Sunday, December 30, 2012

Just Because

     In adherence with the anesthesia board re-certification process and maintenance of my medical license, I've been taking an online, self-study continuing medical education (CME) exam. In all honesty, I've been avoiding it for the last six months. Since the 30 hours of credit expire on December 31, 2012, and I've already paid $300 for the exam, I figured I may as well suck it up and get 'er done over the holidays. The questions range from absurdly easy ones like this (the answer is "Duh!"):


  Which of the following is most likely to occur in rhabdomyolysis?
  1. Hyperkalemia
  2. Metabolic alkalosis
  3. Hypercalcemia
  4. Hypophosphatemia

to redonkulously obscure ones like this (eliciting a head-scratching, hair-twisting "Huh?!"):

   In which of the following situations would a paired t-test be the MOST appropriate statistical test?
  1. Determining the neurologic outcome (graded as "intact," "neurologic compromise," or "dead") in patients with subarachnoid hemorrhage due to intracranial aneurysm
  2. The presence of headache following donation of autologous blood in 50 subjects, each of whom donates 2 units of blood--once with a fluid bolus and once without
  3. Heart rate change from baseline measured in the same individual given neostigmine with glycopyrrolate
  4. Blood pressure changes with propofol versus thiopental for induction of anesthesia in 1000 patients
    To obtain CME credit, I had to answer all 100 questions correctly. As much as I'd like to say I got them all right on my first attempt, I had to go back and reset the responses on more than just a few, after taking time to read through the scholarly discussion provided with each question. The discussions are actually pretty awesome. For me, doing lots of practice tests is the smartest way to study for a written exam. It's no secret that exams don't exclusively test knowledge: they measure how well you take a test. By studying a multitude of questions and answers, you gain an understanding of how they're structured, and even if you don't know the answer off the top of your head, you can usually eliminate at least two choices based on wording alone. "Always, " "only," and "never" are pretty reliable red flags. When you've got it narrowed down to two choices, but you're still unsure, an educated guess will typically produce the correct response. Wrong answers are usually A) the result of not reading the question or answers thoroughly OR reading too much into them, B) a knowledge deficit, C) failure to apply existing knowledge logically, or D) ignoring gut feelings and changing your original answer. Never change an answer unless you're absolutely sure you got it wrong! If you happen to guess wrong, the discussions provide a brief review of the basic science or clinical pathways involved, walking you through a dissection of each scenario so you can determine for yourself why there is only one BEST response. Before I'm even halfway through a discussion, it's already evident why the correct answer is cut and dried. 
    After finally getting through the exam, I re-read the questions, and the answers seemed so simple and straightforward.  None of the material was new to me: I've seen it all before. In fact, I knew it all like the back of my hand when I took my initial written and oral boards in 2006, so it's more like assimilated information that's on hiatus...gone, but not forgotten, absorbed and committed to what I consider an even loftier level of knowledge: intuition. Much of my decision-making in anesthesia practice has its basis in what feels right, which is also how I live my life. I've never been one of those who can recite studies or regurgitate factoids when I'm being pimped onstage, which is probably why I despise the Socratic method of teaching. Real life patients and scenarios aren't textbook. Rarely (if ever) cut and dried, an evolving situation is nuanced, complex, and dynamic in nature, and it won't stand still while you're busy crunching data. Relying solely on logic and reason is myopic at best, eliminating the very real possibility that sometimes, shit just happens. That's when you just have to trust your gut and act accordingly.
     What is it that we think we know and how do we know we know it? Where exactly do we get all of our facts? Aren't there things we know just because--instinctual, intuitive knowledge that defies explanation or justification? Is something spontaneous and fundamental lost in translation when we know that we know, when we start thinking about thinking? In continuity with the universe, we beat our own hearts and breathe our own breaths. We don't have to think about these processes, we just automatically do them: they are central to our existence. It's only when we start thinking about these things that we feel anxious. Self-awareness leaves us wondering if there's something we've missed, ignoring the obvious because we're driven to complicate what's basic and simple, effectively permitting minutiae to supersede experience itself. Does how and why we breathe really matter as long as we're spontaneously breathing? Can all questions be answered at a molecular level, and do our answers always warrant a defense? Although the mechanics and physiology of automaticity have been fully elucidated, they still fail to explain the basic question: what is it that makes our hearts beat in the first place? Why isn't "because we're alive" enough of an answer? It's when "just because" becomes unacceptable that we separate ourselves from nature, and become dispassionate observers, victimized by existence, instead of engaged participants who are too busy enjoying now to worry about what's going to happen next. Here's the thing. I am my body and my body is me. I'm marvelously self-contained, a symptom of nature, a unique expression of the cosmos. I am my existence, not a victim of it. I am just because.

Sunday, December 16, 2012

The Upside of Emptiness

     Naked and robustly feminine, libidinous and carefree, I wandered through a dreamscape of random yet intimate encounters--some sexual in nature--consolidating primal me, briefly merging and coming away absolutely galvanized, with no sense of shame or guilt. It was intensely familiar, a dream I'd never dreamed before, but remembered so well. Some dreams are as simple as reality.
     What kind of person do I think I am? How do I see myself? Ineffable. Wild at heart, with the heart of an artist. Fiercely non-cynical. Resilient. Irreverent. Courageous. Self-effacing. Unapologetically brilliant. Humbly accomplished...I've already lassoed the moon and coralled the stars, and now, I'm giving them back. Complexly simple. Deeply sensual. Love, personified. Happy that I still haven't turned into a boring old grown up. I'm a true original...the mold wasn't broken after me; I broke it myself.
     My mirror isn't selective, and it never lies. It reflects my image without bias, but when I step away, not only do I disappear, it's as if I'd never stood before it. It sees without filters, but remembers nothing. No preconceived notions, no self-criticism, no fear, no regrets. Perhaps that's the upside of emptiness, of having a mind like a sieve instead of a steel trap. Go, primal me.

