Pithy Restroom Proverbs

So the computer was only comatoast. Instead, my car's transmission broke. Had the car towed and went to a (delayed) meeting with the Deputy Director of Soroka Medical Center. Everything went well and a formal contract will be drawn up. Apparently, word of my return has spread like wildfire.  And much to my chagrin, it is seen as a "victory" over Tel Aviv Medical Center which has drawn quite a few talented doctors from Soroka. To be brutally honest, the brain drain was the result of failed policy decisions made not at the level of the hospital, but at the level of the central management of the HMO. My return  resulted from a policy change when the main office realized that doctors need to be paid an appropriate salary. Had they not approached me, I would have never entertained leaving TAMC. After the meeting, I looked up old colleagues. Strolling the hospital grounds, I ran into many familiar faces. All seemed genuinely glad to hear that I will return.


Since I was on the loose in Be'er Sheva, I called up Treppenwitz and asked him if he was hungry. Over lunch he related a very moving story. Good conversation and the bestest shawarma in the South, a combo that can't be beat.

Later, I picked up the kids, then went to pick up Mrs. Sandman from work and we had a family evening. We went to a "concept" restaurant called "The Library". As expected, the walls were lined with bookshelves bulging with books. The food was mediocre. But it was a raging  success (especially with the youngest sandmite) due to the restroom which was equipped with automatic taps for hand washing an an automatic hand dryer. Unsurprisingly, said sandmite dragged me the the restroom no less than 5! times to use the toilet and wash his hands. Above the row of sinks was one of those huge LED signs that had running proverbs and jokes.  The proverb which really caught my eye was:

"When one argues with an idiot, assume that one's adversary is probably doing the same." 

An ode to Sand.

Can you say sandstorm? One might assume with a moniker like mine, I'd like sand. If so, one might assume wrong.


Sand is everywhere. In my eyes, in my ears, and in my mouth.
Sand is on my car, on my wife and in my house.
Sand in the air, sand on a chair,
In my socks and in my hair.
When the rains finally fall, all will turn to crud,
And then,
We will be buried in mud.

Air Pollution

So I'll be working here at TASMC 'til the end of the month.  A few more weeks to enjoy Tel Aviv air pollution.
Home computer  is DOA and SD (Dead on arrival and stayed dead).

Computer Dead

*Sigh*

Change Is in the Air

I'll cut to the chase: I'm leaving Tel Aviv Medical Center, and going back "home" to Soroka. It all started back in August. I was not my usual cheerful self, *ahem*. The long commute, the long hours and almost no vacation time were taking their toll.  Boss Lady noticed that something was wrong and summoned me for a meeting. With her usual charm, she basically was telling me to pack up and leave, or so I thought. Needless to say, I tossed and turned that night (as if I needed another sleepless night), torturing myself with feelings of failure. The next day I groggily asked her to clarify her position.

  

What she said, was partially true. I wasn't living up to my potential, having made a decision to devote what little spare time (none) to my family, thereby damaging my career. She had expected me to stay late every day to do research. But that's not for me. As it is, the last two years were mainly composed of commuting (4 hours a day) and working, lightly sprinkled with bathing our youngest, bedtime story, evening excercise (walking), only to collapse in bed.  Five minutes later the cycle repeats itself. It's a grueling schedule.

What Boss Lady got wrong was that she thought I had enough downtime. In 2009 I took only 6 vacation days. My next vacation was a year and a half later. But I never complained, and I have never been one of the ass-kissers who visit her office every day.

In the end, Boss Lady said that she would accept my decision whether or not I stay. If I do stay she expects me to fulfill my potential and that she appreciates me and considers me an asset to the department. My bruised ego hath been soothed.

I don't know how I twisted our first conversation into a good swift kick in my ass. I'll chalk it up to chronic fatigue induced imbecility. 

