Saturday, December 31, 2011

Piano Keys, Pride, and Prejudice

     In 1970, my family moved from Cincinnati, Ohio to Osawatomie, Kansas. My father, a psychiatrist, had accepted a position as Clinical Director of Psychiatry at the state mental hospital, and we were going to live in the staff cottages just across the street from the institution. I was seven years old, and I wasn't too thrilled about moving. I had lots of little friends at St. Ursula Villa, the Catholic school I attended from kindergarten through second grade, including a potato-headed boy named Darryl McIntosh, who had a crush on me. Darryl picked his nose constantly, and had sent me a love note in the second grade, which my mother promptly placed in her jewelry box, never to be seen again. In July of 1969,  Darryl and I were both in St. Ursula's summer enrichment program, and I remember sitting in Sister Mary Nicholas's classroom, side by side at our desks with our lunch trays, watching with fascination as the first astronauts landed on the moon. Cincinnati had wonderful museums, my favorite of which was the Museum of Natural History. My class went there on a field trip, and my friends and I saw a Tyrannosaurus Rex, brontosaurs, mastodons, and pterodactyls, and I couldn't wait to go back. There was so much more to learn! Our next door neighbors, the Naegels, had a teenage daughter named Tracie, who used to babysit my sister, Emi, and me. She would sometimes come over in the afternoon, and take us for a walk down Grandin Road to visit old Mr. Ernie, a widower who always greeted us with pink and white peppermint and wintergreen lozenges. Our other neighbors, the Mullers, had two adopted children, a boy Emi's age named Michael, and a younger girl named Marty, and we played together with them nearly every day.
     Osawatomie was a small town, compared to Cincinnati, and our new house was very different from the one we'd left behind. First of all, it was blue, and it wasn't modern like our other house. Our house in Cincinnati was an architectural marvel, shaped like an H with a courtyard in the middle, with dark cedar siding, an eccentric pitched roof, and huge glass windows everywhere, my favorite of which was the picture window in the living room. In the fall, when the leaves turned, you could look out that window and see a lone, fiery red maple tree amidst the rest of the yellows and oranges; seeing that tree meant Christmas was near. Our blue house didn't have many windows, and it was small, with three tiny bedrooms. Emi and I shared one of the back bedrooms. My brother, Adam and later, Peter, and my Polish grandmother, Babcia (Bab-cha), slept together in the room across from us. My parent's bedroom was adjacent to their room, and I can't remember if Mom and Dad had their own bathroom or not. When my older brother and sister, Leszek (Leh-SHEK) and Edina (Eh-DEEN-ah), came home from college, they and their friends would sleep in the basement, a frightening place which I avoided after watching an episode of "Dark Shadows" because I was certain that Barnabas Collins was hiding down there.
     Our move occurred in June, while my mother was pregnant with Peter. He was born in August in Shawnee Mission,  and back in those days, there was no such thing as a labor and delivery suite; the birth process wasn't a family affair like it is now. Mom was gone for several days, and we missed her. Dad took us to visit her, and Emi and I wanted to give her a present, so he helped us pick out an orange tube of Tangee lipstick in the hospital's gift shop. It was a neon shade of apricot, which we thought was outrageously mod. To us, Mom was the most beautiful and elegant woman in the world, and she had recently gotten a pixie cut like Mia Farrow, which made her look even younger. Concealing her shock at the garish lipstick shade we'd chosen, Mom immediately tried it on, and continued breast-feeding Peter while sporting electric orange lips. After Labor Day, Emi and I started first and third grades, respectively, and we were now going to public school. Around that same time, my parents decided that it would be a good idea for me to take piano lessons from Babcia Zubowicz (BAB-cha Zu-BO-veech), the elderly mother of one of Dad's colleagues. My family had previously lived in Osawatomie before moving to Cincinnati, shortly after I was born, and Edina, a gifted pianist, was a former student of hers. Leszek and my father were also superb pianists, but they played by ear, instead of reading music, and this was something that Babcia Zubowicz frowned upon.
     My piano lessons took place after school, two or three days a week, and I would usually walk by myself over to Babcia Zubowicz's on those afternoons. She lived in a grey, shingled house, not too far from the staff cottages, and her piano room had a peculiar musty odor, like mildew and cabbage and perfume mixed together. It was exactly the way you'd expect an old Russian lady's house to smell. Her hair was perfectly coiffed, and she had thin lips, a severe, pointed nose, and pale blue eyes, the pupils of which remained microscopic, regardless of the level of light in the room. She spoke Russian, Polish, and English, and she took great pride in the fact that she had once been an opera singer. During my lessons, she would sit in a chair next to me, crooning songs from the old country into my ear and slapping my hands while I practiced HanonEdina, Babcia Zubowicz's star pupil was Nancy Keller, a girl who was three grades ahead of me. Like Edina, she could play Chopin's "Military Polonaise" with deliberate precision. The entire course of each of my lessons was punctuated by "Nancy this" and "Nancy that", and though I had never met Nancy, I resented her for being so perfect. Babcia Zubowicz first taught scales and arpeggios, from which you transitioned directly into the complicated works of Chopin, Beethoven, Brahms, and Strauss. She did not believe in "baby" books for beginners; she expected you to jump right into the classics. Although I am now aware that Babcia Zubowicz considered me to be an excellent pupil, I rarely received direct praise from her. Instead, after a lesson in which I'd made her especially proud, she'd invite me back to her kitchen for a cup of hot tea with honey and some windmill cookies. Nancy and I later performed individually at the same recital, and from a technical perspective, it was obvious that the two of us were light years ahead of the other students, who didn't have Babcia Zubowicz as their teacher.
     For some reason, Babcia Zubowicz was extremely critical of my family, especially my father. Despite the fact that she was good friends with my grandmother, whom she viewed as a saint, she would routinely tell me that my father was stupid, my parents had too many children, and I was too fat. Her son, George, was a psychiatrist, and he was the superintendent of the mental hospital, which made him my father's boss. George and his wife, Charlotte, lived just a couple of doors down from us, and they were close friends of our family. Emi and I both took Polish lessons from Mrs. Zubowicz. Adam adored her, and although he was probably only three years old, he was allowed to walk over in the mornings to visit with her. This was in the early 70s, which was a time when we could play outside all day long and ride our bikes downtown, and our parents didn't worry about us like parents have to now. We knew all our neighbors, and they trusted we were safe. One day, Adam went over to see Mrs. Zubowicz, and she wasn't home. It was customary for him to enter her house through the garage, where she kept an old refrigerator full of eggs, and when she didn't come to the door, his disappointment led him to break several dozen eggs, dropping them one by one, onto the concrete floor.
     I begrudgingly continued my lessons with Babcia Zubowicz until I was in the sixth grade. Over the years, her denigration of my family escalated, and I became increasingly more anxious about going over to her house. I invented all sorts of symptoms, attempting to feign illness, in the hope that Mom wouldn't make me go. Emi and I had taken to prank-calling Babcia Zubowicz, as a way of getting back at her for being so mean to me. One of our friends, a girl named Christina whose mother was Polish, could speak with a perfect, adult-sounding Polish accent. We'd dial Babcia Zubowicz's number, and then, hand the phone to Christina, crowding our ears around the receiver, waiting to hear the old woman say "Hallo?" Christina, in her Polish voice, would reply "Hallo. This is Babcia Zubowicz!" to which the real Babcia Zubowicz would retort, "No, I am Babcia Zubowicz!" This argument would persist for several minutes, with Babcia Zubowicz defiantly insisting that she was indeed herself. We'd then hang up, giggling uncontrollably, feeling smug in our revenge. At some point, my parents realized that my bitter complaints about Babcia Zubowicz were grounded in reality, and they allowed me to quit taking lessons from her. I acquired a new piano teacher, Mrs. Jacks, who was a benign lady with bad breath, penciled-in eyebrows and badly dyed hair. She let me play the church organ and taught from beginner lesson books. In terms of the piano, I didn't learn another thing.
     Many years later, I came to understand that the contempt Babcia Zubowicz had for my family was because she regarded us as competitors, a tour de force of innate creativity, who actively threatened to upset the ingenuity of her own legacy. She recognized that our aptitude for music, art, and language was genetic, effortless, a God-given gift which coursed naturally through our veins. It was something we couldn't help, and she was envious. Her stubborn pride was no match for our shining collective brilliance, and now I realize she simply wanted what we all had, but didn't have to work for. This revelation made it possible for me to forgive her. I couldn't blame her for being jealous of my family, because from a very young age, I too was aware that we were freaks of nature, visionaries, each of us exceptional, uniquely talented individuals who embraced life with unparalleled lust and passion, gladly accepting our originality and our non-conformity as qualities to be appreciated, nurtured, and shared, but never to be taken for granted.