--Inspired by last night's wonderful dream, and this aphorism by Marty Rubin aka nothingprofound: "Once upon a time there was a parrot that kept repeating 'happiness, happiness, happiness.' I am that parrot."

Saturday, December 8, 2012

Goodness, Deconstructed (As Good As It Gets)

     Last night, Spartacus and I attended a Christmas party thrown by the gastroenterology group I work with. Thanks to Atlanta's impossible traffic situation, we arrived an hour and fifteen minutes late to the feast already in progress, both of us starving after our grueling pre-party workouts. Had either of us anticipated that treacherous bottleneck on I-20 eastbound, I would've brought a few snacks for the road. Yeah, I get a little bitchy when I'm hungry. Relieved that we'd finally made it there after our harrowing backroad detour, we loaded up our plates, grabbed a glass of wine, and engaged in pleasant chatter with the folks sitting at our table. I couldn't help but notice that we all clean up very nicely. At work, we spend our days running around in non-descript, formless scrubs, so when I see colleagues dressed in their street clothes, it sometimes takes me a moment to recognize them. It was great seeing everyone so happy and relaxed. Women of all ages were wearing updos and party dresses and sequined sleeveless tops, some on the conservative side, some downright sexy, but they all shared one thing in common: a burning desire to shake their booties on the dance floor.  Needless to say, the air of dance-ticipation was pretty thick.
     As the dinner plates were cleared away, the DJ eased from mealtime muzak into disco, dance rock and good old country, the urgent question on everyone's minds being "Who's going to get up and boogie first?" Glancing about the room, I could see boyfriends and husbands--including my own--bracing themselves, hoping to ward off their respective dancing queens' attempts to drag them from the security of their chairs into the encroaching disco inferno. I assumed the hot young chicks in stilettos and satin mini dresses, priming themselves with shots of Cuervo over by the bar, would be the ones to get this party started. I'd been hearing legendary tales of their dancing prowess for the past several weeks, so I thought they were a safe bet. Surprisingly, and somewhat endearingly, the first rug-cutter was a young newlywed guy. Obviously obliviated and observedly oblivious, he wielded his Bud Light like a homing beacon, solitarily tripping the light fantastic for a few moments before being joined by his laughing bride. Their spontaneity and uncensored delight in one another set the tone for the evening. It wasn't long before a decent-sized--albeit mostly female--crowd accumulated, expertly kicking out The Electric Slide in unison. Hell, I even got out there and busted out a few of my trademark awkward-white-girl moves to Baby's Got Back, and I didn't even have to twist Spartacus's arm to slow dance with me during "Unchained Melody."
     We left shortly before the party ended, our post-prandial sleepiness a welcome promise of sweet, uninterrupted sleep to come. As we made the rounds, saying our goodbyes and thank yous, one of the nurses I work with pointed out an attractive young woman who was clearly enjoying herself on the dance floor. "See that girl? Her mama's one of our co-workers, and she's a real upright holy roller. She's gotta be cringing, watching her daughter dance like that!" The woman looked to be in her mid to late 20s. She was dressed modestly in a long-sleeved white sweater, slim black pants, and open-toed pumps, and although she was swaying energetically to the beat of the music, she certainly didn't appear to be trying to draw attention to herself. She was only having fun. "Good for her for getting out there and dancing!," I replied, supposing aloud that Mama probably believes Jesus didn't dance or drink wine, and then adding, "Morality is what happens when goodness has failed." My friend nodded, "Uh-huh," in agreement, but the perplexity furrowing her brow conveyed an ascending note of misapprehension. "How can goodness fail?"
     Perhaps the better question is what's so good about goodness? And, where do our ideas about goodness come from? From the moment we're born, our goodness is vigorously reinforced. Good boys don't cry. Good girls sit with their knees together.  Good babies sleep through the night; after all, children are best seen, but not heard. Are babies even capable of being good or bad? The easy answer is "no," but what if babies are true goodness personified? If morality is the by-product of faulty goodness, then what came before goodness, true or otherwise? Goodness, it seems, stems from desire. Newborns aren't desirous of attention when they cry, they're simply reacting to hunger or discomfort. They're just being. Through ongoing behavioral conditioning and reinforcement, babies eventually learn that certain cries will elicit predictable responses from their parents, heralding the genesis of self-awareness from which all goodness emanates. Because goodness seeks approval, it is never fully satisfied. Being somewhat of a micromanager, goodness wants what's right, but doesn't trust others to do the right thing. So, maybe goodness is what happens when we cease to be, when life's mysterious, marvelous flow is ignored in favor of duty, expectation, and control. Goodness, deconstructed, doesn't sound so good after all. Still, we're in love with the idea that true goodness exists, and that goodness is good.
     Much like the young woman dancing last night, true goodness doesn't call attention to itself. It just does its own thing. As I stood there watching her, I noticed another one of the nurses I work with, a preacher's wife, dancing alongside her. Aside from being gorgeous and bubbly, Crystal has a wicked sense of humor and a really firm grip on acceptance: she's one of the least judgmental people I've ever met. She's a genuine "live and let live" kind of gal, someone who doesn't pretend to holiness or piety. It was fun seeing the two of them getting their groove on. There's something so primal and spontaneous and human about dancing...even when it's bad, it's still pretty darn good. Goodness like that can't be improved upon. It's as good as it gets.

