Wednesday, April 30, 2008

Crawling through a cave.

One of the greatest dangers of being a doctor is, ironically, forgetting about life. As a group, doctors are motivated and definitely can be labelled "workaholic". However, to be a good doctor, one must first strive to be a good person. A good person does not neglect one's family. But we all get caught up in the rat race, so to speak. First during training, to prove to the professor that one is worthy, then to stay up to date with the current medical literature and finally to get a coveted tenured position. There just aren't enough hours in the day. So it isn't surprising that marriages, relationships and families are the first to suffer from neglect.
At one point I decided that even if my career suffers, I would do my best to give as much time as possible to my family. It's easier said than done. Still the pressure to achieve is great.
Make no mistake, I am no where close to becoming "father of the year". The on calls, the pressure, the nature of medical emergencies all take their toll. I am often short tempered with those that I love the most. I hate it and it's difficult to control, especially when I'm chronically sleep deprived.
For the first time in over a decade, I was able to take the entire Passover vacation to be at home. It was wonderful just to be with the children and not be tired. One of the day trips we took was in our neck of the desert. Every year in Mamshit, an archeological site built by the Nabateans an ancient market is recreated with activities for the entire family. The Sandfamily had the honor of hosting the von Trepp family for this trip. A delightful time was had by all.
Yesterday, I accompanied my daughter's third grade class for their annual field trip. I look forward to these trips for three reasons: 1. I love hiking in the desert (of which we have a plentiful supply). 2. It gives me a chance to be with my daughter without competition from her siblings. 3. And it allows me to observe her in her natural habitat.
We first went to Bet Guvrin which has been wonderfully reconstructed by the Israel Antiquities Authority. We then went cave crawling in the Midras Ruins (sorry, couldn't find an english language site). This was the big adventure of the day as crawling through tunnels just wide enough for an adult to pass brought out the best in the claustrophobes.

Some children opted out before entering. Some started to crawl, but then backed out. Once another group has entered the tunnel behind us, there is no way out but forward. One or two of the children became hysterical and refused to budge. One even cried that he was going to die there. It was all very dramatic. We calmed him down and all emerged from the cave alive and well. The elbows and the knees took a real beating and I used some muscles that I completely forgot I had.
We finished with a visit to Israel's only stalactite-stalagmite cave. This cave doesn't compare in size to the large caves in Slovenia such as the Postejna Cave, but for it's size it has a great variety of stalactites and stalagmites. Besides it's ours.
Father and daughter had a wonderful time. We can't wait for the next field trip.

Monday, April 21, 2008

To Passover or not to Passover?

Anyone who has witnessed the intense insanity that precedes Passover can appreciate the disappointment and anxiety of someone who is hospitalized just before a holiday. The preparation for Passover consists of house cleaning that lasts for weeks and is so obsessive as to put your average sufferer of OCD (obsessive-compulsive disorder) to shame. Then there is the cooking, which is endless. There is always the feeling that there isn't enough food, even though there are at least 5 meat dishes, 10 types of salads and side dishes and soup with matzah balls, there doesn't seem to be enough. In fact, there is enough food at the Seder table to feed the entire population that actually lived through the Exodus with leftovers for the next week.
Just before the holiday, an elderly religious woman was brought down to the pain clinic from orthopedics with severe lower back pain. The surgeon requested a selective nerve block to help assess the pathology and decide on a treatment plan. The woman was bedridden because of the pain and it was an impressive logistic feat to transfer her to the treatment table in the cramped clinic. While the room was being prepared, I noticed that the woman seemed quite upset about something. I asked her what was the matter.
She was distraught because there was no way she could prepare for the holiday and might not even be able to be present for the Seder. I asked her how many children she has. She quickly recited the roll call: 7 children, 15 grandchildren and 20 great-grandchildren.
I asked, "You raised and educated them according to tradition right?"
"Of course", she replied.
"So, your children should be able to conduct the Passover Seder perfectly, right?"
"Of course it isn't the same if you aren't there, but you raised your children the best way possible and everything will be just fine. You need to concentrate on recuperating. Your health is more important than the holiday."
(For those not familiar with Jewish philosophy, briefly and most inadequately: The sanctity of human life is valued above all other considerations, even the most important. So for example, working on the Sabbath to save a life, a limb or relieve suffering is permitted.)
Put in this light, the woman seemed relieved and less agitated. "Your right." she said, "The family will be fine because I taught them well."

Saturday, April 12, 2008

"It ain't over 'til the fat lady sings."