Friday, December 30, 2011

A Rose for the Weiner King

     I spent the majority of my high school years, convinced that Janis Ian had written "At Seventeen" just for me. I was one of those girls who didn't really date, not because my parents didn't permit it or because I didn't want to; something was just wrong with me. I had a crush on one boy from our sophomore through senior years, but he didn't give me the time of day. I used to draw him from memory, imagining what it would be like to kiss his lips, and every time I saw him at catechism class, my heart would pound. I'd sometimes call him on the telephone, just to hear his voice. As soon as he said "Hell-ay?", and that's exactly how he said it, I'd quickly click the receiver down and hang up. This was 1979, long before the days of caller ID or call waiting, when I'd literally sit by the phone, willing him to call. It used to drive me crazy when my mom would get on the phone with her friends in the evenings because what if he was trying to call me? Thinking back, I was a total stalker, hopelessly infatuated with him. Every breath I took was for him, and he didn't even know it. He was a football player, and guys like him weren't interested in girls like me, who possessed what I classify as "awkward beauty." I had blonde hair, blue eyes, decent skin, and I wasn't too fat or too skinny. However, the shape and configuration of my nose was a great source of ongoing despair to me. My nose was bulbous, like Karl Malden's, way too shiny with pores that were too big, and every time I'd see it in the mirror, it seemed even more hideous. I actually tried camouflaging it with contour powder, brushing brown stripes down either side of my nose to make it look more narrow and petite. My attempts at makeup artistry probably made me look like a female impersonator under the classroom's fluorescent lighting, but what else was a quietly desperate, almost 17 year old girl to do? If I could only look like my girlfriends, Eileen and Leslie, then maybe he would finally notice me.
     Eileen, Leslie, and I were inseparable from about tenth grade through graduation. I think Leslie was the first one of us to get her driver's license, and she'd come and pick Eileen and me up on Friday and Saturday nights to go driving around in her little Toyota. One of her brother's friends sometimes stashed his dime-bag of pot in her glove box, but we never touched it. We'd hang out at Wendy's and get slurpees from 7-11, which were occasionally mixed with vodka from my parent's liquor cabinet, but mostly, we just drove up and down Macon Road, Airport Thruway, and the Beallwood Connector in Columbus, GA, listening to the Alan Parsons Project on 8 track. Eileen and Leslie were both natural beauties, and I'd wager that they made regular appearances in many of our male classmates' dreams. Neither wore makeup; they didn't need it because they both had flawless skin, and lovely English school-girl faces. Eileen had wavy, waist-length chestnut hair, which she'd flatten with a household iron. It would swish from side to side as she carried her books down the hall, and on pep rally days, she'd wear it up in a pony-tail. She and I first got to know each other in the ninth grade. We were in Latin class together, and although the entire class regularly cheated on our tests, she was the only one Mr. Martini ever caught. For this crime, she was punished not only by getting a zero on the exam, she also had to move her desk to sit next to him and his hemorrhoid cushion for the rest of the year. Eileen always looked put together, sensible, and her Pappagallo clothes and shoes seemed more grown up than the outfits I wore. Leslie was the tallest of us, and she was doe-eyed and willowy, with delicate features, long glossy brown hair and eyelashes, and an olive complexion. She was very quiet and shy, until she got to know you. Leslie had an absolutely wicked sense of humor, which compelled us to do evil things, like signing each other up for the Army, writing fake love letters to one another from the weirdest guy in class, and putting industrial-sized cans of green beans into a certain friend's mailbox, naively unaware that this last prank constituted a federal offense. Leslie's parents were divorced, which was still somewhat of an oddity back then. Interestingly, both she and Eileen had much older siblings, which essentially made each of them an only child. Their houses were quiet in comparison to the constant chaos which epitomized my household. In addition to me, I had a younger sister and two younger brothers living at home, and our house was the place for sleepovers, presumably because there was lots of energy and drama: one of us was always getting into trouble. For my friends, my house provided a never-ending source of entertainment.
     Neither Leslie nor Eileen dated that much, despite the fact that they easily could have had their pick of the high school boy litter, and contrary to me, this was by choice. They weren't as obsessed with having a boyfriend as I was. In our junior year, Eileen became the unwilling object of one boy's affection, and aside from his notes and phone calls requesting dates, she actually received roses from him. The three of us viewed this as a shocking aberration, a complete departure from age-appropriate social norms. Roses? What on Earth could Greg be thinking? Didn't he know that showering a girl with unabashed adoration would cause her to recoil instantly in horror and disgust? Fearing that Eileen's honor was somehow in jeopardy, Leslie and I declared war on Greg's amorous advances.
     Greg was a year older than us, and he worked as a manager at Weiner King, located at the corner of Airport Thruway and Beallwood Connector. His pride and joy was a red Camaro, which I'm now guessing he worked very hard to pay for, and it was customary for him to park it out back, behind the restaurant. Our plan was to take my mother's egg coupons to the Family Mart, purchase as many eggs as we could, and then pelt his Camaro with them as we entered from the west on Airport Thruway. That way, we could exit going north on Beallwood, and make a clean getaway. The Weiner King could only be accessed from the north side of Beallwood Connector because it was a divided highway with a concrete median, so you couldn't turn left from that side of the parking lot. In other words, if you wanted to head south on Beallwood, you had to make a U turn at the intersection.
     We picked a bright, sunny afternoon in the springtime to perpetrate our dirty deed. At the time, I was driving my mother's blue Honda Civic wagon, and through an act of providence, we were able to cram what seemed to be ten girls in there, including Eileen, Leslie, and my sister, Emi. Emi was sitting in the rear, with the hatch door wide open, her long, skinny legs and bare feet protruding from the back of the car. We procured several dozen eggs, using Mom's 20 cent-per-dozen Family Mart coupons, and headed west on Airport Thruway. I was driving, and I can't remember whether it was Eileen or Leslie in front with me, but all ten of us were armed with an impressive arsenal of extra large eggs. As I turned into the Weiner King parking lot, we readied our weapons, poised for the attack. Crouching down in the Honda to avoid recognition, we rolled up slowly to Greg's prized Camaro, and once we were close enough to grab its front bumper, we commenced our assault. Eggs began flying like missiles, cracking with a reverberating thud onto the windshield, the hood, and the roof, their custardy innards dribbling down the sides of the vehicle like long, viscous fingers, pointing out the highway to hell. Our instant gratification was short-lived, though, and since we still had some eggs, we decided to make another pass through. I headed out on Beallwood, turning east on Airport Thruway, and entered the parking lot in the same manner as before. Giddy with excitement, we crept up once again to Greg's Camaro, eggs in hand, ready to launch our ovoid projectiles, when suddenly, we were surprised by a bespectacled blonde man, running at full speed and heading straight toward us. It was Greg. Apparently, one of his Weiner King co-workers had seen us egging his car, watching as we circled back around to do it all over again, and had alerted Greg. Greg promptly went and hid in the men's bathroom behind the restaurant, so he could abort the second attack. Upon seeing him, I gunned the gas pedal, and roared out of that parking lot. We all braced ourselves as I jumped the car right over the median, heading south on Beallwood, with Greg running so close behind that he could have pulled Emi out of the wagon by her ankles. It was terrifying, and I'll never forget the look of exasperated rage on Greg's face.
     Later that evening, my parents received a phone call from Greg's mom, and Emi and I got into big trouble. One of Emi's classmates, an acquaintance who'd witnessed our folly at Weiner King, identified our blue Honda and gave Greg our phone number from the school's directory. Even though he had immediately hosed down his car in the parking lot, Greg reportedly couldn't clean some of the egg spots off, and as an act of retribution, we were supposed to go and wash his car. I don't remember washing his car, but I do remember inspecting it, and thinking that it looked pretty clean.
     Greg's crush on Eileen abruptly ended after that incident, and he stopped calling and sending roses. I don't think she ever heard from him again. Weiner King closed within a few months, later re-opening as Hartz Krispy Chicken, which was where I ended up getting a job the summer after graduation. Greg no longer worked there. At my 30th high school reunion, I learned that shortly after his managerial stint at Weiner King, Greg had become a police officer. The funny thing is, Greg and I were a lot alike. Both of us were tragically in love with someone who was completely out of our league, unattainable, someone whose affection we craved and lived our days for, vainly clinging to the hope of a single moment of reciprocity which we knew would never come. By sending roses to Eileen, Greg had unknowingly sealed his fate as a lovesick, pimple-faced Mr. Wrong, his simple, sweet gesture condemned as a personal affront by three silly girls who can now only hope he found it in his heart to forgive us.

At Seventeen Lyrics by Janis Ian
Janis Ian, Performing "At Seventeen", 1976

Wednesday, December 28, 2011

The Ballad of the Poorly Timed Anesthetic


In my opinion, The Beverly Hillbillies was one of the most cleverly-written sitcoms of all time, and I never get tired of watching that show. I got the tune stuck in my head today, and decided to re-work the ballad. Believe it or not, this took me about 5 hours to write. The Ballad of Jed Clampett was composed and performed by Lester Flatt and Earl Scruggs in 1962, and the last stanza is heard with the closing credits. If, by some chance, you don't recall the tune, I've provided a link to refresh your memory. You may find yourself humming while you work. Enjoy!
The Ballad of Jed Clampett

Your patient’s on the table, loaded up with Versed
He’s breathing through a mask with a BIS on his head
You give lidocaine, then you push some propofol
And crank up the best volatile of them all
Desflurane, it’s insoluble

A nurse asks you “Can we put this catheter in?”
“We'll hurry so the surgeon can begin.”
You intubate the trachea with your Mac 3 blade
Better get that Ancef in before incision is made.
Prophylaxis, keeps them germs away

Surgery commences and your patient’s doing fine
So you flush that rocuronium through your IV line
Now the wound is being closed and you check the train of four
There ain't no freakin' twitches, it’s a state you can’t ignore
I need neostigmine, y'all! And some robinul!
At last...head lift...pull that tube!

