Urban Legend

I've been working in delivery quite often lately. Some days are busy, some are fairly quiet, and there are those days when all hell breaks loose. One morning, I was working the day case list, IVF, D and C's (dilatation and curettage) and other sundries. During a lull, I was sent upstairs to delivery to perform an epidural because the anesthesiologist up there was preparing for a C-section. I told the midwife that I would do the epidural after my colleague induced anesthesia (since that is the stage when Murphy's Law invariably strikes and help is needed). She was visibly disappointed, but understood my reasoning. 

That epidural was not to be. From one of the rooms I heard a senior obstetrician yell, "We've got an abrupted placenta here, let's get her to the OR fast!". Placental abruption is when the placenta has separated from the uterus. This is a true emergency, because fetal oxygenation may be compromised and there may be significant bleeding. Both mother and child are in mortal danger.

The mother, an obese bedouin woman was indeed bleeding. Since the maternal airway, especially in an obese parturient is often problematic, I asked the other anesthesiologist to delay his C-section, and help me get this one underway.

Induction was no problem and I gave the obstetricians the go ahead. The operation was uneventful until they began the extraction of the baby. Often, the assistant must apply pressure to the upper abdomen thus pressuring the upper end of the womb to help the primary surgeon extract the child. At this point, the maternal heart rate dropped to below 40. I administered IV atropine and the rate rose and hovered around 50 while blood pressure was normal. I apprised the obstetricians of the situation. "I think that there's a lot of pressure on the vena cava, get that baby out quickly (please)!" The obstetricians were straining, but the kid wouldn't budge. 

The obstetricians, both female (very capable docs, with limited upper body strength, however) seemed to be tiring. Then, I had an idea.

"Rose (not her real name), move your hand please."

In place of the assistant, I pressed down on the upper abdomen through the sterile drape and leaned in. I'm no body builder, but I applied just enough leverage and the baby slid out, finally.

Looking at the monitor I noted with satisfaction that the heart rate was back up.

Ever since then, the OB/GYN's (with whom I have an excellent working relationship) have been approaching me with some measure of awe. 

The story has quickly become a local urban legend. Funny, I don't feel any different.

Accidental Hero

Like everyone else in this country, I was glued to the television all day. Despite having worked 24 hours straight on call and total exhaustion, I just couldn't go to sleep. So if this post seems a bit incoherent, please forgive me. I was compelled to watch Gilad's homecoming. Like many, I was incensed by the insensitivity of the Egyptians trying to cash in on a scoop with this clip of Shalit being interviewed by an Egyptian Cow. The interview was conducted without the consent of the Israeli side. The claim that Gilad consented is trite. He was still in the mindset of a captive. But in retrospect, the Cow did us a great favor. This unassuming young man has emerged a bona fide hero. He was kept in solitary confinement for over 5 years, he is emaciated and malnourished, lacks vitamin D due to the lack of sunlight, and had some obvious injury to his left hand. Surprisingly he seemed in good spirits. In addition it seems to me that he did not develop the Stockholm Syndrome. 

He kept his wits and answered eruditely to all questions. Even when the Cow tried to trap him into a political question about working to release Pali prisoners, he said the right thing: That he would be happy for their release provided they stop their violence.

I was astounded. After 5 years of contact only with his barbarian captors and with no opportunity for intelligent conversation, this remarkable young man showed the world his true mettle.

If a hero can be defined as an ordinary person performing extraordinarily in extraordinary circumstances, than I posit that Gilad Shalit is a hero. What joy for all of us, but especially his family to have him returned. Despite my own reservations concerning the prisoner swap, today is a day for joy. Tomorrow we can debate and argue about the price we paid for his return. The contrast with the vile thugs and murderers that were released is blinding. (No, I will not sully my blog with images of those vile fiends.) Shalit is thin and pale. The terrorists are well fed and tan. They had family visits, good food and excercise. Shalit had none of these. So let's just state for the record, our enemies are war criminals, barbarians, amoral and despicable. What comforts me, is that with Gilad's return, we received a treasure, while the Hamas and the PA received a heap of crap.