Serendipitously, my former, and now future, boss contacted me with an offer. Nothing spectacular, but enough to lure me back. When I left, I was the vanguard of a brain drain. Enough anesthesiologists left to cause the closure of OR's.  The management finally woke up and realized that they need to get some anesthesiologists on board. That of course costs money. Money that wasn't available two years ago suddenly turned up. Ain't that amazing?

Long story short, my contract in Tel Aviv MC ends on Dec. 7, and I will not renew. Perhaps, I am again at the vanguard of a stream of doctors who might be brought back to Soroka. What is for sure, is that I will have more time to be with Mrs. Sandman and the Sandmites, and I might even be conscious enough to enjoy it.

Maternal Airway - The Anesthetic Minefield

To paraphrase the emminent Prof. Forrest Gump, "The maternal airway is like a box of chocolates, you never know what's inside."

The anesthesiologist is required to have the most intimate knowledge of the anatomy of the airway.  For if the airway is lost, whether by trauma or drugs, the patient's demise is soon to follow. Navigating the airway of a pregnant woman may be a particularly harrowing experience.  This is the reason that regional anesthesia (spinal or epidural) is preferred for elective C-Sections.  As a result, at night, when the staff are less experienced and tired, occur the most stressful of medical emergencies: loss of the airway during an emergency C-Section.  The stakes are very high, literally the life of mother and child are in danger. The reason for the difficulties in securing the airway lie in the edema or swelling of the soft tissue of the oropharynx during pregnancy which is a normal occurrence. This may turn a normal airway into a "difficult" airway. Emergency protocols exist, but they only serve to guide, experience is the best teacher.

When intubating a patient, we try to bring three planes into alignment: The oral, the pharyngeal and the laryngeal.

If all goes well, then this is what you are supposed to see:

If this is the picture, then it's easy as pie to pass an endotracheal tube through.

Yesterday, at the end of the day, I was supervising the anesthesiologists on call who were finishing up the day's cases.  I had another hour or so to go before the senior on call could take over and I could go home. 

Then a call came, "anesthesiologist stat to the OB/GYN OR"!  Barreling up 5 flights of stairs (the elevators are notoriously slow), I called the ICU which was on the same floor and asked them to send someone.  I entered the OR before he did.  Three anesthesiologists were there, it was an emergency C-Section with a general anesthetic.  They told me that it was an impossible intubation and that they had tried everything including a laryngeal mask airway, and a video assisted laryngoscope, but to no avail.  They were just barely able to ventilate the patient by mask.  Her face seemed swollen with the usual edema, I could only imagine what was going on inside.  The operation was on hold during the efforts to secure the airway. The video assisted laryngoscope was turned on, the reason they couldn't get the tube in was because the special guide wire used with this technique had been lost or misplaced.  The guide wire is malleable but stiff and assists in navigating the tube through odd angles. I asked for a tube with a regular guide wire. I bent the tube into a hockey stick shape.  Inserting the scope, the airway looked like a bowl of cherry jello.  I could just barely make out the arytenoid cartilage at the base of the cords in the upper left quadrant of the screen.  I tried once, twice, I just couldn't get the tip of the tube anterior enough into the larynx.  I bent the tube into a horse shoe shape and said a silent prayer. The tip was just past the cords.  Holding the tube in my fist for all I was worth, I ordered, "remove the guide".  The guide was out, I pushed the tube all the way home.  The capnograph showed CO2 in the the tube, meaning, it's in the trachea. Auscultating the left lung field, no breath sounds.  Gingerly, I pull the tube back until I hear equal breath sounds over both lungs. "OK fix the tube in place".

Nonchalantly, I leave the OR, "thank you all for attending our emergency intubation" I call out.  "You may resume the operation".

Stay Tuned

There are going to be changes around here...stay tuned.

While I recover...

Here, for your listening pleasure is Oscar Peterson; while I recover from the holidays ... and gastroenteritis:

Thoughts and Ruminations

I hesitate to press the button and post this. I am positive that I cannot write anything original or even meaningful.

Ah, well...here goes nothing...

It's been 9 years.  I have nothing to add to all that's been written since then. Yet, I feel the need to somehow mark this somber anniversary by attempting to recall the fading memory of the thoughts and feelings of that day.