     Fast forward to 2:19 to see me, shakin' my groove thang...
     

Saturday, December 1, 2012

The More Of Less

     The sky's pink hue this morning is at once beautiful and unsettling, its radiance irritating me into a simmering inertia that refuses to budge, even after I've had my coffee. I am five years old again. For reasons unknown to me, my beloved red maple tree, the one that stood bravely among the blue spruces and elms and birches in our backyard, is being felled, and I am watching helplessly. The world seems just as crazy now as it did then, deluded by progress and productivity. Has the business of living killed the business of being alive?
     The less I work, the less I want to work. Coming from a physician, that's nothing short of blasphemy. After all, the moment I stepped into anatomy lab, I traded my personal life for a life of personal sacrifices, the clichéd "I am my work" axiom in which I've been assured that running on fumes somehow begets sensitivity and compassion, and that the reward for denying all of my own needs is the immense satisfaction that comes from tirelessly attending to the needs of others. One really has to question the ethos behind this flavor of altruism: it's more like a contagious societal disease.
     I see evidence of infection everywhere, from parents whose lives revolve around their children's sports to volunteers who can never say "no" to my own husband, who's averaging thirteen hour days at his networking job, containing the fallout of a security breach that occurred before he even accepted the position, sometimes going in to work at three o'clock in the morning and not returning until 7:30 at night. Many of his colleagues are working 20 hours a day. Yesterday afternoon, he noticed one of his co-workers, a brilliant senior systems architect, looking uncharacteristically dazed and disheveled, walking with a slight limp, and in desperate need of a bath. "Are you all right, man?," Spartacus asked him. "I've been up for 36 hours. I just got my third wind, so I'm feeling pretty good. I'm ready to go," the poor bastard answered, wearing his glassy-eyed funk proudly, like a badge of honor. A year ago, that was me.
     I'm surrendering to the more of less, sacrificing nothing for a return that's unquantifiable. Because work is no longer working me, I like my job again. Even though I work in a fast-paced ambulatory setting, the pressure to produce is offset by my overall change in perspective, sort of a happy medium. I feel like a consultant in anesthesia again, not a warm body. Maybe what I really mean to say is that the less I work, the less it feels like work. The sense of dread I used to wake up with has vanished. Now, there's plenty of room in my life to do the things I want to do. I actually have time for living. It's funny, because in talking with my physician friends, many of them seem to envy my downward mobility, viewing it as a bravely conducted rage against the machine. Sometimes, it takes a little rage to get the courage flowing. Like that red maple tree, I haven't always blended in with the crowd, but I don't live in fear of my demise. I've just found a way to fly under the radar.

     

Sunday, November 25, 2012

The World Became a "Yes"


     When I was in medical school, I bought myself several pairs of pants at the Gap. Because I despise shopping, I found a style I liked, and purchased four identical pairs in different colors, thinking my surgery residency interview wardrobe was now complete. At $48 a pop, not on sale, this was an expensive investment. But, I needed to start looking like a doctor, instead of a hippie-freak, and as much as I hated dressing up, my wardrobe of ratty jeans, Birkenstocks, and rock T shirts was sorely in need of an overhaul. Interviewing for residency is a complicated business. It's not enough to be smart, you also have to look and act it, projecting professionalism, personality, and poise under pressure. Because of the way residency matching works, you really have to sell yourself, especially if you're a woman in your mid-30s, with a state college nursing background that's accompanied by a startling absence of peer-reviewed publications, research experience, or fancy credentials, who happens to be vying with brilliant scholars nearly half your age for a coveted general surgery spot at Vanderbilt or Emory University.  Here's how "the match" works. You rank each program where you've interviewed, the programs rank you, and when the numbers are crunched across the nation the third Thursday in March, you'll land a spot based on how those two variables match up. Needless to say, the likelihood of being disappointed is extremely high. It doesn't matter who you are or how much influence you think you might have, there's just no manipulating the system. To make matters worse, not everyone will match. This unfortunate circumstance necessitates a day of its own, known as Scramble Day, in which unmatched candidates hustle for vacant residency spots.
     Even though I'd tried the pants on when I was at the Gap, once I got them home, they just didn't fit. They were all too big. I tried cinching them at the waist with a belt, which accomplished little more than bunching them up in a most unflattering way, exposing me to the grave threat of camel-toe. I even tried washing one pair to see if they'd shrink, but that didn't work, either. My attempts at reconciling this Apparel 911 left me with four pairs of pants that didn't fit, one of which now sported a tiny bleach spot. Deeming the pants unwearable, I folded them up and put them back into the bag with the receipt. They sat in the guest room closet for close to two months until I casually mentioned my ill-fated purchase to Rana, my shopping-savvy friend and fellow medical student. She scrutinized me in utter disbelief before exclaiming, "How is it possible that you've made it all the way through medical school, and you can't return a freakin' pair of pants to the Gap?!" It certainly was embarrassing. For some reason, I'd always had a hang up about returning items to the store. Luckily, I don't like to shop. It sounds ridiculous, but I equated approaching a customer service representative to inquire about a refund or an exchange with standing before a firing squad--I'd be at someone else's mercy, risking humiliation, rejection, and bodily harm, most notably to my Achilles' heel, a disabling self-consciousness engendered by my fragile, fragmented ego. What if they said, "No"?  Recognizing that I had a serious mismatching of assertiveness in the intellectual and common sense departments, Rana informed me that, on Saturday, I was going to march myself into the Gap to return those pants, and that she was coming with me.
     At ten o'clock that Saturday morning, Rana whisked me off to the mall. On the way there, we practiced the entire scenario: walking confidently into the store with the ill-fitting pants, assuredly summoning the customer service person, and successfully completing the return transaction. She made it sound so easy. Moments after we entered the Gap, headed straight for the service counter, I froze. I couldn't do it. The dread involved in returning those pants was just too overwhelming. I stood there, motionless, a future surgeon afraid of my own shadow. "Give me your credit card and come with me," Rana instructed. To the woman behind the counter, she simply said, "I need to return these pants. They are unsatisfactory. Here's the receipt." Within seconds, and with no questions asked, the pants were returned and my credit card, refunded. Rana was graceful about the whole fiasco. "Being assertive isn't about being aggressive or bitchy; it's about getting your needs met."
     That was twelve years ago. Since then, in addition to returning items that don't fit, I've arbitrated my divorce, negotiated contracts and warranty extensions, confronted unprofessionally-behaving colleagues, and begun addressing obstacles to communication within my family. I've found a suitable exchange, trading my ego for a voice that's confident, consistent, and congruent, one that enables me to be my own best advocate. The inner me finally matches the outer me. Although I still fall off the wagon from time to time, taking things too personally or letting people get under my skin, I'm aware of it now and can jump right back on. Speaking up for myself actually permits me to listen more receptively to others. I readily acknowledge that the world would be a boring place if I was right about everything, a self-deprecating quality that prevents me from taking myself too seriously. I also embrace the philosophy that opinions are like dirtbuttons...everybody's got one. I don't take anyone very seriously. Life itself is serious, but it's way too short to waste, fearing the unknown. Here's what I've learned about life so far: when I quit being afraid of "no," the world became a "yes."

