medicine, is the original sin. The only thing that disgusts me more than incompetence in a physician is vanity. Hubris is born of fear. Fear of exposure, fear of failure and fear of showing weakness. When you see a vain person, scratch the surface (one may need an ice pick) and you will discover a coward. Not a coward in the sense of external bravery, but one who won't face his/her own failings. Such a person has stopped growing, learning and improving. When that happens, our greatest fear, of harming our patients, is most likely.

SurgXperiences Blog Carnival

Welcome to the June 8, 2008 edition of surgexperiences.

So, I've taken the plunge and am hosting my first blog carnival. Many moons ago I was a philosophy major so I asked bloggers to submit posts with a more introspective and philosophical approach to medicine. I'm pleased to report that the SurgXperiences bloggers have met the challenge.

James Moore presents ... your angel is simply watching. posted at Spiritual Passages Part of a series on dying and life after death, This fascinating post describes near death experiences and what they are.

Øystein Horgmo , a medical cinematographer, presents Detachment posted at The Sterile Eye. Muses on remaining "detached" when witnessing the suffering and misfortune of others.

Jeffrey Leow provides a lesson on the eponyms associated with the famous Jean-Marie Charcot in: Charcot and Reynold posted at monash medical student.

Chris cites a recent article in: Everything I needed to be a surgeon I learned in kindergarden posted at Made A Difference For That One: A Surgeon's Letters Home From Iraq, saying, "It describes several hospitals that experienced decreased malpractice claims and settlement amounts after adopting a policy of full disclosure of complications and apologizing to the patient. It surprises me that anyone would ever follow a policy of concealment and refusal to apologize. " He points out that this is also called: Lying

Charles H. Green refers to the same New York Times article in
What Malpractice Suits Teach Us About Trust posted at Trusted Advisor Associates
He points out another interesting facet, "In other words, the motives of an apology are immediately undercut for the sake of a self-oriented outcome. The apology becomes impure: input is destroyed for the sake of an output. Lowered malpractice costs are no longer a byproduct, they become a goal. All sincerity is lost. And malpractice rates will go up, but with a higher-still level of cynicism."

David Khorram presents Carl Talk and the Folly of Aid posted at
Marianas Eye. This post deals with some of the pitfalls of working for aid organizations.

T. discusses The "F" Word posted at Notes of an Anesthesioboist. What's the "F" word? You'll just have to read the post to find out, won't you?

On the lighter side,
bongi prolifically (is that a word?) provides two posts:
gee thanks and small cut, big surgeon? posted at
other things amanzi. Bongi's wit is self evident.

In I'd like to donate my organs... at The Paper Mask,
Sheepish ponders options for organ donors when their organs are not suitable for transplants.

D. Singh points out the danger of putting one's medical information online in
Google Health Launched. Can We Entrust our Health to Google? posted at Internet Marketing Blog, saying, "Google has entered into the fray of online health record service via a simply branded service, Google Health. Google Health aims to empower us in managing our health information. Google Health proposes to store all this information in a secure and private environment. It even promises that it won’t sell our data."

For those who still need their fix of practicality, rlbates, another prolific blogger sent in two posts: High Pressure Injection Hand Injuries and Abdominal Wall Reconstruction posted at Suture for a Living.

Ian Furst too, offers practical advice in Wait Time & Delayed Care: Block Booking for Procedural Patients posted at Wait Time & Delayed Care, saying, "It's about how to block book for procedural patients and control their wait time. Thanks Ian."

I hope you enjoyed this edition of SurgXperiences blog carnival. Thanks for the submissions and keep blogging!
I have to make a confession: I took advantage of the Instacarnival [beta] feature. Made things a whole lot easier. Hah!

Blog Carnival

The one and only SURGICAL blog carnival, SurgeXperiences is now up at The Paper Mask. This is the 22nd edition.

I will be hosting the 23rd edition on Sunday, June 8th. Submissions will be accepted until the preceding Friday here. The theme is:
"The Philosophical side of Medicine." I'm looking for some introspective blogging but anything interesting will be accepted.

Nasty, Brutish and Short

On call in the mobile ICU. We get a call to join CPR in progress on a 6 year old. The feeling is always different when we know a child is involved. Not that it's more urgent but there is always more tension and more emotion. We arrive and a one EMT is performing chest compressions and another is breathing the child by mask. I examine the child who clearly has some birth defects, the pupils are dilated, the prognosis is grim. I could easily order rescusitation stopped. But I ask my team to continue and institute advanced life support techniques. I have three reasons: 1. I always make the effort until I receive the patient's medical history. 2. It's always more difficult emotionally for the team to "lose" a child. 3. CPR in children is relatively uncommon and it provides the younger members of the team valuable experience. While the paramedic and EMT's were working under my supervision, the family handed me a very organized notebook with all the child's medical documentation. To my surprise, the child was a bedouin adopted by a jewish family. He was born with an impossible constellation of birth defects: Microcephaly (a small brain), meningocoele, blindness, severe psychomotor retardation, obstructive sleep apnea and by the scars on his abdomen, had several operations. This family took in the child in an attempt to relieve the burden on his impoverished relatives. The daughter of the woman who adopted him told me what a miserable existence the child had. Looking at the deformed child reminded me of Hobbes' most famous quote: "life is solitary, poor, nasty, brutish and short". After 20 minutes of advanced life support with no response, I directed the team to cease and pronounced the child dead. Despite the outcome I thanked the team for their effort. I'm satisfied that this team will do well perhaps with another patient who has a chance at life.
Later that day we rendevouz with an ambulance from one of the outlying communities. A 65 year old gentleman with chest pain the first time in his life. We transfer him to our vehicle. I tell the paramedic and the student to make a mental note of the clinical picture. "This is as classic as it gets", I told them. We obtained an EKG which screamed MI (myocardial infarct). Time is of the essence. On route we administer drugs and I call the Cardiac ICU. This is where the advantage of hospital doctors in the mobile ICU is apparent. We've all worked with each other for years and trust each other's opinions. In addition, I'm an ACLS (Advanced Cardiac Life Support) instructor, so all the cardiologists know and respect me (hard won respect I assure you). I described the patient and the EKG and asked that we bring straight to cardiology and bypass the ER. The cardiologist said, "I'll do you one better, bring him straight of to the cath lab." This decision was critical because during myocardial infarction, saving time means saving heart muscle. We arrive at the hospital and go straight to the cath lab, I flash the EKG to the cardiologist who gets excited, a chance for a save.
Later that day we visit the ICCU. The right coronary artery was completely blocked. A stent was placed and a followup echocardiogram showed almost no residual dysfunction of the heart.