Hurry Up and Wait

    Yesterday was my first day back at work after a long Christmas weekend, and it started off with the usual post-holiday bang. In outpatient surgery, we had twenty-five cases among six operating rooms, evenly divided between gynecology, ENT, and orthopaedics. By one-thirty, I had already placed four femoral, three sciatic, and two brachial plexus nerve blocks, and finished interviewing my last case. Although it was hectic, we had good momentum, and I felt cautiously optimistic. If the winds of fortune are blowing in your favor, even if you're the late doc running a busy schedule like yesterday's, it is still possible to have an early day where you get all your work done in ten hours, instead of fourteen. You may actually get to go home while it's still light outside. My cases had all started on time and were moving forward at a reasonable pace, and one of the surgeons was running slightly ahead of schedule. It definitely looked promising. Somewhere around two-thirty, though, the progress came to a roaring halt. We'd suddenly entered a time warp, and time wasn't just standing still, it was taunting and ridiculing us, like a playground bully. Whereas we'd previously been getting cases back to the operating room with Michael Jackson-style choreographed precision, we were now a troupe of unrehearsed dancers, floundering in a slow motion ballet. Instantly, I knew we'd veered off course into that much-dreaded parallel universe known as "Hurry Up and Wait." This is an operating room phenomenon, a dead zone which typically coincides with shift change. Between two-thirty and five o'clock, operating room personnel begin to disperse, reducing the number of available staff to assist with cases.  This loss of personnel translates into fewer rooms that can be run concurrently. A surgeon who had been operating efficiently in two rooms to improve turnover time, will be down-sized to one room in the Hurry Up and Wait zone, and any remaining cases will now be done in series, instead of in staggered parallel.
     Like the Archangel Gabriel heralding the Apocalypse, Hurry Up and Wait is also an unwelcome harbinger of doom, auspiciously warning you of bad fortune that is heading your way. You're almost certainly going to have an unanticipated difficult airway, and you'll probably break a tooth during the intubation. If you're really unlucky, you'll inherit at least one urgent case involving a patient who's had sphincter-altering surgery, with only four hours of NPO time following his lunch of a Big Mac, shake and fries. Your illustrious duties might include starting a central line because no one else can get an IV on your patient, or draining a rapidly expanding neck hematoma on that fresh cervical fusion, the one whose face is bulging and turning blue as he struggles to rip off his hard collar. Don't even dare to think you'll get by without at least one patient who has unremitting post-op nausea. In the world of outpatient surgery, the badness associated with Hurry Up and Wait always seems to be concentrated into the last one or two patients of the day; without exception, the last patient out of the operating room is going to have some kind of unforeseen, frustrating problem. If you're the unfortunate designated late doc on a day like this, you count your blessings if you make it home before eight o'clock.
     There is an old saying that anesthesia is 90% boredom and 10% terror, but Hurry Up and Wait easily encompasses both categories. Characterized by a confounding, circular pattern of microscopic bursts of intense activity, followed by interminably long periods of complete inertia, it sneaks up on you, taking you by surprise. Once you realize you've entered the "zone", it's already too late; you're pretty much toast. The 90% boredom component of Hurry Up and Wait is obvious. For example, at five o'clock yesterday, I was still supervising three anesthetists in three operating rooms. From the way things were slogging along, I knew it would be a very late evening. I didn't leave work until eight o'clock, just after our last patient of the day, who had gotten out of the operating room at six o'clock, was finally discharged from the recovery room. Naturally, she was battling significant post-op nausea, and the nurses and I spent close to two hours rescuing her with IV fluids, Zofran, and Reglan. Boredom is not necessarily a bad thing in and of itself. If you plan ahead and bring along a book or some anesthesia journals to catch up on, you can be productive while you are waiting for your cases to finish. But, boredom makes you sleepy and hungry and mentally dull, making it easy to be caught off guard. You start thinking about all the things you'd rather be doing, like working out or eating dinner with your husband. You watch the clock, and every minute that passes becomes a milestone, a countdown which culminates in your return home, only you do not pass "go" or collect two hundred dollars; you simply collapse into bed. The 10% terror?  That's a little less straightforward. Imagine, if you will, Adam and Eve, at the moment they partook of the fruit from the tree of knowledge. They became sentient, aware, no longer blissful in their ignorance. Surviving just one Hurry Up and Wait day equates to a bite of that forbidden fruit; you only have to experience it once. You are then rendered permanently scarred by the painful awareness that, at some point in the future, you will be revisited by Hurry Up and Wait, and no matter how diligently you prepare to avoid catastrophe, you'll be burned again, terrorized by post-op nausea, sky-high blood sugars in the diabetic who inadvertently received four millligrams of Decadron, or the hyper-anxious Xanax-taking patient who has a room air oxygen saturation of 99%, yet "can't take a deep breath."
     I got home a little after eight last night, my outlook somewhat improved after learning that I'd have today off. Brad had just returned from his job in Dunwoody, and despite enduring the gnarly two hour, against-traffic drive back to Rome, had stopped at Mellow Mushroom to pick up a Greek salad for us to share. We ate the salad, watched a little TV, and went to bed. Tomorrow, I'll once again be the late doc in outpatient surgery. Maybe by then, I'll have snagged my overdue stroke of good fortune, where the Force is with me, and Hurry Up and Wait is nimbly vanquished by Come On, Let's Go.

Tuesday, December 27, 2011

Physician, Heal Thyself!