P.S. I matched in general surgery at my first-ranked choice, Emory University, and was the first person from my medical school accepted into Emory's general surgery program. A year later, I switched to anesthesiology...lifestyle, lifestyle, lifestyle :-)
Our medical school graduation. From left to right, I'm on the end of the 2nd row. Rana is on the 3rd row, third from left.













Saturday, November 17, 2012

A Fortuitous Fracture In Time

     Browsing through Facebook this morning, I came across an e-card that several of my compadres in healthcare simultaneously posted. It features a surgeon, holding a scalpel, and reads: "I work long hours. I wear bodily fluids that aren't mine. I work weekends & holidays. I get screamed at & have my hands in other peoples' orifices. Tell me again how hard you work?" Aware that I was breathing a sigh of relief, I grabbed my second cup of coffee. The realization had just hit me...I've spent the last 27 years providing patient care in various capacities as a tech, nurse, and physician, and this is the first year I won't be barricaded inside a hospital for Thanksgiving, Christmas, or New Year's. As long as I've been working, I've worked nights, weekends, and holidays, while everyone else important to me got to enjoy being at home and sleeping in their own beds. No one wants to be on call. No one enjoys call. Therefore, I feel no shame in admitting that I've hated every minute of it, especially anesthesia call, where you're always someone else's bitch.
     One year ago, I was recovering from what I then considered the catastrophic loss of my job. On November 2, 2011, just five days before my 49th birthday, my boss, a physician-attorney, nonchalantly informed me by telephone that I had to leave our practice because A) a surgeon had complained I was too rigid, and B) the overpaid CEO of The Miracle Center* didn't approve of a humorous Facebook post I'd written about the computerized medical record software the hospital had recently adopted. Why and how Kurt Stinkypants** was alerted to my Facebook page remains a mystery. Although I was never privy to the identity of that whiny surgeon, my best guess is that it involved a cancelectomy*** of some sort. In fact, I'm relatively certain it was the same general surgeon who wanted me to put a non-toxic appearing two year old boy to sleep for incision and drainage of a thigh abscess, even though the boy had a stomach full of chicken biscuit and didn't require emergent surgery. He didn't want to postpone the case until later in the evening, so he cancelled it, and then went crying to administration. Waaaaaaaaah! 
     Although I'd just been disposed of like a used nitrile glove, I was expected to continue working for the next 90 days, until a more suitable replacement could be found. I agreed to this under one condition: that I would no longer take any call. Right after hanging up, I sent my boss, who quelle surprise! was out of town, the following email:
     Just to clarify, my understanding is that the administration is upset with me over a FB post regarding Cerner, and that some of the surgeons think I am rigid, and that is why I am being asked to leave the practice. This essentially equates to a hostile work environment, and obviously, I have grave concerns about continuing to provide services there. I will be willing to work the remaining 90 days, provided I do not take any call, effective today. I think it is shocking and wrong that a benign FB post about an electronic medical record, which is not unique to this hospital, leads to me being asked to leave without an opportunity to defend myself.
     I checked and re-checked my e-mail and cell phone a zillion times that evening, but never received a response. My next scheduled 24 hours of call was Saturday, November 5th, and as far as I was concerned, Boss Man was looking at some major restructuring of on-call responsibilities because I was DONE! I don't know how I did it, but I went into work the next morning. I was still in shock. Everything felt mechanical, a slow motion masquerade of once-familiar faces and surroundings, suddenly distanced by a fortuitous fracture in time, the discontinuity of which threatened to vaporize every last shred of dignity I possessed. Somehow, I made it through that day. I told a few co-workers about what had happened, and it wasn't long before word got out that, come January, I'd be leaving Rome. I spent the remainder of that afternoon and evening, crying inconsolably and freaking out. What was I going to do? At my insistence, Spartacus had just quit his job, and in three months, I would be unemployed as well. Rome was a small town, saturated with anesthesiologists, and unless I wanted to commute like I did when we were still living in Atlanta, we were going to have to move again. 
     On November 4th, I finally received this e-mailed response from my boss:
           I cannot permit this. You are obligated to cover your call as scheduled. You cannot simply announce to your colleagues that you’re not going to take your call and lay the burden at their doorstep. The consequences of this action will be dire! 
     Long story short, I immediately plunged into a mercifully brief, albeit suicidal, depression. I showed up for my 24 hours of call the next morning, and I've gotta say, there's nothing quite like Saturday anesthesia call at the Miracle Center to make you seriously consider jumping off a bridge. It's like picnicking in hell. My emotions were all over the place, vacillating between rage, humiliation, and utter despair. I couldn't stop crying. I was literally running on fumes from the few hours of crappy sleep I'd managed to snag, courtesy of my last remaining 10 mg Ambien tablet, which I'd desperately rationed into four nearly inert fragments. I've never been that distraught before, and it scared me. I think it scared my partner, Steve, too. Because my boss had called all the partners in our practice, telling them I was refusing to take call, Steve had taken it upon himself to cover for me in case I decided not to come in to work. Someone had to take care of the patients. He took one look at me, and my anguished hysteria, and told me to go home. On November 11, I formally resigned.
     My last call was Thanksgiving weekend, the oh-so-delightful Friday/Sunday combo. As you might imagine, it was a suckfest, but by then, I'd at least gotten through the worst of my depression, my anger having begun its dissolution into a resolve so transformative and compelling that life hasn't been the same since. It finally dawned on me that I wasn't trapped. For years, Allen, my dear friend and former  colleague had patiently listened to me complain about feeling trapped, like a caged bird, both personally and professionally. Even though I wasn't happy, I'd convinced myself that I couldn't be happy anywhere else, that I was stuck. "Sweetheart," he'd say reassuringly in his refined South Carolina drawl, "you are never trapped. You can do whatever you want to do! You just have to believe it." 
     I'm not sure why it took me so long to grasp the importance of Allen's message that indeed, I was indomitable. Better late than never, I suppose. In my case, it took a life-altering event for his wisdom to crystallize into awareness. As I walked out of The Miracle Center on that chilly November Monday morning after completing my last call ever, two things occurred to me: I wasn't trapped, and perhaps even more importantly, I've always been free. 
The Reverend Dr. Allen N. Gustin, Jr. (left), who became ordained just to marry me and Spartacus!  This photo was  taken moments before our wedding on October 24, 2009. 