I was also happy to see that Gilad upon arrival in Israel dressed in his uniform. I intuitively feel that it is important that he make a necessary gradual transition from a military life to a civilian one. He is, after all, still a soldier. I was proud to see the symbol of the tank regiment we have both served. I hope he is still proud too.

Of all the emotional images today that literally brought me to tears, this one is my favorite:

It is the very first moment of the first embrace between father and son after over 5 years. It is a very powerful image precisely because we don't see their faces. And that makes it all the more intimate.

Gilad Shalit, comrade-in-arms, fellow citizen and fellow Jew: Welcome home. I salute and embrace you, an accidental hero.

Over The Abyss

נוטה צפון על תוהו תולה ארץ על בלימה
(איוב כו, ז)
He spreads out the northern [skies] over empty space; he suspends the earth over nothing.
(Job 26:7)

Deja Vu.

Two years ago, during the Succoth holiday I posted about the connection between Gilad Shalit and Succoth. This time the rumor and the hope seem to lead to freedom, God willing. How fitting, since Succoth celebrates the freedom of the Children of Israel from the Bondage of Egypt. The whole country is overjoyed with the news. No one can be apathetic to the suffering of Shalit and his family. Yet the joy is bittersweet. It is tainted. Because to gain his freedom, we have to release over 1000 vile terrorists. We know our enemies, they see this as a victory, and it will spur them to kidnap again. It seems that one Jew is worth 1000 Muslims. But not one of those savage barbarians is worth even a hair on Shalit's head. While we celebrate and cherish and sanctify life, they celebrate, cherish and sanctify death. Choose life, we are commanded. If Shalit has suffered Job-like tribulations, I cannot say, but he has suffered. And our leaders have, finally, chosen life for Shalit.

One thing I have in common with Shalit: I served in the same tank regiment (the "Barak" regiment) during my service over a decade after the Yom Kippur War. I imagine that soldiers of the regiment today have been raised as I had, on stories of the tragic destruction of the regiment as they stood almost alone against several Syrian divisions. The horrific tank battles on the Golan Heights and the halting of the Syrian onslaught have since become legend.

Two years ago, just before Succoth, a book was published that described the true story of that regiment during the war. The title of the book "Al Blima" (Over Nothing, or Over the Abyss) is taken from Job. The rather esoteric passage describes the ancient cosmological architecture of the world. But "Blima" can also mean "halting". And in military terms, there is a type of battle tactic (krav blima) that aims to halt the enemy to enable one's forces to regroup. So the title holds that double meaning. The book describes in excruciating detail, the actions of the regiment even down to the individual tank and soldier. One might find this tedious, but there is tension because the tale is true. Almost all the officers and tank commanders were killed or wounded yet the regiment held the enemy at bay. There is also interesting criticism of some of the decisions of the upper echelons. In particular, Gen. Yanosh Ben Gal (then the commander of the sister regiment) was criticised for disobeying an order to reinforce the Barak regiment with one of his battalions. To his credit, Ben Gal had the fortitude to answer the criticism in an on-line forum that appeared shortly after the book was released. He explained that he was closer to the action than his superior officers, and he realised that the battalion would have been sent on a suicide mission. So he wanted to maintain his strength for the battles that were sure to follow in his sector of the Heights. Of those battles is the famous "Vale of Tears" battle where Israeli and Syrian tanks were intermingled on the battlefield in what could only be described as hand-to-hand combat in tanks. The savage battle ended in an Israeli victory, but left many scars.

"Al Blima" overturns our concept of the demise of a regiment. Its greatest contribution is that it sets the story straight and returns honor to the name of the regiment, because the regiment was not destroyed, it did not falter nor did it fail. Rather, like the Phoenix, it arose from the ashes, and with replenished manpower, participated in the offensive that finally drove the Syrian divisions back and defeated them.

I am proud of my service in the "Barak" Regiment, and I hope that Shalit is too. Though I suspect that he might feel, justifiably so, that we failed him by letting him languish in that Hamas hell for so long.

