The Sandman

Urban Legend

2011-12-12T21:46:00.000+02:00

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

2011-10-18T23:48:00.000+02:00

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

2011-10-13T23:54:00.003+02:00

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

2011-08-21T20:59:00.001+03:00

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...

2011-05-26T18:57:00.000+03:00

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.

2011-04-25T19:09:00.001+03:00

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

Happy Passover!

2011-04-17T19:42:00.000+03:00

I'm reposting my all time favorite matzah video:

I couldn't have said it better myself.

2011-04-13T21:49:00.000+03:00

Hat tip: Jamil

The Iron Dome Game

2011-04-09T22:28:00.000+03:00

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

2011-04-09T22:10:00.000+03:00

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

2011-04-06T22:42:00.000+03:00

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

2011-04-06T22:13:00.000+03:00

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

2011-04-03T22:15:00.002+03:00

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

I like air. Air is good.

2011-03-30T22:37:00.000+02:00

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

2011-03-02T21:29:00.000+02:00

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

Chihuly at the Litvak.

2011-01-20T10:48:00.001+02:00

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

2011-01-20T09:42:00.000+02:00

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.

Pithy Restroom Proverbs

2010-12-14T21:47:00.001+02:00

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.

2010-12-12T21:23:00.000+02:00

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

2010-12-06T13:53:00.000+02:00

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

2010-12-05T13:15:00.000+02:00

*Sigh*

Change Is in the Air

2010-11-18T22:05:00.000+02:00

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

2010-10-22T12:30:00.002+02:00

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

2010-10-12T19:03:00.002+02:00

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

While I recover...

2010-10-04T13:24:00.001+02:00

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

Thoughts and Ruminations

2010-09-11T14:07:00.004+03:00

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

2010-09-08T11:48:00.001+03:00

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.

2010-09-07T23:35:00.000+03:00

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

This was found in old Plovdiv.

Bulgaria

2010-09-04T13:14:00.005+03:00

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

2010-08-30T21:21:00.000+03:00

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

Thoracic Epidural

2010-08-14T22:09:00.000+03:00

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

2010-06-15T23:01:00.000+03:00

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

2010-06-14T12:44:00.001+03:00

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

2010-06-13T16:29:00.000+03:00

I've been interviewed at Ilana-Davita.

La Traviata en Mercado

2010-05-22T09:33:00.001+03:00

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

Hat tip: Discarded Lies

Mother Hen

2010-05-21T14:12:00.000+03:00

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

2010-04-15T23:42:00.001+03:00

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

2010-04-08T11:20:00.001+03:00

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

Valleys of Neptune

2010-03-20T02:49:00.004+02:00

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

2010-02-16T10:52:00.001+02:00

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

2010-02-12T11:46:00.004+02:00

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

2010-02-12T11:33:00.002+02:00

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

2010-01-24T13:08:00.000+02:00

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

2010-01-20T22:20:00.001+02:00

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

2010-01-19T23:15:00.001+02:00

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

2010-01-06T21:06:00.004+02:00

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:

The Carsitters

2009-12-30T22:53:00.001+02:00

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

Love Changes

2009-12-02T22:48:00.002+02:00

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

2009-11-23T12:31:00.006+02:00

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.

2009-11-16T22:41:00.001+02:00

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

2009-11-14T20:17:00.004+02:00

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

2009-10-14T22:54:00.002+02:00

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

2009-10-03T20:44:00.007+02:00

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

2009-09-25T14:57:00.000+03:00

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

2009-09-18T14:30:00.002+03:00

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

The Singer

2009-09-12T21:51:00.006+03:00

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

2009-09-06T18:56:00.007+03:00

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

2009-08-15T15:53:00.005+03:00

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

2009-08-12T21:24:00.008+03:00

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

2009-08-11T22:05:00.004+03:00

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).

2009-08-10T21:33:00.006+03:00

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

2009-07-23T16:54:00.008+03:00

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

2009-07-21T22:12:00.009+03:00

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

2009-07-13T21:05:00.007+03:00

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.