*facility name changed
**CEO's name slightly modified
***cancelectomy: when a surgical case is cancelled for various reasons, not the least of which is concern for patient safety

Sunday, November 11, 2012

The Ride Itself

     Sunday's shy mid-morning light dapples my drafty kitchen with a warmth so delicious I can almost taste its honeyed rays. Alternately grey and blue, the sky can't seem to make up its mind. Neither can I. What exactly does it mean to be accomplished? Looking around the room, I see my framed diplomas and certificates displayed on the wall, juxtaposed against a painting that's unfinished, books that are half read, and boxes that are still unpacked from our move almost eight months ago. Why don't I finish the things I've started? Why do I reinvent myself every ten years? From my perspective, looking good on paper isn't the recipe for success it's cracked up to be. Sometimes, people with the most brilliant educations and lofty lists of achievements are also the most malignant, selling out every last shred of integrity in their insatiable quest for status and power, all for the sake of "being someone." There's definitely something to be said for simplicity.
     For the last few weeks, I've been baking our bread instead of buying it. Although I'm using a breadmaker, which the baking purist in me automatically denounces as a form of cheating, I find it deeply satisfying to turn a fragrant, brown, homemade loaf out onto my cutting board, ready to be sliced into thick chunks, slathered in butter and dipped into soup, or made into hearty sandwiches. It's like returning to a simpler, less complicated space in time where I get to enjoy both the process and the fruits of my labor with equal intensity. The bread machine isn't foolproof, though. Factors such as ambient humidity, the actual weight of the flour, and the type of yeast all have an impact on the final product, the interplay between which is easier to assess when making bread entirely by hand, underscoring the importance of understanding that technology is a complement to observation and experience, not a substitute for it. I happen to love troubleshooting recipes that defy logic and reason. Suffice it to say, I've tweaked the manufacturer's recipe here and there to achieve results that I consider desirable. If I do say so myself, this bread just keeps getting better.
     A couple of days ago, I received a letter from my brother, Adam. He's spent the last 12 months of his life in a prison in south Georgia, doing time for a non-violent offense which violated the conditions of his previous parole for drug-related charges dating back to 2000. It was a good letter, full of hope, resolve, and determination. "I've made the absolute best of this bad situation...and come to terms with who I am and who I want to be. I can't go back and make a brand new start, but I can start from now and make a brand new end." He's living proof that a few changes in ingredients and technique can transform a recipe for disaster into a happy accident. On December 17, he'll be released, and will start life anew.
     Who we are and who we want to be...can any of us really answer these questions, without categorizing ourselves in some way? Can we cease being who we already are, or become who we've never been? Are we permutations of an original recipe or are we sophisticated fakes, chock full of preservatives and artificial flavors? And, if we start from now, is it possible to remain there? Isn't life as much or more about the ride itself as it is about where the ride is ultimately taking us? Just like my bread--a recipe still  in progress--life, too, has an expiration date. Enjoyed in the moment, however, it always seems fresh.