Coincidentally, Saul Bellow's first novel "Dangling Man" was translated into Hebrew as "Al Blima". That book describes in diary form the frustrations of an unemployed man waiting to be drafted just before WW II. Gilad Shalit has been dangling over the abyss. And now, he has been pulled up, back into the arms of his loving family, and the embrace of a relieved nation.

Missles

I've let this blog languish for a few months. Not for lack of anything to write, rather my sloth is due to sheer fatigue. I'm working as hard as ever so there is no lack of subjects: The doctors' strike, the nationwide protests for social justice (whatever THAT means), interesting cases, etc... But it is the latest round of terror that has stirred me from my semi-self-imposed slumber. That, and the fact that I'm on vacation and have had a chance to recharge my batteries.

Last week we invited a friend to join us at the pool at our local sports center. When we called to confirm her visit, she was in tears. Her son was on the bus that had been attacked by terrorists along the Egyptian border. He suffered only scratches, but he called his mother to tell her they were under attack...and that he loves her. After hearing that he had only minor injuries, she told him to keep his head down and help the wounded. Only after, when my wife called her did she break down in tears. One of the heroes that day was the driver, who kept his head and raced towards safety.

Since then, all hell has broken loose here in the South. Air raid sirens, missle attacks, dead and wounded. I called the hospital and offered to come in to help, but they said that everything was under control. Yesterday, coming back home from my mother-in-law, my wife, two sons and a nephew were caught in an attack. The sirens wailed. My wife stopped the car and they all got out and hit the ground waiting for the missle strike. They waited an eternity for the explosion, and my wife recited the "Shema" about 10 times. When it finally hit, it was at the other end of the city. Shaken, they continued home unharmed.

When I look at the various news sites, I am struck by the fact that most of the conflict and misery in the world occurs where arabs and muslims are involved. Such a barbaric, infantile, and backward people. When will they grow up?

With neighbors like these...

Who needs enemies?

The Egyptians, don't ya just love 'em? The majestic pyramids, the flowing nile, the inspiring mass demonstrations for freedom. Can't get enough of 'em. The Egyptian border army just loves to send us work in the form of multiple trauma victims.

Sudanese and Eritreans fleeing the horror in their own countries, seeking asylum, hazard the long trek to less than open arms here in Israel. This unwelcome is preferable to the treatment in Egypt,  where en route they are robbed, beaten, raped and killed. Those, like my most recent patient, manage to get to the border only to be shredded by machine gun fire. Those wonderful Egyptians, sometimes they wait for the hapless victim to cross the border, and sometimes they don't, in which case they dump the body on our side of the border. That way, the Israeli taxpayer can foot the bill for their treatment.

The latest victim of Egyptian hospitality was a young  African man evacuated by helicopter. In the Trauma room, he had a pulse, barely. He had gun shot wounds to his abdomen, left leg, right arm, and just to add insult to injury, one bullet ripped through his genitals.

We rushed him into surgery, the surgeons did damage control, stopped the bleeding and and resected damaged bowel. Despite packed cells, plasma, thrombocyte and crystalloid infusions, he wasn't stabilizing. "He's bleeding somewhere else",  I said to the surgeons. I put the chest film on the screen, normal. So, no bleeding in the chest cavity.

We removed the drapes and found blood dripping from the leg and the forearm. The orthopedic surgeon came in. The x-ray showed that the midshaft of the femur was totally pulverized. There was a pulse in the lower leg, so the artery wasn't damaged.  Ortho stabilized what was left of the femur with an external fixator and the bleeding stopped. Vascular came in to find the ulnar artery torn. That was ligated and finally there was no more bleeding. We took the patient up to the ICU in stable condition.

Yep, those lovable Egyptians. Not only are they hospitable, but they are great shots too!

Do NOT jump to conclusions.

Warning, scenario number 4 may not be appropriate for all viewers...

Happy Passover!

I'm reposting my all time favorite matzah video:

I couldn't have said it better myself.