The Cherry Festival

2009-06-23T22:35:00.008+03:00

David and family invited the Sandpeople to his neck of the desert to partake of the Cherry Festival. Those still interested can still go this Friday and next and pick cherries. This festival puts me to shame since I will never rise above the calumny of the infamous (and pathetic) Great Potato Festival Fiasco.

Here for your viewing pleasure are pictures of the pickers:

Me (selfportrait).

One of my pickers.

David caught in the act.

David's main picker.

Mini picker.

The pickees.

Lord Stanley

2009-06-11T18:24:00.002+03:00

The possession of Lord Stanley's Cup will be decided in a 7th game.

Little known fact about me: One of my favorite sports is ice hockey. I grew up in the Philadelphia area during the magical era of the Broad Street Bullies in the mid '70's. Hence my love of that exciting sport.

Some might remember the bumper stickers that read:
"Only the Lord saves more than Bernie Parent."
Referring, of course, to that fabled goalie's almost divine ability to deny entrance of supersonic pucks into his goal.

Though the mind may be boggled, there actually is an Israel Ice Hockey Federation.

Like an Angel

2009-05-24T18:30:00.005+03:00

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.

Rule #9

2009-05-23T20:43:00.004+03:00

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).

The Kiss

2009-05-12T22:33:00.007+03:00

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."

Students: Addendum

2009-05-02T20:52:00.000+03:00

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.

Students

2009-04-27T22:02:00.000+03:00

Students season is officially open!

I've been put in charge of the medical students who are rotating through anesthesia. They arrive in three rotations of two weeks each (actually 10 working days). In this short time, we must teach them the fundamentals of anesthesia, intensive care and chronic pain treatment. It is a Sisyphean task and in essence, we are only able to give them a taste of what it means to be an anesthesiologist.

My job is to be the mother hen: Create the daily schedule which includes daily assignments to the OR, make sure that the students have scrubs, know where to go and when. Remind the lecturers when they have to give a lecture etc...

My philosophy of androgogy (adult education) is that I don't spoon feed anyone. I'm more than happy to teach, or rather guide someone who is motivated to learn. I won't force any student to learn. Of course, one must constantly find ways to be interesting and engaging. Less lecturing and a more interactive approach has served me well. The idea is to ask many questions within the background of a clinical conundrum.

I also like to correct bad habits. One of the most annoying of these is that total lack of ability to present a case in an efficient manner. Differentiating between the wheat and the chaff in the sea of information about a particular patient is one of the most difficult things to learn.

With this in mind I include case presentations as an integral part of the rotation. The students themselves choose a patient to present. Even the most seemingly banal and routine case can be fodder for an in depth discussion about developing the anesthetic plan and anticipating the possible complications.

This first group is particularly sharp. They are interested, ask good questions and seem eager to learn. It is really a joy to guide such students. After the students presented a case to the chief of the department, she called me to say that she was very impressed with this group of students. I agreed, (obviously, one must always agree with the boss) and jokingly added that they were so good because they have such a wonderful teacher. "Exactly," she said, "that's why I called, to compliment you on doing a good job with them."

Of course it always helps to impress the boss. But the truth is, that all the credit goes to the students themselves, because they have the motivation to learn. I recall the very first year that I taught. I was given three students to guide. At the end of the rotation was the obligatory oral exam. One student earned a grade of 100, the second 85 and the third 65 (passing by the skin of his nose). Assuming that I treated each equally, the only explanation for such disparate grades is the ability and drive of each one.

But hey, if the boss wants to think that I'm responsible for their stellar performance, who am I to disagree?

What do do with all that #&*%-ing leftover Matzah?

2009-04-17T10:51:00.003+03:00

This cute video is making the rounds again this year. Michelle Citrin and William Levin come up with 21 (despite the name of the video) creative things to do with all that leftover matzah.

hat tip: The Muqata

Sandstorm

2009-04-16T15:20:00.003+03:00

A couple of night ago while driving home we were caught in a fairly violent sandstorm. It reminded me of snowstorms in the US northeast of my childhood. At times we could drive only 40 kph because of the low visibility.
This is what it looks like if you are lucky enough to be flying above it (photographer - Yonatan Zur):

And this is what it looks like if your in it:

(photographer - Herb Benkel)

Very nasty it gets in your eyes, nose, mouth, ears and even hair. Yuch.

