The Carsitters

Here they are in a gorgeous video: The Carsitters.  A homegrown pop-rock band.  Currently on a European tour.

Love Changes

I recently came across the following poem.  The (poor) translation is mine:

אהבה משתנה

אהבה משתנה מיום ליום

הולכת, על גב הזמן דוהרת

מהים לאוויר עד להבת הנפש

כל מקום בעולם מאירה

אהבה משתנה מצבע לצבע

עד רדת החשכה, כל אהבה

תמיד מתגלה, בשלב בחיים

עוזבת, אבל תמיד נשארת

בתוך לבך

אהבה משתנה כל דקה ודקה

בתוך לבך החם והאוהב

כאשר נפגשים, בתוך הלב

נהיה נעים

Love Changes

Love changes from day to day

Walking, upon time it races,

From the sea to the air 'til the soul's flame

Illuminates the whole world.

Love changes from hue to hue

'Til dusk, all love

Is always discovered, at some time in life

Leaving, but always staying

Within your heart.

Love changes every minute

Within your warm and loving heart,

When we meet, within the heart

It will be nice.

This poem was written by my daughter who is all of 10 years old. I am very, very proud of her.  I ask myself, "When did she become so wise?"


I am also frightened, very, very frightened.

Some of the News That's Fit to Print

So here are some updates to a couple of previous characters in the ongoing story of me: 

I went to visit the woman who survived a monster asthma attack. She was transferred to the high risk pregnancy unit from the ICU. We had something of an odd conversation. She, her gratitude evident by her beaming  smile, me, just trying to avoid inflating the whole story into an epic by engaging in small talk. I was somewhat embarrassed by the accolades I've been receiving lately subsequent to the event.

The OB/GYN's wanted her to remain hospitalized in the high risk unit until she gives birth. But the woman decided she wanted to be at home.  She is receiving preventive therapy, and feels well.  I voiced my concern that if she goes home to her village in the north, she is still 20 minutes away from the nearest hospital, even when there is no traffic. However, she was adamant not to remain hospitalized.  I wished her well and she thanked me again.

You might remember The Teacher's Pet from the incident and angel. The Pet has been removed from the premises. My unfortunate experience with her was just the beginning of a series of problems other doctors from the department experienced with her.  The most serious of the incidents is as follows: Allegedly (and I stress allegedly, because I am informed by word of mouth) a patient who she anesthetized suffered a serious complication.  This could happen to anyone.  The problem is that she allegedly manipulated the anesthesia record to shift the blame to a young resident.  This is immoral to say the least, and stained her character and reputation. She was given the choice of either being fired or leaving of her own volition. She chose the latter.  This is quite a blow to her career.  She was mainly hired to perform research, and now she will be working in a non-academic institution. So, basically, her career has been flushed down the tubes.  I wouldn't wish such an outcome on anyone, but she brought it on her self and has no one but herself to blame.

The Pet is no longer in the building.
I feel vindicated.

  

I could get used to this.

Today I was pleasantly surprised to receive the following extremely moving letter which I have translated to English (and edited for clarity):

Dear Dr. QuietusLeo,

Although it has been a month since you anesthetized our son Y, better late than never.

We wish to express our great appreciation and gratitude for your professionalism in anesthetizing Y despite his suffering from a slight cold and some coughing. The anesthesiologist we met in the pre-op clinic expressed his concerns with proceeding with the operation on the appointed date and we understood that the anesthetic would be more challenging that that of a healthy child. (Note: With young children there is almost never a window of opportunity when they don't have a runny nose-Q.L.)

We wish to express our great appreciation and gratitude for your attitude toward us, the worried and frightened parents. The manner in which you addressed T when she was with Y in the recovery room - calmly, with confidence and empathy - provided us with the realization that our child was in excellent hands - not just professionally but also caring.  The manner in which you spoke to me (the father-Q.L.)  calmed me and conveyed confidence to the sweet child in my arms.

Immediately after Y was anesthetized by mask N (the father-Q.L.)  exited the room, you asked hem to return to give the child a kiss. This seemingly trivial act, resulted in N feeling confident in leaving his son in the care of strangers.

With your permission, we would like to add - that when we were taken from the ward to the OR we were under great psychological pressure, even panicked - not because of the operation but because of the anesthesia. Had we met the doctor who would take responsibility for the anesthesia we would have been calmer.