     Once you become a doctor, especially if you're an anesthesiologist or a surgeon, you abdicate the "right" to be sick. You may have a fever of 102, purulent green sputum, and a cough which causes your colleagues to run and hide in fear of droplet contamination, but if you don't come to work, who's going to take care of the patients? When I first became an attending physician, I had an upper respiratory infection which lasted for 6 weeks, and my office mates were all seriously worried that I'd contracted tuberculosis. You could hear me coughing all the way down the hall. Once I'd get started, I couldn't stop; it came in paroxysms. If I was able to stop coughing long enough, I could feel myself wheezing, so I started bringing one of Nick and Rory's albuterol inhalers with me to work to calm my irritated small airway passages down. It appeared to be a nasty combination of bronchitis and a sinus infection, but the Z-pack (antibiotics) I called in didn't seem to make much of a difference. All I got was a bad case of the runs. God only knows what my patients thought as I coughed and wheezed my way through their pre-operative exams.
     From the moment we begin our medical training, it is ingrained in us that being sick is a sign of weakness, a state of being you must ignore. As a surgery intern, I remember starting an IV on one of the 3rd year residents on my team at Grady. He was so pale and sick that he could hardly stand up. As we sat in the break room, waiting for his bag of fluid to run in, we were stat-paged for a trauma down in the ER. We all took off, sprinting down the corridor to answer the call, and he was right there with us, running with his IV pole in hand. I worked with another surgeon, who became so sick during one of his procedures that an IV was started on him, right there in the operating room. He let the chief resident finish the case, and because he was feeling better from the hydration, went to the lounge to have a snack. He returned to the operating room, where he sat down next to the anesthesia provider, hanging his fluids adjacent to the bag connected to the patient. The anesthetist was busy, preparing the patient for transport to the ICU. Somehow the IV tubing got intertwined, and the surgeon ended up receiving a paralyzing dose of rocuronium, intended for the patient. As he hit the floor, his IV dislodged, and he had to be intubated, completely paralyzed but awake, with a full stomach, while someone tried to start another line. It seems that if you're sick enough to require an IV, you really should just go home and recuperate. The unfortunate outcome of this "rule" against being sick is that physicians become masters of denial in matters concerning their own health, and this, I believe, has an impact on how we care for our patients.
     Before Brad and I got married in October of 2009, we bought a couple of German short-haired pointer (GSP) puppies from a colleague named Cinnamon, who had bred her dog, Roxie. GSPs are a spirited, energetic hunting breed. They are loyal, affectionate, sweet-natured and incredibly intelligent. They grow to be anywhere from 45 to 75 pounds and are blissfully unaware of how strong they are; they just want to play. Simon and Lilly were two little brown bundles of activity, all paws and bobbed tails, constantly wagging. By the time they were 6 months old, both puppies had almost reached their adult weights. We had a special fence built for them around our side yard, one that they couldn't dig under or jump over, but being outside isn't enough for GSPs; they want their people to run and play with them. Neither Brad nor I had any experience in leash-training a dog, and Simon and Lilly pulled and tugged on their leashes like wild horses. The bigger they got, the harder it was to walk them, so eventually, we stopped trying. One day in January of 2010, Cinnamon and I decided to get together and take Simon, Lilly, and Roxie out to Stone Mountain, where she knew of some cool wooded trails. We thought the dogs would have fun, running around together off leash, down by the lakefront. Brad and I drove over to Cinnamon's with Simon and Lilly, and then, we piled back into our cars, with the three dogs in tow. I had really had a tough time with Lilly over at Cinnamon's. She was on the leash, and had gotten so excited by seeing Roxie that she nearly dragged me down the hill, next to the driveway. In the struggle to control her, I thought to myself, "This could get dangerous!"
     Once we arrived at Stone Mountain, Brad and I let Simon and Lilly out of the car. They were already on their leashes, so I took hold of both dogs and walked them a little way from the car, while Brad got their water container and toys out of the trunk. I had neglected to anticipate the mandatory period of excitement, a phenomenon which occurs regularly and predictably with GSPs. Whether you've been gone all day or just stepped out of the room for two minutes, these dogs are so thrilled to see you again, that they start running around in circles, ready to play. As Brad approached us, Simon and Lilly began to run in opposite directions, encircling my ankles with their leashes until they were pulled tight, and within seconds,  I fell backward like a giant sequoia, onto my right elbow. Tim-berrrrr! PLUNK! Crunch! The pain which shot through my elbow was exquisitely sharp, bringing tears to my eyes, along with several overwhelming waves of nausea. Completely stunned, I sat there, crying. I tried to get up, but was so unsteady from the pain that Brad and Cinnamon had to help me onto my feet.
     I must preface this by saying that, like my mother, I have an extremely high tolerance for pain. I rarely, if ever, need to take ibuprofen or Tylenol for anything. I had my wisdom teeth removed without the standard Valium pre-medication; local anesthetic and nitrous oxide were all I needed. I managed to survive my herniated disc without narcotics, and once the inflammation dissipated, with the help of prednisone, I started a walking and core-strengthening program, and now my back is fine. When Brad and I first started dating, we had a habit of making out in the woods behind his house. I broke several of my toes, on separate occasions, walking barefoot over pine straw covered holes and large twigs to get to the clearing where he was waiting, but rest, ice, compression, elevation, and buddy-taping saved me, no analgesics required.
     Cinnamon and I examined my elbow, which was filthy from the dirt and gravel I fell back on, but all we could see were two deep holes. I could flex and extend my arm, so neurologically, it seemed to be intact. There was no bathroom close by, so she got a first aid kit from her car, cleaned up the wound and bandaged it as best she could, and we decided to go ahead and let the dogs play. She showed us a way of looping the leashes around the puppies' hind quarters, which prevented them from pulling, making the walk with them a little easier. They dashed in and out of the water, even though it was cold, running at full speed up and down the sloping hills next to the river. On our way home that evening, we stopped by the drug store, and I bought all sorts of bandages, ACE wraps, Neosporin ointment, and non-stick gauze pads, so I could be ready for work the next day. I sat in a warm bath with Epsom salts, and then got Nick and Brad to help me irrigate my wounds with homemade saline, using an old Water Pik we kept under the sink. I think they were both pretty grossed out because the holes in my elbow were really deep, there was a lot of blood, and the nozzle of that Water Pik was halfway buried within the recesses of those two wounds. I bandaged my elbow, took four ibuprofen tablets, drank a couple of glasses of wine, and went to bed. The next morning, I got ready for work as usual. My elbow seemed to still be oozing quite a bit of blood, so I reinforced the dressing, and shoved lots of Neosporin up into the wounds. I put on my white coat and drove to work. I was supervising the acute pain service, and I started the day by observing one of my residents place an epidural. The patient needed a bolus of IV fluids, and as I reached up with my right arm to move the bag of fluids up to a higher position on the pole, I felt my elbow pop. It was a strange sensation, and it hurt a little bit, too. I started wondering if something really was wrong. I ran into Cinnamon in the pre-op area, and she, along with my team on the pain service, urged me to go down to the emergency room for an Xray.
     It was about 8:15 a.m. The breakfast I'd eaten at 5:30 was long gone, and I was hungry, so before heading down to the ER, I stopped by the anesthesia lounge to get a couple of packages of graham crackers. I went to the nurse's station, and awkwardly explained my situation to the head nurse. She immediately went and found one of the attending physicians, who examined me on the spot, and ordered a set of Xrays. I was ushered into a little room, where the nurse took my white coat, the right sleeve of which was stained with blood, and proceeded to start an IV and obtain labwork. This certainly seemed like overkill to me, but I obliged. I will never understand why she started the IV in my left antecubital vein (crook of the elbow) when I have huge, ropey veins in my hands and forearms. My veiny arms have always been a source of envy for the pre-op nurses: "I wish we could borrow your veins for this patient!" they'd exclaim, as they were struggling to obtain access on a patient who was a difficult stick. The IV was very uncomfortable and the tape used to secure it was itchy. I sat and watched morning television, texting back and forth with Brad, the boys, and the pain service team. Just as "The View" was coming on, the ER physician came in and told me that I had an open fracture of my right elbow. The tip of my elbow had shattered into several fragments, and the joint capsule had been breached. I was surprised about this because I hadn't seen any bony fragments, peering through the wounds. He congratulated me for having had the presence of mind to irrigate the wounds with the Water Pik, and then he told me, "You have to have surgery to fix this today. It's a surgical emergency." I knew that open fractures were surgical emergencies, but somehow, I didn't think it really applied to me. He had already consulted an orthopedic surgeon at the outpatient surgery center a couple of miles from Emory, and I was put on the schedule for three o'clock. I grabbed my white coat, which the nurse had tried to clean with peroxide, and with the IV still in my arm, went upstairs to my office. Judy, the assistant to the chairman of our department, offered to drive me over to the surgery center, so I gathered up my purse and satchel, and off we went.
     The next few hours are a blur. First, I sat in the reception area, waiting to go through the outpatient surgery admission process. Weird thoughts started entering my mind, and before long, I was preoccupied with whether or not I was going to have to remove my underwear for the procedure or whether anyone would see me naked. Most mortifying of all, what if I farted while I was under anesthesia? I used to help staff the surgery center, so I knew everyone who worked there. Heather, the main anesthesiologist and nerve block guru for the facility, was off that day, and another co-worker of mine from Emory was supervising Jenny, the senior resident who was completing her two week rotation there. Jenny was a personal favorite of mine, and I had helped teach her how to do nerve blocks when she rotated on the acute pain service the year before.
     Once I made it up to the pre-op holding area, things began to happen fast. Jenny assessed me, and told me the plan was to do my case with an axillary nerve block and monitored anesthesia care (MAC, or IV sedation). Matt, the attending anesthesiologist, reviewed my chart and Jenny's anesthetic plan, and started helping her assemble the supplies for the block. Brad arrived, looking worried, and sat next to me as I nervously awaited placement of my nerve block. I had no idea what it was going to be like to receive sedation, or to have my arm numbed up. Truthfully, I really didn't like being a patient at all. After I got 4 milligrams of Versed and 100 mcg of fentanyl, being a patient suddenly seemed less awful. Jenny used an ultrasound to perform the axillary block, while Brad and I watched. I don't remember much of anything after receiving the Versed. I remember not being to move my arm, and I vaguely remember being in the operating room. Apparently, I was quite chatty, and Jenny had to give me a little extra propofol to stop talking; it was starting to annoy the surgeon. The tip of my elbow was comminuted beyond repair, and the surgeon ended up having to reattach my triceps tendon instead, using a couple of anchors. I woke up in the recovery room, where the nurses had some ginger ale, and you guessed it, graham crackers, waiting for me. Brad drove me home, which was where I spent the next two weeks. I felt so good that I didn't take any pain meds, a direct violation of the advice I give all of my patients who receive nerve blocks. You want to have some pain medicine in your bloodstream before the nerve block wears off, so you can transition smoothly from one mode of pain control to the other. At 4:00 a.m., I woke up in excruciating pain, and spent the next 24 hours, nauseated from the discomfort, trying to make up for lost analgesia with Percocet.  In all, it was a 8 week recovery period. I went back to work after two weeks, but because I couldn't engage in any activities which required active resisted extension of my triceps, such as CPR, I couldn't work alone in the operating room. I spent the next six weeks, supervising the acute pain service, which was already one of my favorite assignments anyway.
     The worst part of my recovery was seeing my once super-toned right triceps go completely flabby. My vanity got the best of me, and I disregarded some of the surgeon's orders about exercising my elbow. I started using a rowing machine. I rationalized that it was OK, because rowing doesn't really work the triceps, nor does it involve any active resisted extension. Because of that, I now have chronic right elbow pain. I am no longer able to do big girl pushups; I have to do them with my knees on the floor. I can lift weights and do chaturangas during yoga, but I always feel it in my elbow afterwards, and it hurts. I still don't take any pain meds, and just limit my activity if my elbow really starts acting up. If I had to do it all over again, I think I would have followed the surgeon's orders to the T.
     The good news is that Simon and Lilly are now perfect-leash walkers, thanks to the professional trainer we hired following that fateful day. They follow commands, and are generally quite well-behaved. My broken elbow provided the impetus for us to help them gain some discipline. It also made me rethink my role as a healer. In Eastern medicine, healing is a function of body awareness and balancing the flow of Qi (chi or prana) or life force, whereas Western healing is focused on eradicating disease externally, through the use of medications or interventions. Intuitively, the Eastern model of medicine makes a lot of sense to me. It is health-centric, whereas Western medicine is disease-centric. In the Eastern model, the disease state is perceived as a loss of adaptability resulting from a disharmony in bio-energy, and symptoms, such as pain, are seen as the body's way of communicating that the life force is out of balance. Qi is central to Eastern medicine, and life and medicine are considered to be one in the same. In the West, symptoms are viewed as a nuisance or a threat, as something to be actively suppressed, because the focus isn't on body awareness, it's on stamping out disease. This lack of awareness goes hand in hand with the denial I alluded to earlier. If you're not attuned to your body's cues, how can you ever really be healthy? Pain and illness are signals that we need to realign our chakras, so to speak, to pay attention to the messages our bodies are sending us, and re-balance our Qi. I am spending much more time now, listening to what my body is telling me, focusing on wellness, and I am trying to carry this over into my daily practice of anesthesiology. I make time to talk to my patients about smoking cessation and losing weight: it's part of practicing compassionate medicine. I think that if Western medical students and residents received more exposure to the concepts espoused by Eastern medicine, we'd not only become more effective at healing our patients, we'd evolve into more compassionate physicians who are also truly capable of healing ourselves.

Monday, December 26, 2011

The Anesthesia-Chicken Biscuit Quandary: Maybe Mom Was Right After All?

     Before leaving work on Friday, I glanced at the outpatient schedule for tomorrow, which will be my first day back at work following a wonderful, three day Christmas break. It's the typical end-of-the-year rush, where everyone is getting their elective procedures done before the insurance deductibles kick back in. I'm the "late" person, which means I'll be there till the last patient goes out the door tomorrow evening. We're running all six operating rooms, primarily orthopedic and gynecologic cases, most of which will be done with a combination of general and ultrasound-guided regional anesthesia (nerve blocks). It's going to be a crazy day, and because surgeons sometimes need to add cases that weren't scheduled, it may be even more hectic.
     From an anesthetic standpoint, your primary concern with add-on cases lies in whether or not the patient has had adequate NPO time. NPO stands for nil per os, which in Latin means "nothing by mouth." Regardless of whether a patient is having sedation or general anesthesia, the risk of aspirating stomach contents into the lungs is a serious concern. Both types of anesthesia can result in the loss of protective airway reflexes. For instance, you know how you cough violently when you accidentally inhale a cookie crumb or a swig of Coke, and it goes down the wrong way? Anesthesia wipes out that biological safety mechanism, making it easy to upchuck residual food and liquid from the stomach, up through the esophagus, down past the trachea, and smack dab into the lungs. The consequences of aspiration can be life-threatening, ranging from mild respiratory distress to devastating lung injury with multi-organ failure. The American Society of Anesthesiologists has published a set of guidelines for NPO times, some of which are listed below.