The Potato Festival and Other Stuff

2009-04-15T19:13:00.011+03:00

In general, it is great to be on vacation. There are the highs and lows of course.

The 4th Annual Potato Festival was a complete bust. To make it worse, I dragged the Bogner Family (of Treppenwitz fame) to the disaster. I hope that they forgive me. The only thing that made me feel better was that there were several thousand morons just like me who also attended. The day was not a total loss as we had a tasty lunch at our favorite eatery.

Zehava and I traded family faux pas stories. (I believe we are cut of the same cloth in that respect.) Her tale had us reeling with laughter. I can only divulge that the epic will heretofore be known as: "The Great In-Law Incident of '09".

Another highlight of the vacation was the hike through Wadi Mamshit which winds just adjacent to the Nabatean ruins of the same name. Despite the seemingly harsh desert environs this was an easy hike that even our three year old managed (we kept him going during the rough bits by promising that he would scale a volcano, it worked.) Here are some pics:

There is a surprising variety of flora and fauna and this being the end of a rather short rainy season we were lucky enough to see some desert flowers. Although difficult to see, we spotted two hyraxes high up on the cliff face. Here is a pretty good video clip of a hyrax "singing":

That's me with the Aussie bush hat (Nothing beats a good wide brimmed hat). A friend and my two boys.
Taking a break.

Still a few vacation days left. Yay!

Passover Vacation, Yay!!!!!

2009-04-08T15:25:00.001+03:00

Except for one on-call in the middle it is finally vactation time with the family. And the highlight will be the Potato Festival. (Would you believe this is the fourth year???!!!!)
I'm so there.

A Cool Video

2009-04-04T15:04:00.007+03:00

Oren Lavie, a singer/songwriter from Tel Aviv made this great video:

Enjoy.

Hat tip: Isreality

Unexpected Praise

2009-04-03T14:09:00.006+03:00

When I came to work in this hospital, I knew things would be different. What was unexpected, was how different, and how much I would love my work. I had forgotten that feeling. It's not about the difference in the anesthetic approach, though they do exist, they are minor differences. More like different shades of the same color.

The greatest difference is in the atmosphere. Despite an insane workload, there is very little stress. And most people are in a good mood. I can attribute this to the personality of the chief of the department. At the top of her priorities list, next to output, is keeping a happy workforce. It's obvious, isn't it, that a happy worker is a more productive worker? Does one really have to reinvent the wheel every five minutes? My previous boss, though not a bad person, is quixotic and quick to anger, accusing and criticizing in the most uncouth manner. He does this not out of malice but out of lack of style.

Never in ten years in Soroka did I hear one word of appreciation from the boss. I had excellent work relations with the nurses and the surgeons and basically everyone else who works in the hospital. Often these co-workers would express their appreciation whenever we were assigned the same cases. Patients too, would often express their thanks. There was never a kind word from the management. I suppose I got used to this. However, there were those days when I was positive that "public toilet" was tattooed to my forehead.

Now, here in TAMC (Tel Aviv Medical Center), positive feedback is almost a daily occurrence. I'm drinking it up like a thirsty man in the desert. I'm well aware that there is a danger of becoming jaded. However, I am confident that I can avoid that by simply maintaining humility.

The most flattering praise came from the Chief of the department, though, thankfully, not directly. Her secretary told me that she is very pleased with my work. The flurry of superlatives was somewhat embarrassing. But it is, an embarrassment of riches, and I will be the last to complain.

Serendipitously, I ran into one of the deputy directors of Soroka. He told that my leaving was the first signal that something was amiss. Unfortunately for Soroka, I was the first of the 10% of the anesthesiologists who have flown the coop. He admitted that at this moment he doesn't have the means to improve the salary and working conditions that exist here at TAMC, but that things will change. I told him that I didn't leave out of anger, and that if there was a serious offer I would consider returning.