Hat tip: Jamil

The Iron Dome Game

Update: over 50 missiles have been fired into Israel since Saturday morning according to the Jerusalem Post. There should be no mistake, this is causus belli. Now the Hamas political wing is distancing itself from the military wing. We're not fooled. They are murdering savages as they always have been.

The boys in the neighborhood have invented a new game called "Iron Dome" (The antimissle system that has successfully intercepted and destroyed several of the missiles. The system intercepts only those that endanger major population centers): One kid throws a ball into the air, and another tries to knock it down with a frisbee.

Children remain children, even during war.

A Terrible Miracle

I was planning to post more about the doctor's strike because the media is repeating Treasury's propaganda about money hungry doctors. The best laid plans of mice and men...

The Hamas terrorism by missles has escalated. This is actually not true. There are always missles and mortars and katyushas, but this time the results were tragic. But that's not true either. The ongoing terror of Southern Israel by the barbaric arabs of Gaza is ever present. Whether there are casualties or not is irrelevent. The disruption of life is enough. This the world doesn't want to understand in it's quest to champion the cause de jour. We left Gaza, it was painful and traumatic for us. Despite Arab probaganda there is no shortage there of food, fuel or any commodity. What more do they want? It's obvious, they want us dead. To justify their barbarism the Arabs continue to perpetuate the lies that we are oppressing them, when it's the exact opposite. They oppress and terrorize us, and have been doing so for a 100 years.

I was supervising anesthesiologist in the OR two days ago. The alert came: send an anesthesiologist to the trauma room. There was a missle attack on a school bus, one critically injured child is being evacuated by helicopter. "Only one?" I thought to myself. Either there was a terrible tragedy and only one survived or there was a terrible miracle and only one was injured. As it turned out, the bus was empty except for that one boy and the driver. Minutes before, 50 children had alighted the bus. A disaster was narrowly averted. Later, the Hamas took credit for the attack that was perpetrated with an anti-tank missle. This means that the clearly marked bus was deliberately targeted. The bastards.

The neurosurgeon brought the boy, a teenager to the OR. The expression on his face told me all I needed to know. Critical head injury requiring a craniectomty to relieve the elevated intracranial pressure. We did all medicine can do. Now it's up to God.

When we transferred the boy to the PICU (Peds ICU), the parents were in the waiting room. The father stoicly quiet, and the mother crying silently.

Heartbreaking.

Self Service

I've been doing this medicine gig for over 14 years, if you count medical school it's been about 20 years that I've been living, drinking and eating medicine. During these two decades, I've seen some pretty astounding things. And every time that something extraordinary presents itself, I say, "That's it, now I've seen everything. I will never be surprised again." There is a limit to how many surprises one can encounter.

Right?

Wrong. 

Every time something else pops up. And it leaves me scratching my head in wonder. So yesterday I was on call in the OR. The surgeons were bringing down a guy who had stumbled into the Emergency Dept.  a few days ago drunk as a duck after having been savagely beaten by, as he put it, "some very bad people".

The CT scan found some sort of cyst or hematoma in the area of the pancreas and an intimal flap (a small tear in the inner surface) of the aorta.  He was in the ICU and so I prepared the room for an anesthetized ventilated patient. These preparations are actually quite simple since they come from the ICU fully monitored. I call these patients, "plug and play". Just hook 'em up to the anesthesia machine and the monitors and let the games begin.

The intercom crackled that the patient from ICU had arrived, so I hastened to the entrance of the OR. Not surprising, the patient was intubated. Not surprising, the patient was not sedated. Most patients develop a tolerance for the breathing tube, after a couple of hours if there is no other indication, they need little or no sedation. 

The BIG surprise, the thing that made this patient unique, the thing that made my jaw drop and rub my eyes in disbelief, was that the patient was not connected to a ventilator. Well, that's no surprise, I often transfer patients to and from without a ventilator and I ventilate by hand with an ambu bag. However, in this case, the accompanying physician was not ventilating the patient. In fact, the patient was being ventilated by ...

The patient! 

There he was, sitting upright in the bed, an ambu bag connected the the endotracheal tube, and he was ventilating himself.