9 years ago I woke up in the afternoon having napped after call the night before. I came downstairs to make a cup of coffee.  I turned on the television to see one tall building burning. Morbid curiosity shifted to disbelief and then to anger as I watched in real time, an airplane ripping through the second tall building. I instantly realized that this was no accident, it was deliberate.  The first tall building and then the next, collapsed. The emormity of the tragedy was overwhelming.  I had a sense of witnessing history. The sadness and the rage came later.

Only later, years, in fact, I learned that a high school classmate was murdered then.  His widow was interviewed and she told that her husband called to tell her that an airplane had crashed into the building which was burning; and that he loved her. This scenario was repeated many times that day. They knew. They knew that they were in mortal danger. I can only speculate what a person thinks and feels at the moment of realization.  Were they stoic, angry, fearful; Did they feel panic, terror, acceptance?  Did they cry, did they pray, did they hope? Perhaps some just blankly waited for certain death, resigned to the inability to do anything.

I've seen people die. Some were patients in the ICU who were heavily sedated.  Some were trauma victims who were fully concious, until they weren't.  They looked, pleading, into my eyes searching for reassurance. I reassured them even though it was a lie, convincing myself that it was the compassionate thing to do. I don't choose to dwell on it, yet I find myself obsessing about the moment.  What does a person think and feel at that moment? What did they experience at that moment? For the souls in those buildings it was more than a moment, it was an eternity.

As the memory of that day fades, I no longer contemplate the global meaning of what happened. Surely there is a universal struggle against suffering, hatred and evil; inhumanity and cruelty. There is an enemy, and we all know who that enemy is. I choose to ignore the larger issues because they have become hackneyed and common; and thus have lost their meaning. Instead, I focus on the individual experience. I believe that the victims' memories are better served by remembering them. So today, I think about them, the individuals and what they experienced.

I suspect that their experiences  were as varied as the number of people in the buildings that day. Again I ponder a question: At that very moment, when an individual experiences impending doom, does he look for sense in a senseless reality? Don't expect me to provide the answer, it's tough enough just phrasing the question.

Hence, I refer the reader to one of the most important books written during that last century: "Man's Search for Meaning" by Viktor Frankl who survived the Holocaust. He writes:

"Everything can be taken from a man but...the last of human freedoms - to choose one's attitude in any given set of circumstances, to choose one's own way."

So, my advice is to choose. But don't wait too long to do so.

Shana Tova

To usher in the new year I offer some beautiful music featuring Esperanza Spalding. If you haven't heard of her, you should have. She appears on the cover of this month's Down Beat. The amazing thing about her is that she is so young yet so accomplished; and she has only begun to tap her potential!

Here is "Little Fly" from her latest album "Music Chamber Society":

In this interview she describes how her career developed.  She possesses the admirable quality of listening to her elders and following their advice .

In this final offering, Ms. Spalding's contrabass anchors Titan Joe Lovano's new group US Five.

Shana Tova

כתיבה וחתימה טובה

Red Mailbox.

I too have jumped on the "Ruby Tuesday" bandwagon.  The rules say I have to link here.


This was found in old Plovdiv.

Bulgaria

For a much needed vacation, I took the family to Bulgaria. We were joined by another family - good friends of ours.  In once sense, this was for me, something of a roots-finding journey.  I found no roots - I will reveal why,  later.

We decided to avoid the touristy Black Sea resorts and focus mainly on the mountain areas in the south-central and southwestern part of Bulgaria. We began the trip in Plovdiv, Bulgaria's second largest city and ended in Sofia, the capital.  Except for the historical areas of each city which warrent no more than half a day each, neither city had any charm to recommend them. Both cities suffer from East-European-Post-Communist angst. I don't claim to have seen all of these two cities, but what I did see, was ugly.  The view is one of dirty and deteriorating buildings and streets and almost every wall defaced with graffiti (unheard of even 10 years ago).  Even the Alexander Nevski Cathedral in Sofia did not escape the spray paint of the urban vandal.