Ironic.

Then again, I'm not so sure. The commute is a long haul. But I'm so pleased with the way things are that I don't really want to go back.

The Common Cold

2009-03-28T15:12:00.004+03:00

The common cold. It sounds so, well, common. It attacks us at the most inopportune moments (when is it ever opportune?). Doctors aren't supposed to get sick, but we do. And when we do, the "system" makes us feeling guilty for doing so. T has recently posted on this as well.

A few weeks ago I had a sore throat. No fever, just a sore throat and nasal congestion on and off. I continued working and didn't skip any calls. After a couple of weeks it went away, but I was very tired, my immune system all but depleted. I literally felt vulnerable. Then a few days later, it came back, with a vengeance. It was the virus to end all virus' (should that be viri?), the virus that ate Tel Aviv. In short, it attacked me without mercy, laying my upper respiratory tract to waste. Eyes teared, nose ran and throat felt as if it was hosting the Indy 500 for formula 1 virus'. I felt weak, muscles ached, head was spinning, I could barely move. This time I called in sick. The response was not as harsh as expected. "OK, take care of yourself and hope you feel better." (This was not the system I was used to!)

Even though the doctor (yes, when I'm sick, I go to the doctor), recommended a week off I went back after 3 days the minute I felt better. The truth is, that I should have taken all the sick leave as recommended.

I went back to the normally scheduled call schedule. I was on call in the delivery room. I felt fine, but something was missing. A certain sharpness, the usual sense of touch in the fingers was missing. And the women in labor were to pay the price. It was a very busy night, as usual. Many epidurals were requested. I had a bad run of dural punctures. (This is when the needle overshoots the epidural space, puncturing the dura mater, the tissue surrounding the spinal cord, causing a leak of cerebrospinal fluid). Usually it is recognized and is not dangerous, and the epidural catheter can usually be placed at another vertebral interspace. However, 24 hours later, because of the leak, the patient may experience a very severe headache. A dural puncture occurs every once in a while. But such a bad run made me feel pretty much worthless.

Towards the end of the call, when I was envisioning myself soaking in a hot bath, yet another epidural was requested. I didn't feel even at the bottom of my form at this point. By this time the entire staff of the delivery room was aware of the rapidly-fruitfully-multiplying-dural-punctures (tm). I asked the midwife if she really wanted me to do this one. Mindy the midwife, God bless her, said, "You're a great doctor. You'll do just fine." And so it was.

I was so grateful for her confidence in me that I would have kissed her feet.

I'm ruminating

2009-02-27T23:22:00.002+02:00

So please be patient.

Your Mind is Blue

Of all the mind types, yours is the most mellow.

You tend to be in a meditative state most of the time. You don't try to think away your troubles.

Your thoughts are realistic, fresh, and honest. You truly see things as how they are.

You tend to spend a lot of time thinking about your friends, your surroundings, and your life.

What Color Is Your Mind?

Decisions, decisions

2009-02-06T11:19:00.001+02:00

I've reached something of a watershed in my career. And like all crossroads in this life, making the choice is the toughest part.

The choice before me is this: Remain a general anesthesiologist, or concentrate in one particular field. My favorite field is trauma, however this particular hospital treats very little major trauma. One of the reasons that I like this field is that I'm an adrenaline junky. The emergency, the stress, the mess, rolling up my sleeves and getting dirty. I love it. I admit it, I'm addicted to the adrenaline. We can't always save trauma victims, but when we do, there's no better feeling. I admit it. The ego trip of pulling someone who is literally down the tubes back to life is exhilarating.

The reason to stay a generalist is that I like variation. I like the idea that I can anesthetize any patient from 750 grams up to 200 kg. I can handle anything this profession can throw my way, and I like that. If I concentrate on one field, I'll become rusty in the others. I won't forget any of it, but I won't be as sharp. On the other hand, there is the down side to being a jack of all trades and master of none. A very few gifted people can maintain the highest standard in all fields. The rest of us, mere mortals, must do the best we can. Eventually, to ascend the ladder of this occupation, one must specialize. It is expected and encouraged.