Now that's  Self Service!

Now I've seen everything...until next time.

The Doctor's Strike

Today ends the two day warning strike of Israel's physicians. It's not a complete strike since for ethical reasons we must work a weekend schedule. I didn't strike because as luck would have it, I was on call.

The deputy minister of health Ya'acov Litzman has come out against the strike and the union and has tried to paint us as money hungry and blood thirsty. In an interview to the media he stated that during the last strike 11 years ago, less patients died. Strictly speaking, the latter claim is true. Furthermore, it has been true in every physicians strike everywhere else in the world. The reason for the drop in mortality is obvious and clear: During a strike only emergency operations are performed. The vast majority of operations are elective. So when these operations are postponed the accompanying morbidity and mortality are as well, until after the strike. So Litzman, strictly speaking is correct. What makes Litzman's comment troubling is his implication that we harm our patients either intentionally or because of malpractice. So I will say it loud and clear, the deputy minister of health, Yaacov Litzman is a horse's ass.

I now address his first claim, that we are money hungry. True, none of us live under the poverty line, none of us have trouble feeding our families. But the monetary compensation is woefully inadequate for the years of training, the separation from our families, the brutal call schedule, the personal and professional responsibility, the personal price we pay in our own health for working under such overwhelming stress. My friends in other professions were at the peak of their careers ten years before me. Such a "late" start directly affects our pension in terms of accrued benefits. So yes, we demand higher pay that will reflect the investment in time and effort that it takes to become a physician.

But we have other demands, which are really the primary issues at stake in this strike. Because the treasury ministry is squeezing the health ministry dry. We demand that more beds be alloted to serve the growing and aging population. We demand that the formula for physicians per bed be recalculated to alleviate the shortage of manpower. But this formula must be recalculated for the nursing and non-medical staff as well, because there is a nursing shortage no less acute than the physician shortage. And finally, we demand that the hospitals and medical services in the periphery be given priority in manpower and funds so that we can provide the same level of healthcare as in the center of the country.

I have no doubt that the talks will break down, and that next week the strike will be resumed. I have no doubt, because of our experience from the previous strike, when we foolishly agreed to not strike for ten years in return for binding arbitration. The "binding" arbitration dragged on for 8 years and even then, treasury didn't pay up. It took another two years for the courts to force treasury to uphold their end. During this time the public health system has become more ill.

This time, hopefully, will be different. I believe our current head of the Medical Association is more savvy than his predecessor, and we won't make the same mistakes.

For some sense of proportion, many countries, including the United States are suffering physician shortages. I direct the reader to Life in Medicine: A Reality Check by my blogging colleague Anesthsioboist.

Never Stop - The Bad Plus

Saw The Bad Plus at the Red Sea Jazz Festival (Winter Version). They were awsome.

I like air. Air is good.

I've been busier than I thought I'd be. After a well earned vacation, I came back to work, plus some freelancing in a private clinic, plus getting back into research.

And then reality hit. 

All the extra time that I imagined I'd gain without the long commute to Tel Aviv got sucked up by all the work. So I told that private clinic that we'd part friends; my children need me at home more than they need the money (which wasn't that good anyway).

But coming back has been harder than I expected. Any change one's place of employment is stressful.  But it's been more frustrating than when I left. The hospital is being managed into the ground. There are shortages of manpower in all sectors. The result, everyone, and I mean everyone does everyone else's job instead of only their own. The overwork makes everyone irritable.  There are people in the department who are not on speaking terms. Above all, there is a lack of mutual respect. I attribute this to a total management failure on all levels.

The level of most of the residents is appalling. There are some who should have never been accepted to the residency, they are absolutely impervious to teaching. Such a contrast with the residents in Tel Aviv, who were hungry for knowledge. I still have hopes (perhaps in vain) of revamping the teaching program, at least for the few that actually want to learn. But I believe that I'll have a hard sell to the chief of the department.

On the other hand, I still like this profession.  And it's close to home. So, some days I can even pick up the youngest sandmite from nursery school,which has made Mrs. Sandman very happy.