Saturday, November 3, 2012

Greetings from Dog Hair City

     After spending all week trying to determine exactly what's been wrong with me, I've finally figured it out. I've been living in that special hell known as Dog Hair City. A massive sucking vortex of domestic unpleasantry and inconvenience--specially designed for mothers and wives--Dog Hair City bitch slaps you, grabs you by the hair, and pulls you kicking and screaming into a parallel universe where chaos flows like a squeeze bottle of pancake syrup in the grubby hands of a toddler, everywhere but on top of your waffles.
     It all started last Sunday when Spartacus came running breathlessly into the house while I was making us some lunch. "Man, I've just been watching this chick who's been sleeping in that car that was parked out front all night. She gets out of the car, throws on a backpack, and leaves a giant sword on the roof with a blade THIS long, like the kind for lopping people's heads off! Then, she disappeared down the street!" I got so caught up in his excitement that I forgot it was the weekend before Halloween. He pointed at the window by the kitchen sink, where I was washing dishes, "Look! You can see it from here!" Indeed, there was a sword sitting on the roof of her car, eliciting strange looks from passersby walking their dogs. "All right," I said, "I'm gonna go have a look. We better take some pictures." Armed with my camera, I threw on a sweater, and ventured outside to survey the chick's abandoned car. Once I made sure there was no sign of her anywhere, I gingerly approached the vehicle and snapped a few pictures. "Wait a darn minute! Is that thing even real?!," I queried, finally having come to my senses. Motioning to Spartacus, who was standing a few feet away as if the car might explode at any second, I grimace-whispered, "Come over here and see if it's real!" It took him several agonizing seconds to actually make contact with that damn sword, during which I fretted, "Now, his fingerprints are gonna be all over it!," envisioning our mug shots after a fracas with the police. "It's plastic," he reported. And, that's when the vortex sucked me in.
     The rest of the week was an ongoing parade of irritations, the least of which was the self-perpetuating collection of rinsed dirty dishes, left sitting in the sink. Apparently, having two X chromosomes is a prerequisite for  placing such items into the dishwasher, as is returning them to their respective areas of storage once they are clean. I've also discovered a syndrome called Clean Dish Neglect, in which a dishwasher full of hot, freshly washed plates, glasses, and silverware fails to trigger an intrinsic mechanism for detecting obviously scoured and sanitized surfaces, paradoxically prompting sufferers of this condition to initiate the otherwise unheard of dishwasher loading procedure, e.g. placing one's used coffee cup amidst those that are quite visibly pristine.
     The simplest observations seem to elude XYs. It's ironic that "Gee, look at those brown streaks. This toilet needs scrubbing!" or "There's a fine layer of dog hair covering every square inch of this house; it's time to dust and vacuum!," are such foreign concepts that they evoke absolutely no reaction, yet "Damn! There's a smudge on my rear bumper!" prompts an immediate visit to the car wash. Replenishing household necessities, such as toilet paper or milk, also tends to be an afterthought, much in the same manner as handwashing, hanging up wet towels, or putting the seat back down.
     For about two weeks now, I've become increasingly more aggravated over the racket known as emissions testing. The tag renewals on the three vehicles I own are due on my birthday, which is November 7, and because I've moved from a city which doesn't require emissions testing to one that does, I can't just complete these registrations online: they have to be recalculated and prorated. I have to go in person to the tag office with proof of residence, and both my sons' cars have to pass emissions inspection. My son, Nick, is driving my old 2005 Honda Civic hybrid, a car which now has 94,000 miles on it and runs perfectly. When I asked him to get his inspection done a couple of weeks ago, he told me that for some time now, both the "check engine" and "IMA" (integrated motor assist--the hybrid battery) lights have been on, but that he'd googled the diagnostic codes he'd obtained at Auto Zone, and determined that this was some type of non-emergent problem. Needless to say, I was annoyed that he didn't mention this problem to me before now. He showed me a youtube video of a guy who'd cleared those same codes by installing a new 12 volt battery and air filter. It seemed like a legitimate solution; his car was running well, and the IMA battery was staying fully charged. Why not give it a try? Since I'd recently received a notice from Honda about the hybrid needing an emissions-related software update, we decided to take the car in to the dealership after replacing the battery as the video suggested.
     Long story short (and $120 later), the new battery idea didn't work, and neither did the software update: those pesky lights stayed on. It's hard to imagine how a hybrid battery could affect emissions testing, but I'm told it does, and there isn't an inspection site that will run the test with a "check engine" light on anyway. If you're stopped while driving a car with expired tags, it's easily a $200 fine. Time was running out, and unfortunately in this city with its half-assed public transportation, you've got to have a car to get around. To make matters worse, the dealership found a transmission-mount problem--a $366 repair--as well as only 2 mm of brake pads left on the front axle. Yes, in Dog Hair City, you can't win for losing...it's always something.