If I specialize, I'm most interested in obstetric anesthesia. It is a dynamic field, and has just the right dose of adrenaline for my habit. After all, what could be more stressogenic than an emergency C-Section when both mother and child are at risk? On the other hand, I like my peace and quiet. What better way to achieve that than by providing an epidural to a screaming parturient?

NOW I'm Mad!

2009-01-09T15:42:00.005+02:00

That does it. Now I'm really mad. Those Hamas cockroaches have gone too far! The sirens woke us up twice in the middle of the night, interrupting my well earned slumber. If I ever get my hands on one of the despicable pustules on the derriere of humanity I WILL anesthetize him for all eternity (if not longer).

The kids and my mother (thanks Mom!) were sleeping in the shelter so it was just me and the Mrs. who had to wearily stumble in. So many of us are availing ourselves of our parents to help with the kids that this war should be renamed in their honor. My suggestion: "Operation Granny".

The Routine of War

2009-01-05T22:54:00.003+02:00

I wake up early to get the work in Tel Aviv. At the end of the day, I ride the train back south. Feed the kids, bathe them and read bedtime stories in the bomb shelter. Turn on the radio as a back up in case the sirens fail. All in all, the kids are handling this well although the middle son (the sensitive one) seems to be more irritable and probably needs some one on one time.

I'm working late again and I'll have to stay in Tel Aviv. The family is down south in what amounts to a war zone. Luckily our village hasn't been hit by rockets. The kids even went to school for two days, but now there's no school for the foreseeable future. Several of my colleagues have offered to host us, but I've declined for the time being. In the meantime my mother has come down to help out.

Watching the news on TV is frustrating because one part of me wants to be back in Soroka Hospital to help treat the wounded. But another part knows that if Soroka is overwhelmed then wounded will be transfered to hospitals here in Tel Aviv. I'll be where ever I'm needed.

Sirens

2008-12-30T21:11:00.004+02:00

The sirens wailed and we gathered up the children and went into the bomb shelter. The kids are a bit scared but in good spirits. We called my in laws in the city, they heard two explosions. No casualties thank God. Looks like we'll spend the night in the shelter.

Update:

The nursery school in Be'er Sheva that was hit by a missile was the one my eldest daughter attended. It is very close to the apartment we lived in. My in-laws still live in the same neighborhood. Thank God it was at night when the school was empty.

War

2008-12-29T18:01:00.003+02:00

I'm on call here in Tel Aviv in the delivery room. And my family is down south, where war is being waged against the evil that is Hamas. Thankfully, my village is out of range of the rockets. What I feel is mostly frustration, and also outrage.

Frustration. That I'm not with my family.

Frustration. That the world still doesn't see our enemies for what they are: Bloodthirsty barbarians who sanctify death.

Outrage. The world criticizes us for defending our country against the constant barrage of rockets and mortars that have been directed towards Southern Israel for the last 8 (!) years. And FYI, the rockets were fired usually around 8 AM and 4 PM, the time when children go to school and come home.

Frustration. Because the Arabs are too infantile and primitive to accept peace.

Outrage. At the thinly veiled anti-semitism of the world community. Their criticism is directed to the wrong party. It's Hamas who should be condemned.

Yes, yes, I'm not politically correct. Screw PC. The European left, the Israeli left and the hypocritical Arab "intelligenstia" are simply wrong. And immoral.

No Israeli Jew has ever rejoiced at the death of an enemy or at the death of civilians. No Jew has ever murdered a mother and her daughters in the own beds. No Jew has ever smashed the head of a 4 year old child against a rock. No Jew has ever knowingly or purposefully sought out women and children for massacre. (Sabra and Shatila you say? That was payback by Lebanese Christians for years of atrocities commited against them by Muslims. And the bitter irony is that the Jews were blamed.) This is the Arab way and I despise them for it.

There may be moderates in the Arab world but their voice is not heard. And that is too bad.

SurgeXperiences Blog Carnival #212

2008-12-07T11:25:00.004+02:00

Welcome to the the 12 edition of SurgeXperiences Blog Carnival season 2! This is my second time hosting. Enjoy!

