Sunday, May 24, 2009

Like an Angel

Sometimes, one happens to be the right person, at the right place, at the right time. I was sitting in the nerve center of the department.  There is a large screen there that displays the monitors in all the OR's.  In addition, there are visual alarms that alert the viewer to a problem in a particular room.  The only person who is there all the time is the secretary who has no medical training whatsoever.  It is not clear, therefore, for whom the screen was installed.

I was ruminating when I noticed a decrease in oxygen saturation in room number 4.  A few seconds later the oxygenation rose up to a normal level.  This in itself is not extraordinary.  Often, during induction of anesthesia, despite preoxygenation, there is a drop and then a rise after the endotracheal tube is inserted and the patient ventilated.  However, a few seconds later, the oxygen again dropped.  Since I was not busy, I decided to go to room 4 to see if they needed help.

I was right. It was a difficult intubation.  There was a young resident and an attending, who happened to be the same attending (aka the teacher's pet) from the infamous incident. We successfully intubated however the patient was very spastic, I deepened the anesthesia, added a bronchodilator and some steroids and the situation improved.

Once everything was under control, the teacher's pet turned to me and said, "You decended upon us like an angel.  How did you know we were in trouble?"

I smiled and said, "I know everything that occurs in the OR, and I sensed that you needed help."

Her jaw dropped in astonishment.  I quickly added that I had seen the drop in oxygenation on the screen and decided to see if I could be of assistance.  

She smiled and thanked me.

Saturday, May 23, 2009

Rule #9

Assuming that I'm a blogger, it stands to reason that you, don't turn around, I'm writing to you, yes, yes you...are a bloggee. Linguistics aside, some bloggees might remember The Rules. Recently I discovered Rule #9: "It is strongly advised that hemoglobin be maintained within the blood vessels."

The case was a 70 year old patient undergoing a lung lobectomy with the VATS technique. This is minimaly invasive surgery with the major benefits being less post operative pain and quicker recovery. Things did not go well from the start. The anatomy was less than optimal and the surgeon had difficulty visualizing the relevent structures. When the stapler was applied to the blood vessels supplying the lobe to be resected, all hell broke loose. The pulmonary artery was lacerated. The pulmonary artery though not the aorta, is not a vessel to be lightly dismissed. If it weren't so deadly, I'd describe the scene as breathtaking. The velocity at which one's entire blood volume pours into the chest cavity literally takes one breath away.

No doctor, no matter how talented is immune from complications. What is unforgivable is unprofessional behavior. The surgeon screamed at the top of his lungs at the nurse who did not provide the rib spreader fast enough. I understand who stressful such a situation is. No one likes killing a patient, but that is no excuse for venting one's frustration on an innocent team member, especially one who is desperately needed to continue functioning. I have previously stressed how important it is to keep a cool head in an emergency. Even I, with my experience, was frozen in place during the surgeon's cathartic rage. (The surgeon may have felt very good about himself afterwards, but the rest of us felt like crap.) Despite the delay, the rescucitation went relatively well and the patient made it alive, albeit post pulmonectomy, to the ICU.

I personally have no desire to ever work with that surgeon again.

In the Chapters of the Fathers (פירקי אבות), chapter 4 verse 1 it is written:

איזהו גיבור, הכובש את יצרו שנאמר טוב ארך אפיים מגיבור ומשל ברוחו מלכד עיר

In translation:
Who is strong? He who subdues his passions. For it is said: "He who is slow to anger is better than a hero, and he who has control over his will is better than he who conquers a city."

We still have much to learn from our forefathers (and mothers).

Tuesday, May 12, 2009

The Kiss

My uncle Danny passed away on the Sabbath. He began to complain of pain only three months ago. Two weeks ago we finally received the results of all the tests: Lung cancer with diffuse metastates. His condition deteriorated quickly and a week ago we hospitalized him.  Much of the time he was confused and restless but I used my connections to get a consult with the pain specialist and so at least his suffering was alleviated. 

On Tuesday, after work, I visited him.  He was more restless than he had been the previous days and was trying to get out of bed.  He finally mumbled that he needed to use the toilet. But he was very weak and could barely walk.  We told him to relieve himself in the diaper and that a nurse would clean him afterwards.  I eventually understood that despite his confusion, he still wanted to maintain his dignity.  What happened next was out of pure instinct.  Had I thought about it too much I would never have been able to do it.