This is a famous quote by Ralph Carpenter which was misquoted by Yogi Bera. (It ain't over til it's over) But, I digress. This post is not about baseball. It is, unsurprisingly, about anesthesia. I will paraphrase the quote: "The patient is not asleep until he/she is asleep."

It's two in the AM. The next patient is waiting for an orthopedic operation. The nurses inform me he is a 50 year old IV drug abuser. From across the room, I see the patient's chart, the problem list is a mile long and looks like a rap sheet. That seems odd, I would expect such a thing in an elderly patient. I get closer and see that every single diagnosis is trauma related. This man has literally broken every bone in his body, one at a time.
Not only is he a drug addict, but he is a thief as well, and quite bad at it. All his trauma is related to his illegal habit of supporting his habit. And each time he jumps or falls off of roofs or balconies, he breaks a bone and is hospitalized. Oh, that's quaint, I see he's also been shot (by the police, no doubt) and stabbed (by his fellow inmates I suppose).
He is asleep, so I nudge him awake and tell him it's time for his operation. He starts whining that he needs his methadone (a substitute for heroin which alleviates the craving for the drug), he was promised methadone, and he's not having his operation without his methadone. I tell him that we don't have methadone in the OR but I will give him a proper alternative. "No, No, I want methadone , Dr. ----- promised me. "Well, Dr. ----- isn't here, it's 2 AM and I the king of the ant hill right now, so relax and let us take care of you."
I must say, that to my advantage, he had a broken leg, so he wasn't about to run out on me. We wheeled him into the OR; all the while he was bitching and moaning about his methadone. Did I mention that drug addicts are my least favorite patients? At that hour of the night I'm not always able to conceal my feelings.
After attaching the monitors, I begin induction of anesthesia, I start with midazolam (an anxiolytic) and then fentanyl (an opiate) and finally propofol (a hypnotic). The surgeon was studying the x-ray films and then turned towards us and asked the patient a question, completely oblivious that induction had begun. When the patient didn't respond he said, "Oh, he's already asleep?". "Yeah" I said, "the whiney jerk is under."
Suddenly, the patient lifted his head, "Whiney, jerk? Who are you calling a ...."
An extra dose of propofol, and a nice smattering of succinylcholine (a muscle relaxant) and this time he really was asleep.
Luckily, the midazolam also causes amnesia, so he won't remember the memorable proceedings.
So, anyway,like I said, he ain't asleep until he's asleep....

Thursday, April 10, 2008

Food for Thought

This arrived by email. However the source is a book by Peter Menzel and Faith D'aluisio.

How much do you spend on food in one week?

1 - Germany: The Melander family of Bargteheide

Food expenditure for one week: 375.39 Euros or $500.07

2 - United States: The Revis family of North Carolina

Food expenditure for one week $341.98

3 - Italy: The Manzo family of Sicily

Food expenditure for one week: 214.36 Euros or $260.11

4 - Mexico: The Casales family of Cuernavaca

Food expenditure for one week: 1,862.78 Mexican Pesos or $189.09

5 - Poland: The Sobczynscy family of Konstancin-Jeziorna

Food expenditure for one week: 582.48 Zlotys or $151.27

6 - Egypt: The Ahmed family of Cairo

Food expenditure for one week: 387.85 Egyptian Pounds or $68.53

7 - Ecuador: The Ayme family of Tingo

Food expenditure for one week: $31.55

8 - Bhutan: The Namgay family of Shingkhey Village

Food expenditure for one week: 224.93 ngultrum or $5.03

9 - Chad: The Aboubakar family of Breidjing Camp

Food expenditure for one week: 685 CFA Francs or $1.23

Sunday, April 6, 2008

The Chemistry of Hell

There is a fifty percent chance it's not true, but it's still funny:

The following is an actual question given on a University of
Washington chemistry mid-term.

The answer by one student was so "profound" that the professor
shared it with colleagues, via the Internet, which is, of course, why
we now have the pleasure of enjoying it as well :

Bonus Question: Is Hell exothermic (gives off heat) or endothermic
(absorbs heat).

Most of the students wrote proofs of their beliefs using Boyle's
Law (gas cools when it expands and heats when it is compressed) or
some variant.
One student, however, wrote the following:

First, we need to know how the mass of Hell is changing in
time. So we need to know the rate at which souls are moving into Hell
and the rate at which they are leaving. I think that we can safely
assume that once a soul gets to Hell, it will not leave. Therefore, no
souls are leaving. As for how many souls are entering Hell, let's look
at the different religions that exist in the world today. Most of
these religions state that if you are not a member of their religion,
you will go to Hell.