Driving in Bulgaria is, to say the least, a challenge. Bulgarian drivers are collectively insane.  The only rule of the road that I could detect is that there is no rule.  Having come from Israel, that is saying much.  Another difficulty is that one must be able to decipher the Cyrillic alphabet to be able to read the road names in the city.  The problem is that most intersections have no signs, and even if you ask someone on the street what the name of the street is, more often than not they do not know.  Leaving the city, the signs designating places have both Cyrillic and Latin letters.  However, all other road signs, are only in Cyrillic.

Plovdiv was humid and sweltering hot (tribal elders say that this is the hottest summer they can remember). It was torture and we were glad to drive south into the Rhodope Mountains.  The air temperature immediately dropped 15 degrees and was clean.  On the way to our first destination, we stopped at the Bachkovo monastary. I personally don't like monastaries for their dark and oppressive atmosphere.  The monks remind me of our yeshiva dosim. Both are Men in Black (tm).  Theirs pray all day and paint kitchy iconic scenes on the wall; Ours pray all day and study Gemarra.  Neither do manual labor. The reasons for stopping to see this monastary were: 1. To break the drive up into bite sized portions, especially for the children. and 2. The Patriarch of this particular monastary during WWII was very active in protecting Bulgarian Jews, so we came to honor his memory.

We continued to Momchilovtsi, our first destination.  It is a small (550 homes) mountain village named for Momchil who is a local hero. Anyone who resisted the Ottoman Empire is considered a hero in Bulgaria, even if they failed, which is what happened more often than not.  The people of Momchilovtsi are simple, welcoming folk.  It was an honor and a pleasure to meet them.  They spend most of the summer gathering wood and preserving fruits and vegetables for the long winter.

The cool breeze and the vegetation in the mountainside above the village was soothing.

We took day trips to see the sites and hike. This is a church tower in Shiroka Laka:

The air in the Rhodope mountains is particularly clean. The locals claim that is is negatively ionized.  I have no idea what that means. All I know, is that those in our party who suffer from allergies were completely symptom free. The mountainside is cool, lush and tranquil.  This being blueberry season offered bunches and bunches of blueberries begging to be picked.  Which is what we did. All the children turned the task of mashing the fruit for jam into a great jolly blue game.  The jam was marred when the preteen lasses mistook salt for sugar.  The purple conconcoction was pulchritudinous to the eye and absolutely inedible. No amount of sugar could salvage it from terminal salinity.

The neighbors across the road, Elena and her grand-daughter Elena, warmly greeted us. One afternoon, the elder Elena invited my wife into her home and found out everything about us that there was to know.  Most of the interrogation was conducted with much hand waving and when non-verbal communication failed, Elena the younger (like most young Bulgarians, learn English) was summoned to facilitate conversation. A natural connection was made. When it came time to leave, Granny Elena tearfully hugged my wife, made the sign of the cross and blessed us for the rest of our journey.

We made our way west leaving the fertile Rhodope mountains into the drier and dustier Pirin mountains.  Here our base was the ski resort of Bansko.  Many businesses were closed for the summer.  The winter ski-hordes are still several months away.  The day hikes into the Pirin were spectacular.  We first drove up to Vihren Hut.  The "hut" is actually a lodge.  And by Bulgarian law no traveller may be refused lodging. During the busier seasons this means that one might sleep in a hallway. This is still better than freezing to death. The "hut" was the starting point for our first hike here:

As desert folk, we are used to hiking with liters and liters of water.  We soon abandoned this custom when we discovered that everywhere are mountain streams flowing with crystal clear and absolutely freezing potable water.  Thirsty? Just dip a bottle into the gurgling brook and enjoy.  Just as our thirsty lips where satisfied with the delicious mountain spring water, our vegetation-thirsty eyes were sated with the endless forest and the wildflowers:

The next day we took a ski lift to the start off point for our next hike.  The ski lift was an adventure for the children.  The lift took us to Bezbog Hut. Bezbog, ironically means "without God".  This epithet was probably earned for the relative lack of water. No streams, but there was a lake. The vista was absolutely breathtaking.  During the climb, everytime I turned around I was greeted by artwork made by the Almighty Himself:

And each time, I was inspired to record the view even though it was the same view.