Since there is no theme, for better or for worse I've sort of catagorized the posts. This time I'll be starting with posts from patients (after all, we do all we do for them, right?)

Patient Blogs

Raymond, a personal finance expert, posts about his experience with laser eye surgery. It is a concise and comprehensive review of the pros and cons.

A doc at M.D.O.D tells us what it is like to be in a medical emergency from the patient's point of view in: Tamponade, or if it weren't for bad luck...

Every one of us should read this woman's account of emergency surgery for an ectopic pregnancy. Her pre op anxiety was not addressed, and her post op pain relief came too late, for shame!

Kyle Shewfelt shows us some of the hardware that was removed from his leg.

These parents share the frustration of canceled surgery.

Student Blogs

Ben Bryner describes the process of applying to a residency program in: Surgery, Interviews and Rock'n'Roll. He writes: "Actually, nobody's really asked me what I would to if I couldn't be a surgeon. But my predetermined answer is: A sushi chef (like surgery, but more delicious) or a reporter."

Unprotected Text, relates the difference of teaching styles in anatomy class in this post .

Sharps Container wants to scream as she recalls the suffering of a child with burns after child abuse. I urge her to remain a sensitive soul, as she writes: "But now--with nearly a semester of medical school behind me--I think my reaction to the case would be changed...But I would still want to scream. I hope I never lose that impulse."

Resident Blogs

Dr. Alice worries about her upcoming pediatric rotation, but is relieved to find that it's not as bad as she expected. And she even finds time to go to the Library!

Surgeon Blogs

The Prairie Pooch gives us a glimpse of the future of robotic surgery in A Surgeon You Can Swallow.

On the other hand, Paul Levy opines that perhaps there is no added benefit to robotic laparoscopic surgery, but was forced to buy such technology in order to be competitive.

Becky and DrWes both found this interesting story that gives new meaning to surgery at a distance.

Aggravated Doc Surg details the art of "The Bump" (bumping another surgeon's cases for an urgent one.) He also gives thanks that he didn't suffer this nasty fracture.

RL Bates posts an informative post about skin cancer.

Self Mutilation was never so bizarre as Your ER Doc posts in this weird case.

The ever witty Bongi tells us that Out of Benoni he emerged, despite the negative prognostication of an evil headmaster. In words, even the ever cool Bongi loses his composure (justifiably I might add).

In Transplant Gone Wild, Buckeye Surgeon reports the story of an immoral doctor who ran amok, completely unchecked. Shocking.

Medical Imagery

For those who like pretty pictures, KevinMD sent us this gem. Warning to those with a weak stomach: Not for viewing before a meal.

Ron Miguel RN sends this hi res photograph of a surgeon's hand.

Oystein sends two posts: Lego Eye - can you spot the mistakes?, and Inner Sights - illustrates what a little bit of annotating can do to a picture. He also found this delightful music-video celebrating the heart.

Other Stuff (for lack of a better name)

Archeology and Surgery fans will enjoy this find brought to us by Dolce Vita.

Erica Collins posts this site listing 50 awsome video games for Physical Therapy and Rehab.

Anesthesiologist Blogs

Guess what? No posts from anesthesiologists were submitted. Hey wake up people!!

---------------------------------------------------------
SurgeXperiences is a blog carnival about surgical blogs, wherein surgical experiences are shared. It is open to all (surgeon, nurse, anesthesia, patient, radiologist, pathologist, etc) who have a surgical blog or article to submit. The next edition of SurgeXperiences (213) will be hosted by surgical first assistant Make Mine Trauma at "IntraopOrate" on 21 Dec, 2 weeks from now. Be sure to submit your post via this form.

Memes, aren't they annoying?

2008-12-06T18:41:00.005+02:00

Darn, I've been tagged.
Gila, the only reason I'm doing this is because you're such a sweetheart. I usually ignore memes. So let's get this over with. To those whom I am about to tag, please forgive me.

