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"