Returning to the lift, we were greeted by workers who had taken advantage of being on the mountain by picking buckets and buckets of blueberries. I assumed that they had consumed as many berries as they had loaded on to the lift because they waved us on our way with beaming bluetoothed smiles.

After 5 days in the Pirin mountains, we passed through the Rila mountains and the eponymous monastary, the largest in Bulgaria, on our way to Sofia, our final destination. Here is were I hoped to find some evidence of my roots in the place.  On my father's side we are Sephardic Jews. As such, after the Spanish expulsion, my family wandered all over the Balkans, some settling in Greece and some continuing to Bulgaria. My father was born in Sofia and my grandparents were married in the Sofia Central Synagogue.  It was there, with a sense of relief that I finally found something jewish, something with which to identify.

The Jewish community is tiny.  Only about 2000 are left out of 48,000, most of whom left for Israel when the communists took power.  It was a Sunday, and the synagogue was empty. But I felt a need to try to connect with my ancestors.  I prayed the short Minha prayer alone.  Just me and the Lord in a private conversation.  The connection I wanted to make just didn't happen.  Instead, I got the connection that I needed.   I realized that my roots are here in Israel, just where they always were.

Back From Vacation

Spent the last two weeks in Bulgaria hiking with the family. Stories to be posted...

Thoracic Epidural

The paucity of my posting is not for lack of inspiration, it is for a plethora of fatigue.  I haven't had any downtime for  a year and half.  And it's taking its toll. The director of the OR lambasted me and even accused me of sticking a knife in his back (all due to a simple misunderstanding).  He also remarked that I've been in a bad mood lately.  Sure, I told him, every time I ask for some time off, the head of anesthesia said no.  I had to find out my self that one needs to request vacation time almost a year before. In 2009, I used up only 6 vacation days - the least of any anesthesiologist in the department (including residents).  So sue me for being cranky.

The good news is, that I am now officially on vacation. YooHoo!!!!!

Last week, when I was a the end of my tether, I had a case that reminded me why I like my job.  A middle aged foreign worker was scheduled for excision of a dermoid tumor on his upper abdomen.  The surgeons said that it was superficial on CT but it may have increased in size and involved the ribs since the scan was performed. In addition they were planning to take a free flap from the opposite side to close the resulting defect in the abdominal wall. A very painful procedure to say the least. I discussed with the patient my plan to use a combined anesthetic technique, meaning, combining a general anesthetic with a thoracic epidural especially for post-op pain control.  The thoracic epidural is a more difficult technique compared with a lumbar epidural because of the anatomy of the spinal column. For a concise discussion I refer the reader to my fellow blogger Anesthesioboist's  excellent post on "Epidural Elegance".

I prefer the thoracic epidural not only for thoracic procedures (obviously), but also for upper abdominal procedures since this area might be missed by a lumbar approach. The benefits of epidural anesthesia is mainly for its "morphine sparing" effect, that is, there is less of a need for IV morphine (with all its side effects), but also for excellent post-op pain control. I usually use a continuous drip of a local anesthetic (with or without an opiate - I prefer with) and "rescue" doses self administered by the patient if the pain increases. This is called PCEA - Patient Controlled Epidural Analgesia.

The procedure went smoothly, no rib resection was necessary.  In addition, the surgeons decided to forego the free flap and close the defect with a skin graft from the thigh.  I was concerned that the thoracic epidural might not cover that area, but I gave him a good loading dose.  A couple hours later in recovery when the patient was completely coherent, he was smiling and completely pain free.

Nice.

Joy Tempered by Sadness

There's a very old joke about the definition of joy mixed with sadness: It's watching your mother-in-law drive off a cliff in your brand new Cadillac. 