I found a nurse and asked him for the special chair used to take bedridden patients to the toilet.  It is a chair with wheels and a hole in the seat for the obvious reason. I asked the nurse if it would be possible to shower him since we would be getting him out of bed.  He said that it would be better in the morning shift when there were more staff working.  But my uncle needed this now! (How could he possibly wait til morning?)

Without thinking, I wheeled him into the toilet.  When he was done it was quite a mess.  I must mention that in all my years in the ICU, whenever the nurses would clean and bathe patients who were soiled I would usually head in the other direction.  I'm constantly in awe regarding how they can stand to do such filthy (and pungeant) work. I asked the nurse to help me wheel my uncle into the shower and bring me soap, shampoo and lot's of towels.  I don't know where I got the strength to do it but I washed my uncle from head to toe, dressed him in a fresh hospital gown, and brought him back to the room where, for the first time in days he sat in a chair.

It was emotionally very draining and I broke down in my mother's arms.  When I pulled myself together, I noticed that my uncle seemed more alert, though it was still difficult for him to talk.  As I bid him goodbye, he blew me a kiss.  I finally understood, that despite his confusion, he was determined to hold on to every ounce of dignity.
His deterioration continued until he finally passed away on Saturday.

On Sunday we buried my uncle.  For the benefit of my sisters who live overseas (and all who might be interested), and could not attend the funeral, I provide a translation of the eulogy I delivered:

"Adi (my cousin) said yesterday that this had been the longest, yet shortest, week of his life. During this short/long week, many images flashed through my mind. This is fitting, for I first knew Danny through pictures in the family album. Dad told us stories about his kid brother in Israel.  And the stories accompanied the pictures. There is the picture of Danny not much older than my youngest boy.  
Mom reminded me of another picture, and I opened the album again this morning to look at it: The older brother helping his mother tend to the baby brother.  Both boys would soon be orphans when their mother would pass away. There were other pictures, but that one particularly sticks in my mind.  
Then one day, in the mail, we received a photograph of a beautiful young woman serving in the airforce, his fiance, my future aunt.  Then Dad flew to the wedding and came back with yet more pictures. And there were the usual pictures that mark the milestones of life.  Along with the pictures were the images as we lived them. Eventually, I came back to Israel alone. I bid farewell to my family, and exchanged a mother and father for an aunt and uncle. My sisters were replaced with two cousins. Little pests they were, but very cute.  I instantly inherited a family, no explanations necessary, just the most natural thing in the world.  
The  next image that comes to mind is that of the whole family crammed into a tiny kitchen filled with the scents of delicious food.  The special "prassa" meatballs would literally jump out of the frying pan onto our plates where they survived only for a few moments before being devoured.
Danny was an enigma: soft spoken, humble and pleasant. It was difficult to really know him.
During this short/long week, Danny struggled to maintain his dignity and humanity despite the suffering and the confusion and the restlessness.  In my own small way I helped him achieve that goal.  And through the fog of confusion and medications, Danny found the way to thank me without words.  But Danny, it is not you who must thank me, it is I who should thank you for letting me finally know who you really were.
The images of this short/long week crowd my mind.  There is one that supercedes all others: Dad bent over Danny, caressing his forehead and comforting him.  Again, 60 years after the first picture, the older brother tending to the younger.  Nothing has changed.  
But this isn't the memory I want to retain.  The one I want is that of Danny, the gentle, quiet, honorable and respectful.  And above all else, noble.  That is the memory that I want.
May his memory be blessed."   

Saturday, May 2, 2009

Students: Addendum

The first group of students finished the anesthesia rotation and tomorrow a new group will begin theirs. After the exam I conducted a short debriefing with the students to determine what can be improved. It's quite a daunting task to expose and hopefully teach and instill the basics of anesthesia, intensive care and chronic pain treatment; all in 10 days. Impossible you say? Nothing is impossible.

The students unanimously expressed their pleasant surprise that what they expected to be an airway management workshop, turned out to be a very enriching learning experience. This was most gratifying to say the least.

At the end of the debriefing, I wished them all success, and sent them on their way. Needless to say, I was very touched when they honored me with a gift. It is book of letters to and from Israel's foremost philosopher from the previous century: Yishayahu Leibowitz.
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