5 Things I was doing 10 years ago:
1) Began my residency.
2) Amazed everytime a patient woke up at the end of anesthesia.
3) Oldest child in the planning stages.
4) Did my first reserve duty as a military doctor.
5) Had the cat castrated. (No, I didn't do it myself.)

5 Things on my to-do list today:
1) Make sure the patient wakes up at the end of anesthesia.
2) Be more patient with the children, even after being on call.
3) Be more patient with my wife, even after being on call.
4) Enjoy a really good cup of coffee.
5) Study some Gemarra.

5 snacks I love:
1) Poptarts.
2) Chocolate.
3) Olives (yep, I pop down those suckers like extasy pills).
4) Pizza (the kind they make in South Philly).
5) Beer (snacks can be liquid too ya know!)

5 Things I'd do if I were a millionaire:
1) Take the family on a trip around the world.
2) Attain a PhD in Philosophy.
3) Attend 50 Jazz festivals in one year.
4) Establish a college fund for disadvanted youth.
5) Bribe a prominent politician.

5 places I have lived:
1) Jerusalem, Israel.
2) Bloomington, Indiana.
3) Cheltenham, Pennsylvania.
4) Ithaca, New York.
5) Be'er Sheva, Israel.

5 jobs I have had:
1) Truck driver.
2) Short order cook.
3) Dairy Farm worker (cows are some of the nicest

people I know).
4) English teacher.
5) Cashier.

I tag: Baila, Zahava (aka Mrs. Bogner), Jameel, T, Bongi.

Here I set, But elsewhere I rise

2008-11-30T22:19:00.007+02:00

Several years ago, one of my favorite artists, Ehud Banai (singer/songwriter/musician), was interviewed on television. He recounted a short vignette that appeared in his book that was published that same year called, "Remembering Almost Everything".
(זוכר כמעט הכל).

Yuval Glick was only 19 when his airforce plane went down into the Sea of Galilee (in Hebrew - Kinneret). His mother had immigrated from Bulgaria as a teenager and had a difficult period of adjustment. But one day she was taken on a trip to the Kinneret and the sight of the sea that greeted her, made her feel as if she had come home. Every year she would travel to the same spot where she had first seen the Kinneret. She contacted Banai and told him all about her son who had been a fan of Banai's.

After her son died she no longer traveled to the Kinneret, she felt anger towards the lake for taking her son.

Four years later, she called Banai again to tell him of a life changing event. She finally decided to go back to the Kinneret, for reconciliation. During the long journey from the south, she had a tape of Banai's music playing over and over. She would drive, then stop, cry and then continue driving. As she reached the very spot where she had first seen the Kinneret, she heard Banai's voice emanate from the speakers:

"What can I say,
What can I say,
Here I set,
But elsewhere I rise."

מה יש לדבר,
מה יש לדבר,
אני שוקע כאן,
אבל זורח במקום אחר

The recent tragedy in Mumbai has affected everyone here in some way or another. I was on call in the delivery room on the Sabbath providing epidurals for women in labor as the depressing news came in, but I packed it away. After all, babies being born is a joyous occasion.

By all accounts, Rabbi Holzberg and his wife Rivka H"YD, were exceptional people. I didn't know them, but their murder shook me. We all know why they and others in the Chabad House were murdered, because they were Jews. While they were brutally murdered in Mumbai, here, in Tel Aviv, Jewish babies were being born.

Perhaps the sun that set in Mumbai rose elsewhere.

The Incident

2008-11-28T10:25:00.006+02:00

It was bound to happen. I stepped on someone's toes. This someone just happened to be the teacher's pet. And it happened when I was only a couple of weeks on the new job. Great way to make an impression.

One evening I was in charge of the recovery room. The end of the morning shift and the beginning of the call is always a chaotic period. Recovery is full of patients and as the operations finish more are brought in. For the most part the nurses are very independent and recovery runs quite smoothly. But at this crucial time of day a physician is needed to help out.