      It is important for patients, peri-operative physicians, and anesthesia providers to appreciate that the guidelines in this box provide only a "down and dirty" summary of NPO times. In order to fully understand the ASA recommendations for pre-operative fasting, you must read the entire monograph (1). These guidelines apply to healthy patients of all ages, who are having elective procedures. Healthy patients are those with an ASA I physical classification (2), and include those who are neither very young (newborns) nor very old (advanced age) with good exercise tolerance and no organic, physiologic, or psychiatric disturbances. (2) Unfortunately, this excludes the majority of our population here in the United States. An overwhelming majority of my patients are morbidly obese, who by definition have a body mass index (BMI) of greater than 40 kilograms per meter squared, or a BMI of 35 kg/m2 with concomitant obesity-related conditions, such as hypertension or diabetes. (3) To help put morbid obesity into perspective, a normal BMI is 20-25 kg/m2. Morbidly obese patients are NOT healthy, even if they haven't yet developed high blood pressure or diabetes yet, and they all warrant an ASA III physical class designation in my book. An ASA III is a person who is functionally limited by one or more severe systemic diseases, which is not immediately life-threatening.  These are patients with morbid obesity, a prior history of heart attack or chest pain that is stable, poorly controlled high blood pressure or diabetes without end organ failure, chronic renal failure, and controlled COPD or congestive heart failure. (2)
     Moving right along, these pre-operative fasting guidelines "are not intended for women in labor"; parturients are an entirely different breed of patient. When you have a laboring patient, there are two people you have to worry about: mom and baby. I assign most pregnant patients an ASA II physical status; if they have a pregnancy-related condition with severe systemic effects, such as pre-eclampsia, or if they abused tobacco, alcohol, or other drugs during the pregnancy, or were morbidly obese pre-pregnancy, they get a III. An ASA II is a patient with no functional limitations from a mild systemic disease, such as those who are overweight or mildly obese, smokers without COPD, controlled high blood pressure or diabetes, and pregnancy. (2) That's right, pregnancy IS a disease! Pregnancy is accompanied by a whole slew of physiologic derangements, not the least of which is altered gastric motility and delayed gastric emptying. Virtually every organ system, including the woman's airway anatomy, is affected by pregnancy. These patients represent a unique challenge to anesthesiologists and anesthesia providers because they are highly prone to aspiration under general anesthesia.This is why we use regional anesthesia, such as spinals and epidurals, for laboring patients who require C-sections.
     Now for the kicker, the part of the guidelines which is often conveniently ignored by both anesthesiologists and surgeons alike, the two considerations which, for some reason, are not listed in the box above. To reiterate, these NPO guidelines specify healthy patients, undergoing elective procedures. Common sense dictates that patients with co-morbidities, especially those known to be associated with neurological or mechanical delays in gastric emptying or altered sphincter tone, such as diabetes or a prior history of gastric or esophageal surgery, as well as patients who have difficulty swallowing or gastro-esophageal reflux disease or any patient where there is concern about a difficult airway, necessitate additional consideration. For patients affected by these conditions, the guidelines recommend longer NPO times, e.g. eight hours or more. (1) Additionally, the ASA consensus panel strongly agrees that meals consisting of solid foods which contain meat or are fried or fatty warrant eight hours or  more of pre-operative NPO time. (1)
     I cannot tell you how many times I have questioned patients about when they last ate, only to find that he or she consumed a piece of Grandma's fried chicken or a bacon-sausage-egg biscuit or a couple of doughnuts six hours or less before their scheduled procedures. For me, that's a deal-breaker, and the surgery will be postponed. The ASA guidelines were written by a panel of experts for a reason: to protect our patients from the risk of aspiration which is inherent in every anesthetic. Paying attention to the guidelines is more about doing what is right for our patients, and less so about covering our asses.
     In general, most of us adhere to these guidelines pretty tightly; others, not so much. For instance, I've heard of colleagues who are quoted as saying, "Down here in the South, a doughnut and a glass of milk are clear liquids." I certainly hope they are only joking. On the other end of the spectrum, I've been accused of being too rigid with these guidelines, despite the fact that, in almost 7 years of practice, I have rarely had to cancel a case for insufficient NPO status. Here's a scenario to consider. A two year old child has a lower-extremity abscess that needs to be drained. The child is playful, not acutely ill or toxic-looking, meaning that the surgery is semi-urgent, or closer to being elective than emergent. Because of the fact that the child is only two, and will not likely tolerate incision and drainage of the abscess at the bedside, he will need a general anesthetic. You learn that the child consumed a chicken biscuit 5 1/2 hours ago. As an anesthesiologist or anesthesia provider, what would you do? If you were the child's parent, would you rather hear your anesthesiologist tell you, "Oh, he'll be fine. We're close enough. Let's just proceed with the case." or "Why don't we give that chicken biscuit a couple more hours to fully digest before we put little Tommy 'to sleep'?" Judgment calls can be a bitch, and that's part of what makes being an anesthesiologist so stressful. Some of us are comfortable, flying by the seats of our pants. Through either the mystical power of clairvoyance or more probably, sheer dumb luck, there are those among us who seem able to "cut corners" without experiencing a bad anesthetic outcome. I'm not there yet, nor do I ever intend to be. I'm a big fan of the age-old, tried-and-true axiom: "An ounce of prevention is worth a pound of cure." Why would I want to play with fire where a human life is at stake? My Mom always told me, "It's better to be safe than sorry!"and although I hate to admit it, this is one piece of advice where I'm pretty darn sure she's right.
ASA Practice Guidelines for Preoperative Fasting
ASA Physical Classification System
What is Morbid Obesity?

Sunday, December 25, 2011

Merry Christmas AND Happy Holidays...It's All Good!

     On Christmas Eve, Nick and his girlfriend, Haley, Rory, Brad, and I celebrated our Christmas together. We're a mixed crowd of vegetarians and meat-eaters, so I ordered a mini Honey-Baked ham, and then spent the rest of of the day preparing simple, yet exotic vegan and vegetarian dishes. Our  menu included a salad of roasted kale with toasted coconut chips, dressed with  nama shoyu vinaigrette;  Gruyere-topped mushroom-wild rice casserole; Spanish piquillo peppers, stuffed with a garlicky puree of cannelini beans, kissed with a splash of good sherry vinegar; a warm fingerling potato salad with roasted broccolini and chopped eggs in a red wine-mustard sauce; a gingery, peppery stir-fry of tempeh and cauliflower rice. For dessert, there was vegan sweet potato brazil nut crunch pie, which was out of this world! In all, it was a stunningly colorful, earthy, tasty feast, designed to please all palates. As my husband, Brad, aptly put it, "There's a lot of different flavors going on here!"
     Nick works at Return to Eden, a natural foods store in Atlanta. Most of the people who work there are in the under 40 crowd, and seem pretty committed to living a healthy lifestyle through thoughtful nutritional choices, yoga, meditation, etc. I guess you could say there is a likemindedness among Nick and his coworkers. Because he has to stock the freezers sometimes, Nick wears an old Mexican-style hoodie that my sister, Emi, gave him a while back, in order to keep warm. When he showed up to work with that hoodie, his boss laughingly teased him, saying, "Nick, 1994 called and it wants its hoodie back!" There is a stigma associated with certain types of attire, and the Mexican hoodie harkens back to the days of grunge. It was a time before cell phones, PCs, iPods and the Kardashians. It was a time when Generation X was expressing its disenchantment with society through groups like Mudhoney, Nirvana, Alice in Chains, Soundgarden, and Pearl Jam. I remember being excited back then, thinking we were on a verge of a cultural revolution, a time of progressive thinking, a time of enlightenment.
     It is now almost 2012, and I have never seen American society as polarized as we are of late. We are still reeling from September 11th, and the xenophobia is palpable, more rampant than ever. We have divided ourselves into the 99% and the 1%. Occupy Wall Street continues in full force, and you're pretty much for or against the movement. If you support OWS, you're either a lazy, entitled, poor excuse for a human being, or you're someone who's fighting for civil and cultural equality and basic human rights, depending on which social order lens you're using. We're at a strange impasse politically, with a cartoonish group of Republicans and Tea Partiers, vying for the 2012 election against Obama, who stands alone. People are cranky and unhappy and becoming increasingly critical of people and groups whose ideas they don't care to understand, and much of the vitriole seems to be fear-based in origin. I think about how my father came to this country in 1956 to live his dream, and wonder exactly what it was like for him as a new immigrant. I sometimes find myself wishing it was still 1994.
     Nick told us he recently had a woman customer, who inquired snottily while eyeing his Mexican hoodie, "Do you say 'Merry Christmas' or do you say 'Happy Holidays'?" In his usual low key, respectful manner, he replied "I don't have a problem with 'Merry Christmas', but I don't see anything wrong with 'Happy Holidays', either." For some reason, our society become especially divided about Christmas this year. Most notably, we've endured the white Coca-Cola can debacle, a campaign intended to raise awareness about polar bears, which triggered public outrage, presumably because changing the iconic red Santa can was perceived by some as an attempt to pander to other religious groups, such as Jews and Hindus. Some consumers even reported that the Coke in the white cans "tastes different." Honestly, I don't drink Coke, so it really doesn't matter to me. But, I do believe that society at large is placing too much value on symbols, on things, that are meaningless in and of themselves. The formula for Coca Cola hasn't changed, and isn't it what's on the inside of the can that counts? Who cares if the can is white or red? And for that matter, what does it really matter whether someone wishes you Merry Christmas or Happy Holidays; isn't it the thoughtful gesture of well-wishing that's important? Without going into detail about how the Christian, Jewish, and Islamic faiths borrowed their traditions and stories from the Vedics, there is a reason for the season, and the reason is this: peace on Earth and good will toward humankind. My Christmas wish for our society is that we will spend less time this year fretting about how we're different, and more time reflecting on how we're alike: we are all human, and we are all eternally interconnected through a force none of us really understands. Peace out, man, it's all good!