Sometimes life mixes joy and sadness in the cruelest of ways.

On call in the delivery room. The senior OB/GYN gave me the heads up on a parturient that we would be seeing later.  The young woman presented to the OB department in labor in her first pregnancy.  The admitting doctor noticed a swelling in her neck that she had never noticed. After the relevant tests and consultations she was diagnosed with lymphoma. Her chest film looked similar to this one:

She decided to proceed with a vaginal delivery.  At one point she requested an epidural but upon reexamination she had progressed quickly and was about to give birth, so the epidural was not necessary. After giving birth she was brought to the OR for a retained placenta and to suture some tears in the birth canal. I decided on a spinal anesthetic in order to avoid intubating and ventilating (even though there were no clinical signs of respiratory compromise). The procedure went well. 

During the entire time there was something unsaid in the air. We knew and she knew. We knew that she knew and she knew that we knew.  But no one mentioned the ogre in the room.  I brought her to recovery (I had briefed the nurse there before we started the procedure) and presented her to the nurse. I conveyed my congratulations and wished her: 

רק בשמחות

Which is a short version of the wish to meet only at joyous occasions.

To which she replied, "Amen".

We Con the World

Since YouTube in a spineless, despicable, jihadi-placating move has banned this satirical video, I too embed it on my site.  Hey YouTube! There's a nice spot on my derrière for you to kiss!

Interview

I've been interviewed at Ilana-Davita.

La Traviata en Mercado

Verdi's "La Traviata" in an unconventional venue:







Hat tip: Discarded Lies

Mother Hen

I've just finished tutoring three rotations of med. students.  As their tutor, I had to decide on the content of the rotation, the schedule, make sure they had scrubs, lockers, food, basically worry about everything except wipe their noses. I felt more like a mother hen than a clinical instructor.  The first and last group were good. The second group made me depressed.  They seemed completely uninterested.  Whenever I asked a question (my style of teaching is very interactive) I was answered with silence and the glassy-eyed gaze of a newborn calf. I asked one of the students, based on her family name if she was related to the CEO of one of the health funds.  She replied that she was his daughter. I thought to myself, "Now I understand how she was accepted into med school."

During their rotations, I'm not assigned any particular schedule, so I help out whenever necessary and do emergency cases. One morning, I heard a call for help on the PA, when the call was repeated I went to that room. I asked the anesthesiologist was was wrong, she said asystole - cardiac arrest.  For some reason, she was drawing up meds and had not started closed heart massage.   I immediately started heart massage, other anesthesiologists came into the room and the incident quickly became a "mass caregiver event" (as opposed to a mass casualty event - which is much easier to manage.) After atropine and adrenaline the patient's pulse returned. And I left the room.

Reflecting on the case, I recalled what I learned in the ACLS instructors course: Recall of course content is very poor, hence requiring recertification at regular intervals. This was certainly true of this case, since the anesthesiologist did not immediately begin heart massage after calling for help.

My suggestion that I give a couple of refresher lectures to the department was accepted by the boss.

P.S. - The patient recovered completely with no neurological or cardiac sequelae.

A Veritable Madhouse

This link is to a story on the online edition of Yediot Aharonot, a hebrew daily. There is no english version so I will provide a brief synopsis.

The article describes an altercation between the Chief of Anesthesiology and the Deputy Director (who is by profession, a psychiatrist, sexologist and stand-up comedian. His routine is concerned of course with sexology) of the hospital where I was previously employed.

During a meeting between the two, an argument ensued. Voices were raised and the venerable Professor of Anesthesiology cursed the honorable Deputy Director. The choice of words left no doubt as to the Professor's opinion of the latter's mother's chosen profession as being, ahem, less than honorable.

The honorable Deputy Director then proceeded to suffer chest pain thus necessitating admission to the Cardiac ICU.

End of article.

What isn't mentioned is the cause of the argument. Apparently, it was over promises made and not kept to increase the number of positions available for specialists in anesthesia.  I personally know of one case of an excellent (ahem) anesthesiologist who left to work in another hospital, who might have stayed if a position were available.