Please convey our gratitude to the young doctor whose name we don't know (a young resident-Q.L.) who worked under you that day and also approached us with a smile and empathy (Done that and told the boss too!-Q.L.). 

May there be more doctors like you,

The L. family.

I've said it once, and I'll say it again.  I was only doing my job.

But the pat on the back is very, very, very appreciated.

The Mother of all Asthma Attacks

I was on call in the delivery room. The phone rings and the secretary announces that there is a woman in the maternity ER in critical condition.  All eyes were on me.  "Oh, you mean me?" By the looks on the midwives and obstetricians faces the answer was affirmative.
I hastened down 4 stories and entered the ER. "Where?" A nurse pointed to an examination room.
Entering the room, I make eye contact with the senior obstetrician on call, a good friend, "what's the story?"
"A nurse from medicine, 32 weeks pregnant, just got off her shift with her husband, also a nurse when she fainted, they brought her in here."
One look at the woman tells me that she is having the "Mother of All Asthma Attacks"(tm). She is very agitated and is literally turning blue.
"Let's intubate, give her 100% oxygen, draw up 200 mgs Propofol and 100 mgs scoline." While the nurses prepare the syringes, I connect the bag-mask-valve apparatus to oxygen.  The patient is making an effort to lie down (usually, patients with breathing difficulty try to sit up) a sure sign that she is about to crash.  The syringes ready, I nod to the obstetrician, "Give it all."  He injects the contents of both syringes, within seconds the woman is motionless, anesthetized and paralyzed.
This is the moment of truth, I call out: "cricoid pressure" (to prevent aspiration of stomach contents). I place the laryngoscope into her mouth - a perfect view of the glottis, the entrance to the trachea.  I see the snowy white bands of the vocal cords forming an upside down "V".  The epiglottis just above poised to cover the glottis during swallowing to prevent aspiration.  The two buttons of the arythenoid cartiledges at the base of the glottis.  Most importantly, the void between the vocal cords, the space where the endotracheal tube is to be inserted.
Without averting my eyes, I extend my hand, "tube!"  My friend places the tube in my hand in the correct position for intubation (God bless him!). I slide the tube into the trachea, remove the laryngoscope, inflate the cuff, attach the bag, squeeze and simultaneously auscultate over the epigastrium.  It feels like ventilating a brick wall.  Left lung breath sounds, very wheezy, very very.  Right lung sounds the same.
The pulse oximeter, measuring the patient's oxygen saturation, changes tone from tenor to alto to mezzo-soprano, to soprano - 100% oxygen saturation.
We start giving bronchodilators.  Eyebrows are raised when I employ a trick I learned from one of my professors: Intranasal salbutamol. Unorthodox, but effective, especially with such extreme bronchospasm. Given usually by inhalation, in such conditions, little drug would get to the bronchi, but given intranasally, the drug is instantly absorbed into the blood stream and flows to the bronchi by the back door so to speak.
The obstetrician does an ultrasound, the fetus is very sluggish, he voices his concern that the fetus suffered severe hypoxia along with the mother.
Within a few moments the drugs take effect and it is easier to ventilate.  After 15 minutes there are no signs of bronchospasm. A repeat ultrasound shows normal fetal movement.  Everyone sighs with relief.
The ICU doc on call comes to transport the patient to the unit.
The next morning after an exhausting call, I visit the woman in the ICU, she is extubated and fully conscious. I introduce myself and tell her my version of the events of evening last.
The ICU docs congratulate me on the "save". The senior says, "You realize you saved her life?"
I somnolently nod through the post-call haze. I think to myself that it was just plain luck.  She was lucky that the asthma attack occurred so close the hospital.  Had they made it to the evening rush hour traffic, the results might have been much more tragic.


Oh, yeah, and happy second blogoversary to The Sandman.   

Presenting: The Laryngospasms

If you liked this song you should also enjoy The Laryngospasms:

Waking up is hard to do:

Breathe:

Rollin':

Hat tip: SeaSpray

Succoth and Gilad Shalit

Succoth (The festival of Tabernacles) and Gilad Shalit is there a connection? I believe there is.