     I was more than a little irate that the dealership had installed the software update and assured Nick that everything was fine, only to receive a text message from him at work the next morning saying, "The lights came back on." WTF?! He took it to a service station and had them run the diagnostic codes for those lights, and although the emissions codes were now cleared, the two most dreaded codes of all, those signaling "premature hybrid battery degeneration" were still present. Anyone who owns a Honda hybrid knows this is a $2500 to $3500 fix. Anyone who owns a 2003-2009 Honda hybrid also knows that there's a huge class action lawsuit regarding fuel economy and IMA battery warranty-related issues on these vehicles. Anyone who knows me knows that as much as I despise conflict and confrontation, I can resort to full-on bitch mode when the situation gets desperate. This situation was about as FUBAR as it gets.
     First, I called the dealership to register a customer service complaint. They should have run the codes after updating the software to confirm that the "check engine" and "IMA" problems were indeed resolved. After leaving a rather long and rambling voice mail rant for the service manager, I looked at the car's original warranty. As I suspected, the IMA battery was only covered up to 80,000 miles. I reviewed the class action lawsuit and did some googling, and learned that Honda had extended the battery warranty to 100,000 miles in states like CA and NY, which presumably contain the highest concentrations of hybrid cars. Although Honda agreed to extend the battery warranty for an additional 12,000 miles as a result of the lawsuit, at 94,000 miles, we were just outside of it. Basically, we were screwed. Unless I could somehow get a 100,000 mile warranty extension or register the car in a county that didn't require emissions testing,  a practice which borders on fraudulence, Nick would be risking a sizable fine if he got stopped after the tag expired.
     I could see where this was going. Either I was gonna pay $3k for a new IMA battery, or we were going to be scrambling to trade Nick's car in for something that'd pass emissions. Because I don't like dealing with middle men, I went straight to the top, and called Honda headquarters. In a recorded conversation, I made what I thought was a good case for them to consider extending my warranty to 100,000 miles, namely the fact that I've been a loyal Honda customer for the last 20 years, and that Honda had already extended the warranty in select states. It was a magnificent waste of time and breath. After a brief "conference" with the powers that be, I was informed by the woman with whom I'd been on hold for 20 minutes that "there is nothing we can do to assist you," as well as "No, there's no one else for you speak with here." Click. Believe me, I was seeing red at the end of that conversation. Just as I was googling Honda's CEO so I could email him a scathing letter of complaint, I received a call from the service manager at the Honda dealership where we'd initially taken Nick's car for the software update. I could tell that he was pleasantly amused by the VM I'd left him because he was laughing good-naturedly. He told me to have Nick bring the car back in to make sure that the correct software update had been installed, and that he would contact Honda's regional manager on my behalf to see about extending the IMA battery warranty. "Believe me, we deal with this issue all day long. I'm confident that Honda will cover all, if not most of the battery replacement." Professional and reassuring, he restored my faith in customer service. Now, all we had to do was wait.
     Because we are short-staffed and busy, I worked extra this week, providing me with welcome diversion from vehicle-related woes. Even so, I was still irritable and short-tempered. Minor nuisances that I'd otherwise overlook, like dog hair on the coffee table and unwashed dishes in the sink, were magnified into mini-disasters of epic proportion, threatening to coalesce into one huge catastrophic meltdown. I tried to remain in the moment, but the moment sucked. Thursday afternoon, as Nick was making himself a smoothie, the Vitamix blender started smoking. It's an expensive high horsepower blender, which fortunately is covered by a seven year full warranty, and both Nick and I use it several times a day. I guess all that frozen fruit overwhelmed its functional capacity. As I started launching into a sanctimonious lecture to Nick about how to correctly layer wet and frozen ingredients so this wouldn't happen again, he got a call from the Honda dealership. "Mom, Honda's going to cover the cost of the battery. All we'll have to do is pay $325 for the labor." Hallelujah, maybe miracles DO happen! Either that, or my persistence paid off.
     As mysteriously as the sword-wielding chick appeared and vanished, so did Dog Hair City. Well almost. I still woke up this morning to a house in dire need of dusting and vacuuming. I dreaded the thought of spending Saturday morning, cleaning. Spartacus must have read my mind because the minute he rolled out of bed, he made himself a coffee, and immediately started vacuuming and taking out the recycling like a mad man. Then, he went out to hit some golf balls, but not before placing his mug into the dishwasher with all the other dirty dishes :-)
That chick's scarily realistic-looking plastic sword.