Saturday, December 24, 2011

Braised Veal and Bug Spray

     In our third year of medical school, my girlfriend Rana and I developed a sister-like bond, drawn together by a mutual love of food and cooking. We spent hours talking about fabulous meals we'd created for our families in the past, as well as exchanging tips and techniques, such as the proper way to prepare risotto. To produce a good risotto, you first pan-toast the arborio grains in a little olive oil. You should already have several cups of stock, barely at the simmer, so that once the rice is toasted, you can begin incorporating the hot stock, a cupful at a time, stirring continuously until the liquid is almost completely absorbed. You then add another cup of stock, stirring again, and repeating until most of it has been used. When you have perfectly al dente rice suspended in a deliciously creamy sauce, the risotto is finished, and you can then sprinkle in a handful of freshly grated Parmesan cheese. Rana introduced me to the wonders of parmigianno reggiano, which adds salty tanginess to a risotto, and is also delicious on its own, with a few drops of excellent quality aged balsamic vinegar. Since most of our conversations centered around food, we decided to inaugurate her kitchen by throwing a little dinner party at her house.
     Rana was renting an old Craftsman-style bungalow at the corner of Euclid Avenue and Vineville Street in Macon, GA. It was a lovely house, with sturdy walls, hardwood floors throughout, and a big front sitting porch. It had three bedrooms, one of which housed her grand piano, two large tiled bathrooms, an attic and a basement. The bathroom in Rana's room had an inner door handle that frequently came off the moment you stepped inside, and you were pretty much stuck in there until someone noticed you were missing and came to let you out. To me, though, the best part of Rana's house was her kitchen. It wasn't all that modern or updated, but she had a gas stove top, and several large Le Creuset Dutch ovens, which were perfect for slowly braising tough cuts of meat. Her cookware was well-seasoned from years of caramelizing meat and onions, and each faintly perfumed browned remnant, clinging to the bottom of her enamel-coated cast iron pots, revealed a sensual glimpse of all of the fragrant dishes she'd ever created.
     Our dinner party menu included osso bucco and risotto, and I think I brought a pavlova for dessert. A pavlova is an Australian confection, named after the Russian ballet dancer, Anna Pavlova, and although it looks impressive, it is really quite easy to make. You start with a classic French meringue, made by whipping egg whites and sugar to stiff, glossy peaks. The egg whites need to be at room temperature to achieve the best volume, a task which can quickly be accomplished by placing the eggs in a bowl of warm water while you are gathering the rest of your your supplies. Your bowls, utensils, and beaters also have to be absolutely free of any traces of fat, or you'll end up with a sad, deflated goo. You whip the egg whites, salt, and cream of tartar at low speed until the mixture resembles a thick foam, at which point you begin adding sugar by the tablespoonful, along with vanilla, a bit of cornstarch, and a splash of vinegar, increasing the speed until it has coalesced into a uniform, pristinely white amalgam that holds its shape as the beaters are lifted from the bowl . You then mound the silky mixture into a circle on a parchment-lined baking sheet, and bake at the lowest oven temperature until the shell is crispy on the outside, but still creamy inside. Finally, you fill the delicate, airy shell with fresh fruit, such as kiwi, strawberries, and peaches, and top it with a generous dollop of sweetened whipped cream. Truly elegant in its simplicity, the dessert can be made a day or two in advance, as long as the ambient humidity is low, and assembled just before serving.
     When Jim, the boys, and I arrived at Rana's house, she had already finished searing the veal shanks and browning the vegetables for the osso bucco, which was happily simmering away in a giant blue Dutch oven. A Miles Davis CD was playing in the background, and the atmosphere was casual and relaxed. We snacked on olives, sopressata, and Brie, spread thickly on good crusty baguette, and she introduced us to Alice White Chardonnay. Back then, big oaky Chardonnays were standard, yet this wine was pleasantly crisp and light, making it dangerously drinkable; at $5 a bottle, it was a sound value for poor foodies like us. Nick and Rory, who were 9 years old, had gorged themselves on cheese and Coca-Cola, after which they became a little restless, and asked if they could explore Rana's attic. The attic stairwell adjoined the kitchen, and she invited them to go up to have a look, while the three of us continued chatting and getting dinner ready. We took turns, stirring the risotto and putting a salad together, inhaling the rich aroma from the veal braising on the stove. Rana had two sons, Gian Carlo and Christian, who were both young adults, and she entertained us with stories about funny things they did when they were small. Gian Carlo was a musician, an excellent drummer, and he was living in Atlanta with his father. Christian, I believe, was in the Navy, stationed out of state; he later became a top gun pilot.
     Soon, the boys came down from the attic, and now, they wanted to watch TV. Rana's television was back in her bedroom, and she settled them on her king-sized bed, which had lots of big, downy pillows. The bedroom quickly became Nick and Rory's favorite place in her house, and after we left that night, Rana found a sweet little note on her nightstand, in which the boys thanked her for dinner. This note-writing became a tradition, and Rana saved several of them for me to keep.
     The osso bucco was nearly ready, gloriously tender and falling off the bone, but the risotto still had a little cooking time left. We were in the moment, enjoying the visual and olfactory beauty of our feast in its various states of readiness, mutually pleased that the boys were content and quiet, watching cartoons in Rana's bedroom. There were no time constraints and no sense of urgency: we were thoroughly relishing the process of a meal in progress. As we stood around, sipping our Alice White and nibbling on olives, all three of us became acutely aware of a strange odor which seemed to be wafting into the kitchen from somewhere else in the house. It was an acrid, overpowering smell, the kind that burns the insides of your nostrils, provoking an instant wave of nausea. We thought maybe there was a gas leak. Jim went back to the bedroom to check on the boys, and they were nowhere to be found. We split up, calling into the attic, although none of us had seen them come into the kitchen to go back up there, while frantically checking the other bedrooms, the front porch, and the backyard. Except for Miles Davis, the house was eerily silent, and we were getting more worried by the minute. Where could Nick and Rory possibly have gone? Our search efforts exhausted, Rana and I met back up in the kitchen, which was now completely enveloped in a blanket of caustic fumes. After a few moments, we heard heavy footsteps, which sounded like they were coming from under the house. In our panic, we had completely forgotten about the basement. We ran back to the hallway, where Jim was emerging from the basement with Nick and Rory. They had slipped, unnoticed, out of her bedroom to do some more exploring, and had discovered the door to the basement. One of their favorite cartoons featured a bespectacled boy named Dexter, who had a secret laboratory, where he mixed potions and invented all sorts of interesting things, and Rana's basement served as a perfect spot for Nick and Rory to enact some of his experiments. When Jim found them, they were industriously emptying and pouring liquids back and forth from several brown glass bottles, one of which happened to be a very old vintage of malathion, an insecticide typically used to get rid of mosquitos. They were like two tow-headed mad scientists on the brink of a ground-breaking discovery, and they were having a grand old time. Alarmed and concerned about organophosphate poisoning, Jim rushed them back upstairs, where we scrubbed their hands and monitored them for evidence of parasympathetic signs and symptoms. They were fine, but I think their egos were a little bruised after having their lab busted up.
     We opened all the doors and windows to air out the house, and somehow, we managed to enjoy our dinner amidst the noxious cloud, redolent of braised veal and bug spray. Jim and I were terribly embarrassed about what the boys had done. Rana, in her usual perfect form, remained gracious and accommodating, showering the boys with hugs before we left that evening, and inviting us to come again soon. It took months for the malathion smell to dissipate completely. Over the years, Rana and I have cooked many memorable meals together, but that disastrous first dinner party remains our all-time favorite. Rana later confided to us that she never saw another bug in that house again. Perhaps the boys' ill-fated experiment had been a success after all, simultaneously driving all the bugs away while solidifying the foundation of our friendship, one which is built on the joy of cooking for the people we love.