Shalit is an Israeli soldier abducted by the Hamas over 3 and a half years ago. His release has been the subject of prolonged negotiations. Too prolonged. Our previous Prime Minister (a complete failure if ever there was one) didn't have any idea how to conduct business. What he should have done was to demand proof of life before agreeing to negotiate. That is how hostage negotiations are conducted.  If it were up to me we would have released terrorists from our jails, in pieces, until such proof was provided. Barbaric? Yes, that's how one speaks to barbarians in the language they can understand. They don't understand gestures of goodwill, the concept is beyond them. Be that as it may, we have finally received proof of life in the form of a video clip. The connection to Succoth is this:  One of the symbolic aspects of the holiday is to remember and recreate the temporary dwellings of the Children of Israel as they wandered in the desert after being freed from the bondage in Egypt. This collective memory is to be cultivated and taught throughout the generations. It is fitting that the video confirming that Gilad Shalit is indeed alive, was released on the eve of the holiday.

Here is the Succah I built this year:

My parents recently returned from a vacation in Italy.  My mother describes the following surprising scene:  After climbing an endless flight of stairs in Rome, she was rewarded with the sight of a wonderful statue.  She then snapped the photo of said statue:

Then she noticed in the background a familiar image:

The text reads: "Rome wants its citizen Gilad Shalit freed."  
Apparently, Rome granted Shalit citizenship in July of this year.  I'm sure the liberal Italian "intelligentsia" are nauseated. Good. I say:
Viva Roma, Viva l'Italia!

And may God grant Rome's citizen freedom, and soon.

Yaffa's Salad

Yaffa means "beautiful".  She is an OR nurse. She also makes "the greatest salad in the world" (tm).  She makes enough salad to feed the entire delivery room staff. It is worth being on-call on Sabbath eve just to taste a sample.  The salad is deceptively simple. Just a raw vegetable salad. I could list the ingredients, but it would do you no good. The main ingredient cannot be bought in any market, nor found in any garden.  For Yaffa's salad is imbued with love. I have just partaken of this gastronomic romance.  

If you could see our faces right now, you would see people who have attained Nirvana.

Now I'm ready for anything.

Shana Tova

After 30 hours on call, it's time for the holidays. Yay!
Shana Tova!
!שנה טובה! כתיבה וחתימה טובה

The Singer

Airway management is an important part of anesthesia. We give drugs which cause respiratory depression and often, muscle paralysis. So the anesthesiologist must be an expert in maintaining a patent and functioning airway. Like many other technical subjects, the best way to stay out of trouble is recognizing the existence of a problem before it occurs. This is why the anesthesiologist will always examine a patient's airway beforehand. This includes inspecting the range of motion of the neck, dentition and the oral cavity. The latter basically means that the patient is asked to open the mouth wide, stick out the tongue and say "ahhhhhhhhhhh" (although there is some evidence that saying "ahhhhhhhhhhh" is not necessary).

At this point I have a running joke: I ask the patient if he/she is a singer. No matter what the answer, my reply is always applicable: "I can see that." Some patients ask wide eyed "really?" I usually just wink.

During the airway examination of a recent patient, I deviated from my usual joke and said, "I can see you are not a singer". As luck would have it she was a singer. So I explained the joke and she thought I was all the rage.

As I prepared to anesthetize her I asked what type of music she sings. She is a singer/songwriter of the folk-rock variety. I told her that I like almost all music but my favorite is jazz.

She began singing "Round Midnight" for me. She has a beautiful voice and is obviously a professional singer. As I administered the anesthetic she lost consciousness. This is the first time in my experience that a patient sang herself to sleep (with a little help from my friends ;P )

The Pancake

Two patients from the last few weeks stand out.

The first because of an unsual tattoo. The patient, a middle aged white collar type presented for minor surgery. He turned out to be a typical Tel Aviv Bohemian. After anesthesia was induced I exposed the chest to auscultate (i.e. listen to the breath sounds) after intubation. I was surprised to see an anatomically correct tattoo of the heart, the great vessels and the coronaries. The tattoo was similar to this one:

Without hesitating, I shouted, "Get the boys from cardiothoracic surgery in here stat, they might learn somethin!"