Since there is more than one of these religions and since people
do not belong
to more than one religion, we can project that all souls go to
Hell. With birth and death rates as they are, we can expect the
number of souls in Hell to increase exponentially. Now, we look at the
rate of change of the volume in Hell because Boyle's Law states that
in order for the temperature and pressure in Hell to stay the same,
the volume of Hell has to expand proportionately as souls are added.

This gives two possibilities:

1. If Hell is expanding at a slower rate than the rate at which
souls enter Hell, then the temperature and pressure in Hell will
increase until all Hell breaks loose.

2. If Hell is expanding at a rate faster than the increase of
souls in Hell, then the temperature and pressure will drop until Hell
freezes over.

So which is it?

If we accept the postulate given to me by Teresa during my
Freshman year that, "It will be a cold day in Hell before I sleep with
you," and take into account the fact that I slept with her last night,
then number two must be true, and thus I am sure that Hell is
exothermic and has already frozen over. The corollary of this theory
is that since Hell has frozen over, it follows that it is not
accepting any more souls and is therefore,extinct......leaving only
Heaven, thereby proving the existence of a divine being which explains
why, last night, Teresa kept shouting "Oh my God."


Tuesday, April 1, 2008

Patients are People too.

This is the last month of my pain clinic rotation. The commuting has been draining. On the other hand, I've had the chance to take in the scenery on the way. The hills in the Judean Wilderness are still green, but there is just a hint of the dryness of summer at the threshold. The wheat fields are verdent and lush. But I know that after passover they will slowly turn yellow and the wheat will be harvested by Shavuot.
One thing I've noticed over the years. We all wear a uniform of sorts and it often masks the person inside. Patients wear pajamas so they are different from us, the staff. The nurses have their uniforms and they are given orders and tasks to perform. OR staff in scrubs with caps and masks. Only the eyes give any indication of humanity.
But then, I see a patient or a nurse on her way home in civilian clothes. All of a sudden, they look like people. The hectic days, the impossible work load, the drive to get it all done, they distract us from seeing the person in front of us. Every now and then, I seize the opportunity to talk, actually talk to a patient. I've never regretted doing so.
Every person has a story to tell. Especially in this country, most people have seen their share of hardship, drama, upheaval, pathos and ethos. But some have incredible stories to tell. Of the hundreds and even thousands of patients I have treated, these stand out and I may even remember them years later.
One morning an elderly woman came to the pain clinic accompanied by her husband. Right away they seemed to be a colorful couple. The woman explained her problem. She complained of pain in her shoulder. She was depressed at the loss of function. She said that she spent her entire life with farming tools in hand and felt helpless. Her husband seemed impatient at his wifes verbosity and insisted on conveying the information in the most concise manner possible. Despite his apparent bad temper, something in his manner or perhaps the way they looked at each other told me that there was more to the story than meets the eye. These people were the salt of the earth, and much more.
After reviewing her medical history and the physical examination, the pain specialist decided on a series of injections performed under x-ray guidance. Usually I take part in the treatment (that is, after all, the reason I'm doing the rotation). But I never made it into the treatment room. The husband asked me if I spoke Russian to which I replied nay. (I'm somewhat of an anomaly in the local scene, an anesthesiologist who speaks only Hebrew (OK and some English)). Noticing his accent (who doesn't have one in this country?), I asked when they came to Israel.
With no warning whatsoever, the following story unfolded: They came from Poland in 1949. This most certainly meant they are Holocaust survivors. But he continued. The were childhood sweathearts and war orphans. After the war they wandered from Poland to Czechoslovakia and then Austria and finally ended up in France. In 1947 at Marseilles, they boarded a ship bound for the Land of Israel. That ship was called the Exodus. The story of the Exodus is one of the most dramatic incidents of prestatehood Israel and was the inspiration for the book by Leon Uris. The book, in turn was made into a film by Otto Preminger. The ship was intercepted by the British and eventually sent to Hamberg. Of the over 4000 passengers, over 600 were orphans including the couple who came into the clinic that day. Only two years later, after the State of Israel was established would they come to settle here.
After a short time the treatment was finished. As they got up to leave the husband thanked me and shook my hand. I suppose that I was the first stranger who had ever heard his story.
Had I not asked the question, I would have remained ignorant of who this couple were, and I would never have had the pleasure of hearing the story first hand. I can only wonder how many stories like this have I missed for not asking the question.
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