The article clearly assigns blame to one of the gentlemen. I offer perhaps a somewhat more objective opinion.  I am acquainted with both gentlemen. The Sexologist was one year ahead of me in med school, and the Professor was my former boss. Both are former colleagues with whom I worked for several years. Both may be described as very colorful characters who hold strong opinions and are quite adept in expressing themselves in a verbal arena.


The Sexologist is tall and, well, to put it delicately, portly and there is no evidence that he should be accused of partaking in any organized sport whatsoever (to my knowledge, being fruitful and multiplying, his field of specialty, is not an organized sport) . The Professor is vertically challenged, slim and a competitive swimmer. To say that the Professor is a man of tact would be deceitful. To say that the Sexologist is a delicate soul prone to mortal injury when exposed to epithets of generous decibels would be hallucinatory. I do not believe that there is a hero and a villain in this. It was a clash of titans of sorts and one emerged injured, or was he? If the story is to be taken at face value, then there is sympathy to be gained and injury to be redressed. I will let the reader decide if the chest pain was the result of bad habits, mental stress or a combination of the two.  I was not present at the incident and make no pretense to know all that transpired.


I know one thing. The hospital is going down the tubes. Patients and staff alike will suffer.


Thank God I escaped the Madhouse in time.

Beatallica

Lookie, a heavy metal song about....me!

Valleys of Neptune

How does a deceased artist release a new album? In the case of Jimi Hendrix you find never before released studio versions.  The rare, hard to find Valleys of Neptune has finally been issued on a new CD with some familiar songs and some not so familiar songs. All are Hendrix at his best and most creative. Here is a clip of "Foxy Lady" for your enjoyment.

The Jimi Hendrix Messenger

A Change of Plans

The follow-up x-ray showed that the bones were no longer aligned.  How do you keep a 7 year old from playing for 2 months?  Our middle child underwent surgery last night to internally fixate the radius and ulna.  He sailed through the surgery and anesthesia like a champ. (Thank God and the wonderful staff at TAMC)

He woke up and said, "I have stridor."  Only a doctor's son would wake up and make his own diagnosis.

Since the ward was packed to the gills they allowed only one of us to stay with him through the night. So, we asked him who he wants to stay with him.  He chose Grandma (my mom, Hi Mom! thanks).  I was sure he would choose his mother and my wife was sure he would choose me.  We asked why grandma and he replied, "Because I haven't seen her in a long time." Bless him.

We performed a change of the guard this morning.  Grandma is none the worse for wear.  Wife just called.  They played cards, there is a classroom on the ward and he's been playing games and the organ.  She's worried that he's not complaining of any discomfort. Such a worry wort. 

Silly me, I thought no pain was a good thing.

Sphinx

Yesterday, I anesthetized a patient who sports the last name of one of the more prominent organized crime families.

In the holding area I interviewed him and put him at ease with my usual banter and I believe I  achieved a good rapport with him.

Having forgotten that discretion is the better part of valor, I asked the question that should not have been asked.

"I'm sure you've been asked a million times, but are you a member of that famous family?"

He smiled and said, "I'll answer your question with a question."

"Shoot." I said. (Another unfortunate utterance.)

He asked, "Do you know why the Sphinx has been around for about 4000 years?"

"Why?"

As his smile disappeared he said, "Because he asks no questions."

Point well taken. 

Broken Arm

Child number 2 broke his arm...again. Again he tripped on another kid's feet while playing soccer.  Midshaft radius and ulna fracture, same arm.  No more soccer for you young man!

The orthopedists in our local hospital didn't like how the fracture was set and determined that he needs an operation. I decided to get a second opinion mainly because I have lost confidence in the doctors in the hospital where I used to work.  Here in Tel Aviv, not only is there an entire department of pediatric orthopedics, there is even a specialist in pediatric fractures.  I made a beeline to him for his opinion and he concurred that internal fixation was necessary.