The next patient was also scheduled for minor surgery in a nether region. This is surgery that is performed in the prone position.
After performing a saddle block, we positioned the patient. At some point, the patient said he was dizzy, I glanced at the monitor which showed a heart rate of 34 and then he flat lined. "Asystole, we need to start CPR."
The surgeon asked if we should turn the patient back supine and I answered in the affirmative. The patient was no lightweight and neither was the surgeon who could have played linebacker on any NFL team.
Within seconds he flipped the patient over like a pancake. Luckily the patient started breathing again immediately on the position change. He probably developed a vasovagal response due to anxiety. The pressure of his abdomen on the vena cava probably didn't help either. Since the patient was feeling nauseous, we decided to postpone the surgery.

Afterwards I told the surgeon that it was a good thing he was there instead of an itsy bitsy 50 kg surgeon.

The King of Swing

Little known factoid about moi: I am an avid fan of jazz. I even subscribe to Downbeat Magazine in its original form, you know, ink on paper, it arrives in the mail once a month.

In the 75th (!!) anniversary issue there is, among many archived articles, a series on the King of Swing: Benjamin David Goodman aka Benny Goodman. He was the 9th child out of 12, born to Jewish-Russian immigrants. Goodman's career spanned the 20th century. Even when the heyday of swing was over, Goodman filled venues with his phenomenal music. Goodman was also one of the first to lead integrated bands (in the 1930's!!!) when such a thing was unheard of.

Here is Goodman's most famous big band in the movie "Hollywood Hotel" playing "Sing, Sing, Sing". If this doesn't get your foot 'atappin, you should check yourself for a pulse.

For those with more stamina here is a fascinating 9 minute version,

again with Harry James on trumpet and Gene Krupa on the drums.

I don't know who is playing the tenor sax.

I love this version for the crackle of the old vinyl records.

Here on "Moonglow" the old master is at his best

playing the clarinet as if praying.

He is surrounded by other masters:

Gene Krupa, Teddy Wilson and Lionel Hampton.

This version of "Body and Soul" is a masterpiece.

The Plea

I have a sneaking suspicion that there is no such thing as a coincidence. I was assigned to opthamology today. So it just so happened that I anesthetized the patient that I examined yesterday. Today, however, she was much more anxious.

After finding a very small vein to administer the anesthetic drugs, I continued with my preparations for inducing anesthesia. Then with tears in her eyes, the patient gasped a choked plea, "I don't want to die."

I reassured her, that I would take care of her and that I would be by her side the entire time. She seemed more calm.

I applied the oxygen mask to her face, asked her to breath deeply and began to administer the drugs. Again I told her that she would be OK. She quietly said, "I love you," and lost consiousness.

Later, in the PACU (post anesthesia care unit aka recovery room), I greeted her and told her that she was out of surgery. She asked with disbelief, "I fell asleep?"

"Yes", I replied, "The operation went well and and it's all over, you're doing just fine."

She then just held my hand for a while.

Contrasts

Today I worked in the pre-anesthesia clinic. It is a nice change from OR routine. One of the patients was an elderly woman scheduled for surgery for an obstructed tear duct. She was accompanied by her daughter who acted as translator since the patient spoke only Yiddish.

No words passed directly between us. All communication was non-verbal. Much smiling and nodding. At the end of my physical examination and perusal of the chart I provided the usual explanations regarding general anesthesia. I wished her a successful surgery.

As the daughter was backing out of the room with her mother in a wheelchair, the daughter began a tirade about the long day and the inefficiency of the both the clinic and the ward. I was trying to diffuse the situation but I had trouble concentrating because the mother was vying for my attention. She was smiling as if to say, "Just ignore her, she gets like that sometimes."

Then she stretched out her arm to show me the tattooed number on her arm. She is a holocaust survivor. I nodded in understanding and returned her smile. As her daughter continued her whining, she backed the wheelchair out of the exam room and the mother was smiling and waving to me. In my mind's eye, she was indicating her confidence in our ability to care for her.

Plov and Army Logic (or the lack thereof).

The touching letter I recently received from a grateful father has made waves. It made it's way to my boss and her bosses, the Director of the hospital and the deputy directors.

Being relatively new in this hospital, this is good for my reputation, to say the least.

In other news:

I just returned from reserve duty. The medical unit that I command had a training excercise. This is a small very close knit unit. We usually organize a festive meal at the end of the excercise. This is of course against army regulations because only army cooks are allowed to cook and feed the army. (Actually, much of the cooking has been outsourced to caterers. Don't get too excited, it's still army food!).

