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.