A patient after a long operation was brought to recovery. The anesthesiologist briefed me on the patient's history and the operation. A few moments later, the nurse called me over to examine the patient who was not breathing well. In fact the patient was in respiratory distress and need to be intubated and ventilated. The anesthesiologist was still around and she didn't want the patient to be reintubated. A rather vocal argument erupted between the nurse and the doctor. I told the doctor that I'm working in recovery and she might as well go home for a well earned rest. She didn't take the hint and stayed. Against my better judgement I went to tend to other patients. But moments later, the nurse, this time more agitated than before, called me again to see the patient who was not doing better. At this point I told the anesthesiologist that I believe that this patient needs to be ventilated. She said that she wants to check the ABG (arterial blood gas). This blood test shows the oxygenation, ventilation and metabolic status of the patient. I said that the patient is clearly in respiratory distress and that even if the ABG is normal, she still needs to be ventilated. The nurse, again added her vociferous opinion and was very rude. To diffuse the situation I again suggested that the anesthesiologist go home that I would take care of the situation. Again, she did not take the hint, drew blood for the ABG and went to place the sample in the machine. While she was absent, I asked the nurse for the intubation tray.

The ABG showed normal oxygenation but PCO2 (a measure of ventilation) of 45 mmHg. This is the borderline normal, but a person with respiratory distress should be hyperventilating and one would expect the PCO2 to be much lower. This result shows that the patient is tiring and will eventually stop breathing. Even though the text books mention a PCO2 of 55 as the indication for ventilation, I never wait for the patient to breath so poorly before intubating, it's just plain cruel. I said as much to the anesthesiologist but she remained unconvinced. Again, the nurse rudely voiced her opinion. I was getting tired of this and proceeded with the intubation. Flustered, the anesthesiologist said she was going to tell the boss. I felt like I was in kindergarten.

With the patient safely intubated and ventilated, I was called to the phone, the boss was irate. I was raked over the coals for being insubordinate to a more senior physician. She (the boss), asked rhetorically, if I thought I was more familiar with the patient than the anesthesiologist who had spent the entire day with the patient in the OR.

Flashback to kindergarten, no, nursery school. The teacher asks why did you break the window?
Oh, I dunno, I decided to evolve into a teenage punk a bit early and vandalize. Holy crap, is there any right answer to such a stupid question?!!!

The next morning, I apologized to the other anesthesiologist, that I had no intention of insulting her, but I felt that the patient's condition warranted immediate action. She, surprisingly, thanked me! Holy cognitive dissonance Batman! Yes, she actually thanked me for distancing her from the rude nurse!

(BTW, I actually have great respect for the rude nurse's vast clinical experience. She was, well, just rude.)

Then we were called to the boss' office where again I was raked over the coals, albeit very charmingly (did I mention that the boss is normally a very charming woman?). The important thing was not the clinical question of whether to ventilate or not (silly me, I thought that was the point), but that we maintain a good working relationship among the staff. This was starting to play out like a Fellini film. (Did I mention that I'm a great fan of Fellini?)

After a long beautifully crafted speech, I said, "Boss, you've burst through an open door, because we've already kissed and made up, the wedding is in three months." For a moment she had no idea what I was talking about, then, the light bulb lit up. "So why did you let me go on and on?"
I said, "it was such a nice speech, and you obviously spent some time thinking about what you wanted to say, I just didn't have the heart to stop you."

I figure, if one is to be raked over the coals, do it with style.

Post Script #1: Since then, my reputation has only improved.
Post Script #2: A month later, I serendipitously anesthetized the same patient for a tracheostomy because she still hadn't been weaned off the ventilator.
Post Script #3: I want to announce to all involved: "I told you so!!!". But I won't, because I was brought up to know better. (Thanks Mom and Dad).

Happy UnBlogoversary

2008-11-24T21:11:00.003+02:00

With my usual impeccable sense of timing, I've completely missed my 1st blogoversary by one full day. So, on this inauspicious occasion, I wish to wish myself a very Happy UnBlogoversary to me.

Upcoming Surgical Blog Carnival

2008-11-22T20:04:00.004+02:00

I will be hosting the next SurgeXperiences BlogCarnival on Dec. 7 (a day that will live in infamy). There will be no theme this time. All relevant subjects will be considered. So, surgical bloggers, get your creative juices flowing! Submit your posts here.