Crawling through a cave.

One of the greatest dangers of being a doctor is, ironically, forgetting about life. As a group, doctors are motivated and definitely can be labelled "workaholic". However, to be a good doctor, one must first strive to be a good person. A good person does not neglect one's family. But we all get caught up in the rat race, so to speak. First during training, to prove to the professor that one is worthy, then to stay up to date with the current medical literature and finally to get a coveted tenured position. There just aren't enough hours in the day. So it isn't surprising that marriages, relationships and families are the first to suffer from neglect.
At one point I decided that even if my career suffers, I would do my best to give as much time as possible to my family. It's easier said than done. Still the pressure to achieve is great.
Make no mistake, I am no where close to becoming "father of the year". The on calls, the pressure, the nature of medical emergencies all take their toll. I am often short tempered with those that I love the most. I hate it and it's difficult to control, especially when I'm chronically sleep deprived.
For the first time in over a decade, I was able to take the entire Passover vacation to be at home. It was wonderful just to be with the children and not be tired. One of the day trips we took was in our neck of the desert. Every year in Mamshit, an archeological site built by the Nabateans an ancient market is recreated with activities for the entire family. The Sandfamily had the honor of hosting the von Trepp family for this trip. A delightful time was had by all.
Yesterday, I accompanied my daughter's third grade class for their annual field trip. I look forward to these trips for three reasons: 1. I love hiking in the desert (of which we have a plentiful supply). 2. It gives me a chance to be with my daughter without competition from her siblings. 3. And it allows me to observe her in her natural habitat.
We first went to Bet Guvrin which has been wonderfully reconstructed by the Israel Antiquities Authority. We then went cave crawling in the Midras Ruins (sorry, couldn't find an english language site). This was the big adventure of the day as crawling through tunnels just wide enough for an adult to pass brought out the best in the claustrophobes.
See?

Some children opted out before entering. Some started to crawl, but then backed out. Once another group has entered the tunnel behind us, there is no way out but forward. One or two of the children became hysterical and refused to budge. One even cried that he was going to die there. It was all very dramatic. We calmed him down and all emerged from the cave alive and well. The elbows and the knees took a real beating and I used some muscles that I completely forgot I had.
We finished with a visit to Israel's only stalactite-stalagmite cave. This cave doesn't compare in size to the large caves in Slovenia such as the Postejna Cave, but for it's size it has a great variety of stalactites and stalagmites. Besides it's ours.
Father and daughter had a wonderful time. We can't wait for the next field trip.

To Passover or not to Passover?

Anyone who has witnessed the intense insanity that precedes Passover can appreciate the disappointment and anxiety of someone who is hospitalized just before a holiday. The preparation for Passover consists of house cleaning that lasts for weeks and is so obsessive as to put your average sufferer of OCD (obsessive-compulsive disorder) to shame. Then there is the cooking, which is endless. There is always the feeling that there isn't enough food, even though there are at least 5 meat dishes, 10 types of salads and side dishes and soup with matzah balls, there doesn't seem to be enough. In fact, there is enough food at the Seder table to feed the entire population that actually lived through the Exodus with leftovers for the next week.
Just before the holiday, an elderly religious woman was brought down to the pain clinic from orthopedics with severe lower back pain. The surgeon requested a selective nerve block to help assess the pathology and decide on a treatment plan. The woman was bedridden because of the pain and it was an impressive logistic feat to transfer her to the treatment table in the cramped clinic. While the room was being prepared, I noticed that the woman seemed quite upset about something. I asked her what was the matter.
She was distraught because there was no way she could prepare for the holiday and might not even be able to be present for the Seder. I asked her how many children she has. She quickly recited the roll call: 7 children, 15 grandchildren and 20 great-grandchildren.
I asked, "You raised and educated them according to tradition right?"
"Of course", she replied.
"So, your children should be able to conduct the Passover Seder perfectly, right?"
"Yes."
"Of course it isn't the same if you aren't there, but you raised your children the best way possible and everything will be just fine. You need to concentrate on recuperating. Your health is more important than the holiday."
(For those not familiar with Jewish philosophy, briefly and most inadequately: The sanctity of human life is valued above all other considerations, even the most important. So for example, working on the Sabbath to save a life, a limb or relieve suffering is permitted.)
Put in this light, the woman seemed relieved and less agitated. "Your right." she said, "The family will be fine because I taught them well."