One of the officers on the base made a point of reciting the regulation, but, if we cook off base then he can't do anything. We were under the impression that we were off of the base because we were, in fact, outside the perimeter fence. But it turns out that there was a second fence. We of course completely ignored the regulation. One of my soldiers is an excellent cook, and he was cooking up a storm in a huge cast iron pot. He made us some "plov":

(click to bigify)

Nothing will come between the medical corps and its plov!

Close to midnight, as we were about to dig into the enormous portions, the officer again contacted us, this time to order us to disperse because we couldn't be off base with the vehicles after midnight.

Wait a minute, when we were cooking, we were on the base. When we were eating we were off the base. The thing is, we hadn't moved in 4 hours.

This reminds me of the famous maxim: "There's the right way, there's the wrong way, and there's the army way.

Hungarian Rhapsody No. 2 by Franz Liszt

Last week's pneumonia has now affected 4/5ths of the family. I've recovered, but now my wife has it and both the boys have fever. Apparently we were all infected by the canaries with chlamydia psittacci. Needless to say, the foul fowls have been evicted. Person to person infection is extremely rare so, Trep, you are safe (you ol' germaphobe you!).

As a result I'm not at work. The upside of all this is the "quality" time I'm spending with our youngest child. We are watching lot's of DVD's together. And his (and my) favorites are the Bugs Bunny shorts.

My favorites are the musical cartoons and my all time favorite is "Rhapsody Rabbit" based on Franz Liszt's Hungarian Rhapsody No. 2. The funniest bit is when the phone rings inside the piano and Bugs answers, "Franz Liszt? Never hoid of 'im." I have several versions of the Hungarian Rhapsodies but this was the first one I ever heard and it still makes me laugh. So here it is:

Here are some other versions:

And for the purists:

The Gift

A month ago, a 12 year old boy needed ultrasound guided drainage of Perforated Appendicitis with Abscess. This invasive procedure often requires sedation and I was sent to the radiology suite for that purpose.

I talked to the patient and to put him at ease I asked him what movie he would like to watch during the flight. He eagerly wanted to see the latest James Bond movie (I thought 007 was retired!). I told him I'd do my best.

The procedure went well. In recovery the boy was very agitated and complained of abdominal pain. The parents were in tears. I prescribed pain medication and asked the patient to breath slowly and deeply (a great meditation and auto-hypnotic technique) and explained that he would feel less pain.

This was at the end of Thursday and I was eagerly anticipating joining the rest of the family for a long weekend at a hotel near Jerusalem. Before I left the hospital, I went back up to Radiology to see how the boy was. The father seemed more worried than ever. Despite my desire to leave, I answered all his questions to the best of my ability (the surgeon could better answer most of his concerns, however at that point in time I was most available). After about half an hour of discussion, the father seemed somewhat relieved.

When I got to the hotel, I called the hospital. The boy was back in the pediatrics ward and was no longer suffering from pain.

A few days later I again met the father at the local cafe. He was all smiles and said that his son was fine and was being discharged. He thanked me and I went to work.

This week, when I returned to work from sick leave, I was given a package. It was a letter of thanks and gifts. The package included a very portable 3 book set of the Mishna and a silver bookmark. I have never received such beautiful gifts for just doing my job. This gift means quite a lot to me. Among the changes in my life this past year, is an interest in the sacred texts of Judaism, and I have begun (albeit sporadically) to study the Talmud with my local Chabad Rabbi (who, in my humble opinion is a genius).

However, the accompanying letter is very touching. Here is a (very) rough translation:

Dear Dr. L,

On Thursday xx/xx/09, my son was brought to the ED because of abdominal pain. The diagnosis of Acute Appendicitis with Peritoneal Abscess was made in the ED and within an hour Prof. K and Dr. N performed an invasive procedure which saved my son's life. This procedure couldn't have been performed without your dedicated help. Now, having been discharged from the hospital, is the time for giving thanks:

"...you are charged day and night to remain by the side of a patient in distress at all times and all hours...you have been taught to understand the heart and soul of the patient and lift his spirits with understanding and the love of humanity...

