Sunday, November 30, 2008

Here I set, But elsewhere I rise

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.

Friday, November 28, 2008

The Incident

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).

Monday, November 24, 2008

Happy UnBlogoversary

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.

Saturday, November 22, 2008

Upcoming Surgical Blog Carnival

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.

Wednesday, November 12, 2008

That Really Bugs Me

The hours are long, the commute is long, but I'm very pleased with this hospital. The work load is tremendous, almost impossible. But there is a very positive atmosphere. Although there are things that I prefer about my previous hospital, there are things here which make the work much more enjoyable. There is much support in the the small tasks in the OR that together add up to more than the sum of their parts. In general the running of the OR is much more efficient. In my previous place of employment, besides anesthetizing the patient, at the end of surgery I would bring the patient to the PACU (Post Anesthesia Care Unit aka recovery) and have to personally inject all the iv meds that I ordered for the patient. Then, run back to the OR and prepare the equipment for the next case.

In this OR, the PACU nurses perform all the tasks ordered by the anesthesiologist without the anesthesiologist being physically present. During this time there is the support staff that prepare the OR for the next case. This means that I have more time to be a doctor and just be with the patients. I actually have the time to talk to them. In addition to medical history and physical examination, I have the time to actually get to know the patients, even superficially. Surprisingly, I've discovered that most patients have jobs! Last week I anesthetized a dancer with a broken leg. Today I anesthetized a composer. We had a lengthy and fascinating conversation about the Israeli jazz scene (jazz is one of my passions).

Not surprisingly, these short exchanges calm the patients as much as, if not more than, iv anxiolytics. One can't feign interest, the patients respond to someone who sees them as people and not as "cases". Even the brief interaction between a patient and the anesthesiologist can be meaningful. This is all the more intense when the patient is faced with life altering events...

...The operation should have been scheduled for the morning when everyone is fresh. But all the rooms were booked which means that the operation would be postponed for another day. The parents were red-eyed from crying. They brought their young child to the hospital because of generalized weakness. The diagnosis: a brain tumor in the posterior fossa, which involves a particularly difficult operation fraught with danger. The most senior anesthesiologist on call took the case while the rest of us continued with the "regular" emergency operations. Working through the night, at 7 AM the child was transported to the pediatric ICU. I can only imagine the turmoil the parents went through. Their previously healthy child was diagnosed with a life threatening tumor and within hours underwent uneventful surgery.

This story will most probably never be reported in the newspapers. There is a "journalist" in one of Israel's dailies who has made a career of "exposing" malpractice. Obviously, I don't condone malpractice. But this evil man, by twisting the truth has ruined careers, all to sell a few rags. His vitriolic articles spew hatred for doctors and the medical system. Perhaps he or a family member were victims of malpractice. Some say he has a chip on his shoulder because he wasn't accepted into medical school. Whatever the reason, he writes negative articles exclusively. To be sure, there is malpractice, most often it can be attributed to the insane pressure of an impossibly overworked system. He will never write about the good things we do on a daily basis. That really bugs me.

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