Stories will be posted shortly. I just found some air to breath. I like air. Air is good.

Homeopathic Parody

Nothing against homeopaths you see, but this is rather clever:

Chihuly at the Litvak.

I took advantage of my vacation and went to Tel Aviv for the day to visit the Chihuly exibition at the Litvak Gallery in Tel Aviv. After touring the gallery, I met my 2nd cousin's wife who works for the obscenely rich Mr. Litvak. She gave me a solo tour of the private gallery which is reserved for art collectors. Here there were additional works by Chihuly and other glass artists.  Truly mind- (and glass) blowing. So here are some samples:

No Boss

I have no boss. I finished working in one hospital and haven't started at the next yet. So I am as free as a man can be. OK, strictly speaking that's not true. So I'll revise that: excepting The Almighty...and my wife (not necessarily in that order)... I have no boss. I'm just enjoying the vacation - resting,  reading, and bonding with the kids (I'm much older than they remember; and they are much older than I remember). 3 weeks of vacation is just fine with me, not too much and not too little.

It's fitting, that the last medical act in my previous job, was to save a life. I had finished 13 cases on the Gyn. day case suite.  Finally made a cupa, took one sip and a nurse shouted in the hallway, "Senior anesthesiologist to room one!". The tone of her voice indicated that something had happened, something bad.

I hastened to OR 1. The patient was a young lady having a C-Section with a spinal anesthetic. At the beginning of the case I peeped in the room to see if everything was alright. The resident, one of my favorites and an excellent doctor, had everything under control. Now, everything had changed, she seemed flustered and was trying to breath the patient with a bag-mask apparatus.  The patient being obese exhibited the usual problems of the maternal airway, and the resident was having trouble ventilating. I took over the ventilating and asked what had happened. The resident told me that she had hung a drip of oxytocin (to cause the uterus to contract and stop bleeding) and the blood pressure dropped (a common side effect). She then gave ephedrine, a vasopressor. That's when the patient lost consciousness and stopped breathing. Looking at the monitor, blood pressure and heart rate were normal, but the oxygenation was 70% (quite low) but rising since I started to ventilate her. She exhibited some odd twitches in her face and running through the differential diagnosis in my head, I entertained the possibility of epilepsy.  Within less than a minute, the patient began breathing spontaneously and regained full consciousness.  She asked me what happened, I replied that I don't know, yet. Then she told me that she had been awake during the incident that she had heard every word and felt the mask on her face. Now I had a pretty strong suspicion of what had happened.

After ascertaining that the patient was unharmed, I reviewed with the resident what had happened. I studied the anesthesia cart and the opened ampules of drugs that had been given. There is was, as plain as day. It was a drug misadministration. Instead of a vasopressor, she injected a muscle relaxant, albeit diluted, only 10% of the normal dose, but enough for the patient to stop breathing. I explained to the patient what had happened and why, and then reassured her, and the resident, that no lasting harm had been done. In this case, the reason for the mistake was that the pharmacy (as usual) had bought drugs for the best price from the same pharmaceutical company. These two drugs were supplied in almost identical ampules. Even the names of the drugs were printed in the same color. And, the two drugs are physically close to each other in the anesthesia cart. An accident waiting to happen. A couple months before, I had noticed this and mentioned it to the director of the OR. I told him, "It's not if it will happen, but when when." He seemed uninterested.

So under pressure, the resident made a mistake and gave the wrong drug. Drug misadministrations are more common than we think. These errors are made by both doctors and nurses and almost always human error is to blame. There are several variations: Wrong drug, right drug wrong dose or wrong mode of delivery. Many cases go undetected because no harm was done. Some cases are discovered with no harm to the patient. And the most serious cases the error cause the patient harm.

In this case the pharmacy had set a trap, and the resident fell in. The result was serious but luckily the patient emerged unharmed.

Addendum:

I just got off the phone with the resident. As a result of the accident, those two drugs have been placed at opposite sides of the cart.

All's well that ends well...I think.