So it is written in the Physician's Oath (the Hebrew version. Here is the original with the biblical references. -QL)

At times, in life, events occur which bring into focus the meaning of the word: humanity. So it was in this case.

Deeply stirred, frightened, unable to speak, I watched as the doctors worked calmly with determination to save my son, and again understood the sanctity of your work and especially your humanity.

Thank you from the bottom of my heart for the dedicated treatment and for literally saving the life of my son. Blessed is the man who has known you.

In the tractate Sanhedrin (from the Mishna - QL) it is written:

"He who saves one soul - saves an entire world."

On behalf of the entire family, please accept this humble gift.

I will end with the 8th blessing of the Amidah:

"Heal us Lord, and we will be healed, save us and we will be saved, bring complete healing for all our illnesses, for you are a compassionate healer."

With Infinite Gratitude,

The L. Family

I called the family to thank them for their generous gift. The son answered the phone. When I identified myself he said that I had done a poor job because he didn't see the James Bond movie. I apologized and assured him that it was much more important to be healthy again.

He then passed the phone to his father. I thanked him for the gift. He said it was only a small token of appreciation. I assured him that it was much more than that.

Hypochondria by Proxy

On the cel phone my wife was sobbing, "Thank God!" and she hung up. My temperature must be up again, I'm having an auditory halleucination. My wife is actually thanking God that I have pneumonia. I'm definitely hearing things. "Nurse!" I call out, "get me a psych consult...for me!"

Let me start over. Most people have one Yiddishe Mama, the biological one (Hi Ma!). I have three:

1. My actual mother.

2. My mother-in-law.

3. My wife.

Of the three, my wife is the most accomplished. To be sure, it is genetic, her whole family are master worryworts. And they have taken Hyphochondria by Proxy to completely new levels. Every cough, rash, sneeze, pain, tingle and premonition in a family member is cause to seek expert consultation.

About four months ago I was hit with the ol' one-two punch. I got the common cold and then when I recovered, I got it again. I was pretty worn out. Since then, I've had this cough. Just a dry cough and a constant tickle in my throat. It got to be so routine that I didn't even notice that I was coughing.

Eventually, my wife and mother ganged up on me. "Go to the doctor!" "But I feel fine, besides I'm too busy". Both were true, I felt fine and I was very busy.

But last week, I developed a fever. It started in the middle of a very long operation. The surgeons had the air conditioner on full Siberia mode. And I felt awful. I took a surgical drape and fashioned a balaclava out of it. So, the next day I called in sick and went to my family doctor. "Your lungs are clear, it's probably just a viral infection. No cause for worry." (I've used that line myself many times) "Good, I can finally reassure my wife the hypochondriac by proxy." He laughed.

A few days later, my cough got worse, more productive. I went back to the doctor and this time He heard crepitations in my right lung. "You've got pneumonia." OK, Emergency Dept. here I come. First I went home to drop off the mail and tell my wife. I was met with the patented hypochondriac-by-proxy-gaze. She looked more worried than ever. I tried reassuring her, "It's just to get a chest xray to confirm the diagnosis. I'm fine, really." The gaze became a black cloud.

I went to the ED in the hospital I worked in for ten years and received the royal treatment. I was actually enjoying myself seeing old friends and co-workers. The most senior internist in the ED recognized me and took my chart even though any resident could take my case. A couple hours later, after blood work and a chest xray I was the proud new owner of a right middle lobe pneumonia. See?

Well It is actually hard to see if you're not trained to see it.

Anyway, then transpired the conversation that began this post. I must be insane, my wife is relieved that I have pneumonia? When I got home I was greeted with that "I told you so" look. That too is patented. I swear, I'll have "My wife told me so." engraved on my tomb stone.

It was only today that I asked my wife what she was thinking when she thanked God that I had pneumonia. "Something worse, much much worse."

"You mean cancer?"

"Don't say that word in this house! Besides, your mother must think I'm a loony toon."

"Oh, Oh. Why?"

"Because, when you were in the ED I phoned your mother. She said it was probably pneumonia, and I said "I hope so.""

Just for the record, had I gone to the doctor a month ago, he wouldn't have found anything. I was assymptomatic (except for the cough), my lungs would have been clear on auscultation and the chest film would have been normal.

But "I told you so" just can't be lived down.