Can you say Intrathecal?

Today I provided sedation for an unfortunate baby girl 8 months old with leukemia who needed both an intrathecal injection of methotrexate, a chemotherapeutic drug, and a bone marrow biopsy. Just before I arrived in the hematoncology ward there was an air raid siren. We entered the bomb shelter and waited it out. We counted the explosions...one...two...three...after about 12 we lost count. Later on the news channel reported that there were 20 missiles fired at Be'er Sheva at once. Three got through the iron dome and landed in the city. Thank God no one was injured.

What made this child noteworthy, is that she is from Gaza. Actually, it's quite common. We treat many patients from Gaza. Even during times like these when we are being attacked from Gaza.

I asked my pediatric hematoncologist colleague if there are any specialists in Gaza. She answered that there is one in all of Gaza. He has the knowledge and experience to treat these children. The problem lies elsewhere. They don't have the special drugs needed to treat children with cancer. Apparently, for the Hamas terrorist government, money is better spent on missiles, mortars, rockets and other weapons of terror.

So, all the children in Gaza with cancer, all of them, are treated in Israel.
Even at times like these.

The Bellboy

In a flash of comic genius, Jerry Lewis produced, wrote, directed and acted in a movie called "The Bellboy". Lewis plays, of course, a hapless bellboy who is sent on all manner of errand which all end up terribly bumbled. It is not a silent movie, but Lewis is silent throughout. That is, until the final scene, when the hotel manager asks him why he has never spoken:

So I haven't posted these many months, not because I had nothing to say, but because no one asked. But now, in light of the events in my country, I received a comment from one of the few readers that haven't forgotten me. And I am unable to remain silent, now that someone asked.

Seaspray wrote the following comment completely off topic to last post that appeared:
"...I just want you to know that I've been thinking about you and all of Israel. My heart breaks for you and I continually pray for your safety."
So to Seaspray and anyone else who share these sentiments: Thank you. Your prayers and support are greatly appreciated.
The situation here can be described as ranging from not so bad to catastrophic, depending on one's physical distance from Gaza. Luckily, for my family, we are not in the direct line of fire, so while there are infrequent air raid sirens, there haven't been any direct hits in our village. The people most affected are those closest to Gaza. They are basically living in bomb shelters. It is these civilians who have been suffering like this for the past 10 years. Almost everyday they have weathered mortars and missiles that have gone unnoticed by the international media. That is the hypocrisy, only when we retaliate does the world take notice, and censure us. To be sure, the civilians in Gaza are suffering terribly. They suffer many more casualties than we. This is not merely because of our military might, but principally because of our different ideologies. While prepared for this war by building bomb shelters and defensive measures like iron dome, the Hamas-run government has used the considerable funds provided by the U.S. and EU to arm themselves with weapons whose only purpose is to terrorize Southern Israel. While we embrace life they embrace death. They don't deny it: 

That is why they die and we live. That is why even while they terrorize us with missiles fired from civilian areas, stockpile rockets in schools, mosques and hospitals, we treat their sick (who are allowed to cross into Israel) along with our sick and wounded. This is our moral strength and their moral weakness. This is why we will prevail.

So Seaspray, now that you've asked, I answer your concern with this: 

"Our lives begin to end the minute we become silent about things that matter."

-Martin Luther King Jr.

Anti-Smoking Video

Smokers who enter my pre-anesthesia clinic usually get more than food for thought. This video does it nicely in a non-preachy way. (h/t Treppenwitz)

Mpemba Effect

Which freezes faster, hot water or cold water? It's obvious, isn't it? Before you make up your mind, watch this:

This effect has been known for centuries and was first described by Aristotle. In modern times it was rediscovered by Erasto Mpemba in 1963. He was a Tanzanian schoolboy at the time and noticed the effect while preparing ice cream in a cookery class.

Here is a layman's explanation. 

For you physics braniacs here is a technical paper outlining 7 experiments.

Amazingly, such a seemingly simple (yet counterintuitive) phenomenon still has no conclusive explanation. 

I'm wondering if the sun will rise tomorrow morning.

Universal Anesthesia Machine

"Necessity is the mother of invention" comes to mind.

Hat tip: Joe

Urban Legend

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

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

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

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

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

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

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

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

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

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

Accidental Hero

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

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

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

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

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

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

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

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