Then began the debate.  Should we operate in Be'er Sheva or in Tel Aviv.  My wife wasn't keen on the idea of the logistics of traveling far from home (1 hour 15 minutes is far in Israel).  I told her that our boy deserves the best treatment possible even if it is inconvenient.  We'll get the grandmothers to look after the other kids and we will make the effort.

In the mean time the consultant asked that we take another x-ray the day before the operation because sometimes the alignment improves.  The new pictures showed better alignment, but not perfect.  The orthopedist said that he can do even better.  He removed the cast, reduced the fracture (this caused no pain, just mild discomfort BTW) and applied a new cast.  The re-x-ray was perfect. 

Long story short, no need for the operation. Yoohoo!

Come on honey, say it, say it out loud, you know what I want to hear: "You were right."

Jezrael Valley

Weekend pictures from the Jezrael Valley (actually the eastern portion plus the Gilboa mountain range) and the ruins at Bet Shean.

Kibbutz Nir David

Persian Cyclamen

Crown Anemone

Mount Gilboa

The Ruins at Bet Shean

The Bath House Floor

Pioneer Soup

IDF Field Hospital - Update

I text messaged my friend, Dr. Alex this morning.  He later called me (isn't technology nifty?). After working 48 hrs straight he finally got some rest.  He called just after he woke up due to another earthquake. He said the work was frustrating because they have nowhere to evacuate the most serious cases that even the field hospital can't treat.

On the news this evening it was reported that a U.S. Navy hospital ship (with over 1000 staff!) just anchored off of Haiti.  Hopefully, they will be able to treat the tough cases.

IDF Medical Corps Field Hospital in Haiti

The field hospital deployed by the IDF is doing a spectacular job.  Needless to say, this is a great source of pride.  I have several good friends there.  In the following clip my good friend and colleague, Dr. Alex Zigerman gives a very short explanation of some of the equipment. 

To Alex and the entire staff of the hospital, we back home are very proud of you, keep up the good work. 

Rule Number 10

I will begin with a caveat. I mean no disrespect towards my surgical colleagues with the following rant, I have an excellent working relationship with the vast majority. Having said that, today I was unfortunate enough to work with one of those despicable characters who believe that the Sun rises from their derrière (pardon the rude language). He is nearing pension and is of the generation of surgeons who sincerely believe that mere mortals should bow down and bask in the glow of their specialness. They do not recognize the fact that surgery today is a team effort, and no matter how good a surgeon is, he/she can't do magic without the supporting staff, period.

Today's prima dona was of the aforementioned species. This particular surgeon entered the OR all fire and brimstone, bitching and moaning about the floor being crooked, the current generation of residents having no work ethic, why aren't the lights adjusted correctly over the surgical field, blah, blah, blah, blah, ad nauseum.  (I'm thinking, "Oh shut up and operate already!") He had an attitude with a capital "A" and no one, but no one was beyond censure.

At some point during the operation, the muscle relaxant wore off and just as I was about to inject another dose he started complaining.  I replied that I noticed and was in the middle of the injection.  He responded with, "A good anesthesiologist would have noticed long before." The Bastard.

I saw red. Nobody, but nobody, talks to me that way. I have a couple of good retorts for supercilious jerks. However, I was taught to be polite to my elders. Besides, the Talmud urges us to show respect for our elders (even if they are total cruds).  I firmly told him that insulting me was unnecessary and I could find him a different anesthesiologist to work with.  He settled down after that.

Fret not dear readers, I will shortly expose my famous comebacks.  These are usually reserved for surgeons who habitually fail to show me proper respect. These are not cases of treppenwitz.  These have been used in real time.  I believe in humility, but I will not back down and meekly accept insults from such bullies.

Response number one:

     I'm sorry, I'm an excellent anesthesiologist, wait just a moment and I'll get you a merely  good one.

Response number two aka Rule #10:

     A surgeon is assigned the anesthesiologist he/she deserves.

I like the sound of that, me thinks to have that copyrighted. So:

All rights reserved to me.