Friday, December 23, 2011

A Bitter Pill to Swallow

     Prednisone makes me absolutely psychotic. I'm not just talking about being antsy or jittery; when I take prednisone, I transform into a full on, super-charged nutcase. It's insidious, because at first, I experience a profound sense of well-being, which then deteriorates into a rapid-fire flight-of-ideas, culminating finally in extreme paranoia and inexplicably irrational behavior. I'm guessing it's a pretty uncommon phenomenon, based on the number of patients I see every day who are taking prednisone without ill effects. Anesthesiologists frequently hear patients reporting that they are "allergic" to epinephrine and steroids. This kind of thing usually causes our eyes to roll back in our heads because it's so absurd: how can you have an allergy to  catecholamines and hormones when your own body produces them? Even so, my reaction to prednisone is as close as it gets to being allergic.
     The first time I took prednisone was somewhere around the second week after I started medical school. In a supreme moment of stupidity, I herniated my L5-S1 disc by trying to force open our electric garage door. I came home from school, and was mad because I couldn't get into the garage. The clicky-thing that was clipped to the visor in my minivan wasn't working, so I entered the house through the front door, ran downstairs to the garage, and tried to open it using the wall switch, but that didn't work, either. It was another annoying thing to have to worry about, and I knew that replacing the motor for the door was going to be expensive. Fuming, I walked back down to the driveway and commenced trying to lift that door myself. Assuming a position like a world champion power lifter, I squatted deeply with my back straight, grabbed the door's handles, and with a simultaneous groan and Valsalva maneuver, attempted to curl the 250 pound door straight up. Within a millisecond, I was visited by the most excruciating pain you can imagine. I couldn't straighten myself up, and I had to hobble up the stairs to get back into the house. Initially, I thought it was just a pulled muscle, and tried taking some ibuprofen, but the pain in my back was severe and it persisted for several days. Sitting through class was unbearable, and after a couple of days, I went to see the doctor. He put me on a two week Medrol dose pack (prednisolone, which is converted to prednisone in the gastrointestinal tract) and sent me home. After only a couple of doses, my thoughts began to race, and I started thinking my husband was plotting against me. It was hard to sleep, and I'd get up after a couple of hours in bed to raid the refrigerator. I consumed massive amounts of large curd cottage cheese, sprinkled heavily with salt. Although it was 1997, and the world wide web was still in its nascence, I managed to find a website which sold religious icons and figurines, and loaded up my shopping cart with several Jesuses and Marys. I didn't realize what had happened to me until I tapered off the prednisolone, and things went back to normal. It was as if I had just stepped off of Mr. Toad's Wild Ride.
     Fast forward to September 2006,  and I am now an anesthesiology attending at Emory University, getting ready to take my oral board exam. Nick and Rory had turned 16 years old in July, and now they were driving an old white Volvo 940 station wagon every day to school. That car was a veritable tank, and probably could have withstood a nuclear attack. I bought it used, and my intuition told me that not even a teenager would be inclined to gun that engine and go speeding down Henderson Mill Road; it just wasn't that kind of a ride. In order to get to school, the boys had to make a left turn from our street onto the main road. It was a scary left turn because the house on the corner lot had a fence facing the main road which was massively overgrown with tall, bushy vines, completely obscuring the view of oncoming traffic coming around the 50 ft curve. When I bought my house in 2005, I had noticed how treacherous that left turn was, and tried to get Dekalb County to come and cut those vines back, but they would only trim them to within 5 feet of the curb. This was not adequate for viewing or anticipating traffic. Once the boys started learning to drive, the vines remained a serious issue, so I approached the homeowner about it. She was an elderly lady who was sick with Alzheimer's. Apparently, her husband used to keep the bushes and vines trimmed, but he had died several months ago, and now, she was alone. I asked her if it would be OK for me to have my yard guy come and trim the overgrowth, but she deferred to her daughter on that issue. Her daughter happened to be there, so I politely, but assertively, expressed my concerns, explaining that the overgrown vines were preventing the boys and me from being able to safely negotiate the left turn. She immediately became defensive, telling me that the entire neighborhood, most of which I'd never even met, thought I was crazy and then, complaining about how loud the boys played their guitars in the afternoons. She was really dreadful, and it was evident that she was going to be of little help. I was exasperated with her for being so unreasonable; after all, I had offered to pay my yard guy to do the work in her yard! I had worried about those vines long enough, and I decided to take matters into my own hands.
     The following Saturday, I got up early, before it was light outside, armed myself with hedge clippers and pruning shears, and walked over to the old lady's fence to begin lopping off those vines. This generated some interest in passers-by out on their daily walks. I was doing mortal combat with bushes and vines in some else's yard, and I was taking no prisoners. I felled one long skinny branch after another with my clippers, hurling them like javelins up and over the fence, into the adjacent yard. I was on a mission, and I felt I had done everything I could do to rectify the situation before resorting to such extreme measures. The sun was starting to shine, and I became aware of a rustling noise on the other side of the fence. Thinking it was the old lady's daughter coming to confront me, I crouched behind a bush, phoned Nick, and told him to come and pick me up across the street. I gathered up all my equipment, and made a run for it. From the corner of my eye, I could see an elderly Asian man, standing on the sidewalk on the other side of the street, watching me with an amused expression. I sat down on the curb, waiting for Nick while surveying my handiwork, and unfortunately, I had hardly made a dent. The rustling noise ended up being a real estate agent, who was coming to place her sign on the street corner: the old lady's house was up for sale.
      That evening, I developed an itchy red rash, which I thought was poison ivy. It was all over my arms and legs, and it looked horrible. I tried Benadryl and calamine and hydrocortisone cream, but the itching persisted and soon, I was clawing at my skin. I could hardly concentrate at work because the itching was so bad, so I called the dermatology clinic and got an appointment that afternoon. The dermatologist was impressed with the severity of my reaction, and based on the serpentine pattern of the welts, he determined it was calcium oxalate-induced dermatitis, not poison ivy. I had never heard of this before, but certain vines and plants, like daffodils, contain needle-like calcium oxalate crystals, which can lodge beneath the skin, causing profuse itching. He put me on a very high dose of prednisone for two weeks, and the timing couldn't have been worse. I was flying to San Diego in a couple of days to take my oral boards. Predictably, after the first day on prednisone, I was bouncing off the walls, and by the time I got to San Diego, I was crazy as a loon. I slept only one or two hours every night for the few days I was in my hotel room, not because I was studying, but because I was steeping in steroid-induced psychedelia. Somehow, I managed to pass my oral board exam. I hardly remember anything about about San Diego, the boards, or the trip Nick, Rory, and I took to Toronto for my cousin's wedding the following week.
     Yesterday, I had the day off from work, and I spent the early part of the morning getting our Christmas tree decorated and planning the menu for Christmas Eve dinner. It's been a down-to-the-wire kind of holiday for me, and I was determined to cross those two things off my list, no matter what.  I've felt kind of Grinchy this year, but that's a whole other story; no wait, that's actually a book. As I was wrapping the last of the Christmas gifts, a job I don't particularly care for, I carelessly bent over at the waist to pick up a big package. I felt my back tighten protectively, so I adjusted my posture and kept working. That sensation in my back always makes me think about being laid up in bed after herniating my disc, tripping on prednisone, and it occurred to me that there's a freaky causal relationship between my sometimes self-destructive sense of determination and the subsequent need for prednisone. The sense of urgency I felt about the garage door that was stuck and the overgrown bushes in the neighbor's yard blind-sighted me, and I ended up in worse shape than I was before. Now that I'm nearing 50, my perception of what's truly urgent in life has changed drastically, and I spend a lot less energy reacting foolishly to life's little challenges. I'm happy to report that I've been prednisone-free for the last 8 years. It appears that what I'm really allergic to has been my own stupidity in situations where I have no control, and that's an even more bitter pill to swallow.

Thursday, December 22, 2011

Last Tango with the Virgin Mary

     I started medical school at the age of 34, in August of 1997. Nick and Rory had just turned seven, and their father, Jim, and I had re-married one another a few months earlier. We moved from Marietta to Macon, GA, which is where Mercer University School of Medicine is located, and bought a comfortable house with a big yard, in a neighborhood that had a pool and lots of kids running around outside. Our move took place in June, so the boys and I got to enjoy the summer together before I started school. We went to the pool every afternoon. They took swimming lessons in the morning, and we'd return after eating lunch later in the day, just to have fun. There was usually a lifeguard present, often a kid from the local high school, and there was always really good alternative music playing on the radio in the concession area. Macon is hot, like a sweaty armpit, in the summertime and that pool was a real godsend. Our neighborhood had a loosely organized association of elected officials who ensured that pool dues were collected and the property was maintained. That particular summer, the group's president happened to be Violet Grover*, an unpleasant, leathery-skinned older lady who was a terrible gossip. I honestly don't know how she got elected. She would come to the pool everyday, in her frumpy one-piece bathing suit with its little attached skirt. Violet never wore sunscreen, and she would sit on her lounge chair throne, indiscreetly criticizing everyone who walked through the gate to the unlucky person sitting next to her. You really had to mind your p's and q's around her, because she had the power to determine who was "in" and who was "out" with regard to the pool: she was the Pool Nazi. I used to bring a little cooler to the pool, filled with juice boxes and snacks for the boys, and sometimes, I'd throw in a couple of cans of beer, which I concealed with a koozy to prevent Violet from seeing the labels. She was the eyes and ears of our neighborhood, and you definitely wanted to fly well beneath her radar.
     In no time, the boys made friends with many of the kids who frequented the pool. One day, a pretty woman who looked to be about my age, showed up with her children, and she and I began to chat. Her name was Wendy, and her daughter, Ashton, was one year older than Nick and Rory. I learned they would be attending the same school together. Her son, Little Todd, was probably about three years old, and he was a real pistol, his insolence often precipitating a visit to his rump from the dreaded Mr. Spoon. The kids all had a blast playing with each other, and it was nice to have an adult to talk to. We learned that we had much in common, namely the fact that we'd both grown up in very large Catholic families.
     I moved to the South in the seventh grade, and quickly learned that down here, many folks don't consider Catholics to be Christians. The only boyfriend I had in high school was a guy I dated my senior year, and he was a Baptist. We got into a ridiculous argument right right before Christmas about whether or not Catholics worshipped the Virgin Mary, and I quickly discovered that trying to reason with him was an exercise in futility. He gave me a crappy bottle of Avon Sweet Honesty spray cologne for Christmas, and then, I found out he was cheating on me with another girl in our class. What a jerk! Anyhow, Wendy and I became good friends, and when I started medical school at the end of the summer, the boys would ride the bus home with Ashton, and Wendy would keep them for me until I returned home in the late afternoon.
     In medical school, I became friends with a guy named Matt, who had been in the Peace Corps in Benin, Africa, and he impressed me as being very altruistic. I don't remember if he was religious or not, but I perceived him in that light. His tales of helping people in the African village to which he was assigned made me think of Mother Teresa for some reason, and it got me thinking about my own family's religious non-situation. My parents had taken Nick and Rory to Mass with them in the past, but it was not a regular thing. My mother converted to Catholicism after marrying my father, who was a Polish Catholic, and I think she enjoyed going to Mass a lot more than he did. When my younger brothers were small and we lived in Kansas, Dad would stay home with them, building them giant towers out of colored blocks, while my sister, Emi, and I got stuck going to catechism class and Mass with Mom. We were pretty jealous that the boys got to stay home with Dad and build stuff with blocks. Our family went to Mass on vacation, and on holy days, and I swear, it seemed like a new holy day was invented every single week. Neither Jim nor I were religious, despite his Episcopal and my Catholic upbringing, and I guess you could classify us as borderline agnostics. He had studied philosophy at Emory University, and I think he may have actually read the Bible from cover to cover. We used to have some of the most amazing conversations about world religions, and I think both of us felt that, intellectually and intuitively, the teachings of Taoism or Buddhism most closely approximated our spiritual roadmaps. We both knew people who had been damaged by organized religion, and wanted to protect Nick and Rory from a forced system of beliefs.     
     After I met Wendy, I decided to give church another try. At the time, I thought this was a good idea; I was re-defining myself as a budding physician, and I remember thinking that being a church-goer would help me feel more grown up and professional. I also thought it might benefit Nick and Rory to have some formal exposure to religion. Jim declined to attend Mass with us, except for the boys' First Communion, but was overall supportive of my decision. I did enjoy getting to hang out with Wendy in the adult catechism class, which was held before Mass, but found some of the other people in that group a little frightening. There were several converts from various Christian fundamentalist religions participating in the class, and these folks were extremely literal in their interpretation of the Scripture, especially the part about women being subservient to their husbands. I had never really studied the Bible. When I made my First Holy Communion in second grade, I received a children's Bible that had graphic illustrations, and when I got to the story about Abraham and Isaac, I was mortified. The picture showed a boy tied to a rock, with his father holding a big knife over his belly, ready to sacrifice him. After that, I wasn't too keen on Bible stories.
     One of the men in our group was an old codger named Frank, who still lived with his mother. He was a Macon historian, and he gave off an "I'm-intellectually-superior-to-you" vibe, just because he'd had a book published at some point in his career. It was anti-abortion week, and that was going to be the topic of our group discussion. Just before class started, one of the women in group confided in me that she'd had an abortion many years back. She still felt guilty about it, and was looking for absolution. We sat next to each other, and I thought about how tough that decision must have been for her, even though I didn't know anything about her circumstances at the time. Somehow, Frank ended up hijacking the discussion, launching into a tirade about how he thought women who had abortions should still be publicly stoned. He was dead serious, and the room got very quiet. All I could think about was the woman sitting next to me, and how horrible that must have made her feel. I felt disgusted by him, and started questioning just why I had decided to go back to church in the first place. That same morning, the boys were in their catechism class, where their assignment had been to decorate folders in which to contain their classwork. After my class disbanded, they came running up to me, proudly holding out their folders, exclaiming "Mommy, Mommy! LOOK!" On each of the white folders, the boys had drawn a picture of Jesus on the cross. Jesus was saying "Help!" and around His cross were several Chinese yin-yang symbols. In Rory's drawing, a spaceship also hovered nearby. Apparently, one little boy in the class found their artwork blasphemous, and immediately informed them that they were going to hell. The next and last time we went to Mass was in 2003, to attend my father's funeral.
     Yesterday, as I was exercising, I listened to "All Things Considered" on NPR, and heard an interesting piece about how people who are religious report being happier in their lives than those who aren't. The author, Eric Weiner, who considers himself spiritual, but not religious, described how he had traveled the world, meeting people from all types of faiths. In surveying them, he learned that the people who approached their faith with questions, instead of seeking answers, tended to have the most deeply gratifying religious experiences. They pray, they meditate, and they are OK living with doubt and uncertainty. He concluded the story by saying, "I don't care what you believe. What do you experience?"
     I still have Nick and Rory's Jesus/yin-yang folders, and I still love looking at them. While I sat in  religion class, listening to a pillar of the community condemn women for exercising their legal right to abortion, my eight year old kids, who'd had no prior religious exposure, effortlessly distilled the mysticism of both Eastern and Western thought into two simple drawings. Although their drawings are childish and primitive, they convey an intuitive grasp of the concepts of spirituality and compassion, an aspect of faith which I believe we only experience by questioning everything, learning something, and answering nothing.**

*first two consonants of last name changed
**original quote borrowed from Euripides
All Things Considered: A Quest to Seek the Sublime in the Spiritual
Euripides: Question Everything. Learn Something. Answer Nothing.

Rory's Catechism Folder, 1998

Nick's Catechism Folder, 1998
A self-portrait I painted in 1988 of me in my First Communion dress & veil

Wednesday, December 21, 2011

Ordinary Moms

          Our loft is finally beginning to look like Christmas. The UPS man delivered our new fake tree today while I was at work. Steve, the guy who runs the nutrition store below us, receives our packages when we're not at home, and he had 4 large boxes waiting for me. We loaded everything up on his handtruck, and dumped it all off in the foyer. After I finished a good sweaty workout, I carried the 40 pound boxed tree upstairs, and began the two hour process of assembling it. The tree that was supposed to have gone up the night before last, the one that was missing its stand when we took it out of the box, for which Nan from Lowe's found a replacement stand and only charged us two dollars, experienced a permanent fatal error. One strand of lights just wouldn't work. We replaced fuses and mini fuses and finally, changed out every single light in that damn strand, and still nothing. It was so disappointing. I considered running over to Michael's to get a couple of strings of lights to weave through the tree, but just couldn't gather the energy to deal with the holiday rush I knew awaited me in there. So, I went online and ordered another tree, paying $64.99 extra for two day shipping. It's always something.
     I collect Santa Clauses, and this afternoon, I set them all out on top of my piano. There are probably about 75 of them; some are round, some are tall, some are whimsical, and one of them is riding a unicycle. It's the one my sister, Emi, gave me many years ago, when our boys were all tiny tots. Although I'm two years older than she is, she got married four months before I did, and had her first child three months before my boys were born; she was sort of a trailblazer. It was amazing to watch her breastfeeding Alex, and I couldn't wait for my own twin boys to arrive.
     A few months later, the boys did arrive, and they were eight weeks premature. I had gone into preterm labor, the result of Listeria sepsis, a type of food-borne illness that can cause devastating meningitis in newborns. Luckily, the boys didn't suffer that complication, but they did end up on ventilators because their lungs were immature. Nick and Rory stayed in the NICU for several weeks. They were receiving breast milk and Pregestimil though a feeding tube, but they were both failing to thrive. Nick's poop turned white, precipitating a surgical consult and discussion of a liver transplant for presumed biliary atresia. Naturally, my husband and I were terrified.  Several days later, Nick underwent an operative cholangiogram, and afterward, we were told he probably had cystic fibrosis. The boys were sweat-tested once they reached eight pounds, and both were diagnosed with CF on Halloween of 1990, when they were just three months old.
     The next couple of months were exhausting. The boys were always hungry, and I nursed them every two hours. We had to feed them pancreatic enzymes mixed in rice cereal to help them digest my breast milk. They cried incessantly and didn't sleep through the night. Sometimes, I really thought I was going crazy. I would put them down for a nap in the afternoons, and then I would fix myself a giant bowl of peppermint ice cream with hot fudge sauce and marshmallow topping. I'd  sit on the carpet, watch soap operas and cry. I felt sorry for myself, and it all just seemed so unfair. More than anything else, I had wanted to be someone's mom. I was ecstatic when I found out I was pregnant, especially because Emi was also pregnant. We read "What To Expect When You're Expecting" together and compared notes. I went to her baby shower, and she organized one for me. When Nick and Rory were still in the NICU, I would watch with envy as she nursed Alex, a big chunky toddler of an infant who weighed 10 pounds 4 ounces at birth. When the boys finally came home, Emi would bring Alex over, and we'd sit on a quilt on the floor, feeding and playing with all three of them, as if we were ordinary moms, and I'd marvel at how giant Alex seemed in comparison to my tiny boys. I'd sometimes think guiltily to myself that Emi really had it easy.
      I have a vivid memory from that first Christmas, where I was trying to bake some cookies, and the boys just wouldn't stop crying. I had them, tummy down, on a big Danish modern sofa in the living room, right next to the kitchen, and I was trying to pipe icing onto gingerbread men while they napped. Their naps only seemed to last a few minutes, and in the midst of the cookie-decorating, they woke up, screaming. This was around the time "thirtysomething" was popular on TV. In my mind, I had this idea that life was supposed to be just like it was on that show, where all the characters had perfect, healthy children, and they had perfect yuppie lives. My own life seemed so abnormal. I wasn't doing normal "mommy" things; instead, I was feeding my kids pancreatic enzymes, giving them breathing treatments and doing "pitty pats" (chest percussion to loosen up the mucus in their lungs). Every day seemed like an insurmountable chore, and I was depressed. I was deeply afraid of outliving my own children. Attempting to comfort me, Mom used to tell me "By the time Nick and Rory turn eighteen, they won't cry like this anymore!", but I couldn't picture that day ever getting here. I had to get away from the crying for just a few moments. I checked to see that the boys were secured on the sofa with big pillows around them, and walked outside to the mailbox. In those days, walking to the mailbox was a pretty big deal; it was the only "me" time I had. I stood out there, breathing in the cold grey December air, trying to imagine what my life would be like on this same day, eighteen years in the future.
     Seeing Unicycle Santa reminded me of that Christmastime so long ago, when each day seemed eternal.  It is now 21 years later, and Nick and Rory have experienced remarkably good health. They both work, they both are excellent musicians, and they have wonderful, supportive friends and girlfriends who make sure they do their respiratory treatments and take their enzymes. They really aren't too much different from other young men, living life in the big city. Emi's boys are also grown up, and this is her first Christmas as an empty-nester. Reflecting back on the days when our boys were small, and Nick and Rory were so sick, I realize that Emi didn't have it easy at all. Not only was she a new mom taking care of Alex, she was doing everything she possibly could to give me moments where I felt like we were just two ordinary moms, enjoying our children together. Where I couldn't see the light at the end of the tunnel, she was there, leading the way.  What she gave me was the gift of her own hope, her vision of a future with a little bit of normalcy, and the courage to keep loving Nick and Rory by abandoning my fears and making life fun for them, by letting them be boys.