Saturday, October 27, 2012

Big Deep Breath

"Big deep breath...in through your nose, out through your mouth."

     Today's gonna be a good day. It's Friday!!!! Our first case is a "double dip," an EGD--short for esophagogastroduodenoscopy, an endoscopic exam of the esophagus, stomach, and first segment of small intestine--and colonoscopy combo, evaluating a chief complaint of abdominal pain and rectal bleeding. No big whoop. The patient's a healthy 51 year old female; no medications, no allergies, no medical problems, just a little rectal bleeding noted after the endometrial ablation she underwent two weeks ago to alleviate her heavy menstrual periods. "After the surgery, I couldn't 'go,' so I inserted half of a glycerin suppository, and that's when I noticed I was bleeding from my rectum. Maybe I tore a little hemorrhoid?" Sounds reasonable, especially since she's so thin, healthy, and asymptomatic. Aside from having a maternal grandmother who died from colorectal cancer, there's nothing too remarkable in her history. This'll be a piece of cake.

"Big deep breath. You'll start feeling really sleepy in just a few seconds. You're gonna feel that oxygen blowing in your nose a little harder as you're drifting off to sleep, OK? See you when you wake up."

     It's 7:40 a.m., but here in the GI suite, the propofol is already flowing as freely as cheap wine at a house party. After only 80 milligrams of this wondrous milk of anesthesia, my patient's snoring like a true champ. "Wow, she's a lightweight! This case is gonna be a cinch." The scope goes in at 7:41 and comes back out two minutes later. "Her EGD's normal," says my gastroenterologist colleague, Dr. Selleck*, as the procedure nurse and I spin the stretcher around in the opposite direction for the colonoscopy. Everyone in Room One's in a good mood, chatting excitedly about our weekend plans...did I mention it's Friday? We get our patient positioned, and I push a little more propofol as Dr. Selleck performs a standard pre-colonoscopy rectal exam.
     "Oh, FUCK!," he blurts out, his tone unexpectedly grave and serious. "Something's not right. She's got a mass in here." Praying it's only a thrombosed internal hemorrhoid, we all watch silently as he passes the scope a few millimeters into our unconscious patient's anus, collectively groaning, "Oh no..." as the olive-sized, ulcerated tumor comes into view. "It's cancer," he says quietly, his voice heavy with compassionate despair, "and it's a bad one." I deepen the anesthetic, and we proceed with the remainder of the exam.
     Because the tumor is situated so close to her anal sphincter, it can't simply be cut out without affecting continence. "Depending on whether this is squamous cell or adenocarcinoma, she might be looking at a permanent colostomy," he remarks as he takes a few endoscopic biopsies of the now bleeding tumor. "She reported having rectal pain, which is indicative of a more invasive and very likely unresectable tumor. She'll need a rectal ultrasound and CT scans for staging, and we'll go from there." I felt myself starting to become a little undone: "A permanent shit bag? Are you kidding? She's only 51! Jesus Christ! I'm not sure I'd even want to live with an irreversible colostomy." The procedure nurse, a 31 year old woman, nodded in agreement. "Well," Dr. Selleck said, "at least you'd still be alive."

"Hey there, you're just waking up. Big deep breaths for me. We're going to recovery now, and when you're awake, Dr. Selleck will come talk to you about your results."

     Mercifully, the propofol sedation lingered long enough to allow for a peacefully sleeping patient with a no-questions-asked transfer to recovery. I don't think I could have handled it if she'd been awake. People waking up after their procedures always want a confirmation that everything went all right. I was exceedingly thankful that it wasn't me having to deliver such devastating news, especially because I'd already determined that if it were me and I was looking at forty-plus years with a permanent colostomy, I'd probably let the cancer metastasize and die in hospice.
     Just a couple of nights ago, I awoke from a terrible nightmare. It was Thanksgiving, and I was sitting at a long dinner table in the house of someone I barely knew, a conservative woman who appeared to be very wealthy and kept talking incessantly about Jesus. I didn't know anyone else at the table, but they all looked uptight. No one was having any fun. I felt a sense of awkward discomfort, like I was in the wrong place at the wrong time, and I didn't know how I'd gotten there. I ate what was offered, but otherwise kept my mouth shut. Looking across the dining room into the foyer, I could see a bunch of twenty-somethings dressed in garish Halloween costumes clamoring down a large staircase, prompting the hostess to get up and investigate the commotion. Somehow, I knew that they were renting rooms upstairs. That's when I saw Pocahontas and a big fuzzy bumblebee pointing their shotguns, and I knew we were all going to be robbed. There was no time to escape, and that's when I awoke.
     What's it like to wake up as your normal self one morning, only to be informed a few hours later that your days are numbered by a disease, that your body's been invaded by a cancer that will probably leave you disfigured? Although our patient took the news pretty well, her husband was visibly shaken. Instead of heading home with his wife after her uneventful colonoscopy, he was accompanying a newly diagnosed cancer patient to the hospital for CT scans of the abdomen, pelvis, and chest to see if the tumor had already spread to other parts of her outwardly perfect body. Interestingly, the patient disclosed that she'd suspected it might be a cancer. Perhaps her calm demeanor wasn't from the propofol after all; evidently, she'd been discreetly preparing herself for the worst possible scenario.
     I've had a really hard time shaking yesterday's disturbia. I'm turning 50 in a few days, a birthday which nowadays means, "Congratulations! It's time for your screening colonoscopy!" I'm relatively certain that mine isn't going to be normal, either, given the fact that I was diagnosed with Crohn's disease when I was 19, and have endured a lifetime of gut-related misery that I've just learned to live with. I don't like taking medicine, and I don't "do" sick very well. That's been good motivation for eating a healthy diet and keeping myself in excellent physical shape. I value my independence and my intactness. I like my body the way it is, the way it was designed to work. Anesthesiologists are known for our tightly toned sphincters, making it even less of an irony that I find the idea of being surgically altered so unappealing. As yet, I'm undecided about whether or not I'll submit to a colonoscopy.
     Last night, I kept thinking about that dream I'd had, and how uncannily it paralleled my patient's cancer. Like a malevolent uninvited dinner guest, her malignancy had been lurking unnoticed for God knows how long, serendipitously discovered because the rough-edged surface of the glycerin suppository fragment she'd used to treat her post-surgical constipation disrupted a friable time bomb that was ticking away patiently, aggressively straddling her sphincter. It also occurred to me that continuing to sit at a table full of Jesus-talking conservatives is very much like what I do for a living. The practice of medicine necessarily involves a controlled level of hypocrisy. I've given anesthesia to people having all kinds of procedures that I personally would never consent to, with the understanding that although I'm obliged to inform them of risks, benefits, and alternatives of the anesthetic, it's not my place to judge what's right or wrong for them. For some of us, quality of life is what's important; for others, it's sheer quantity. Just how much surgical disfigurement or chemical alteration one is willing tolerate in order to stay alive is a reflection of one's perception of quality, the metaphysics of which are complex and uniquely individual. No two definitions of quality are the same. From an acquired disease perspective, quality of life becomes a matter of adaptation. In contrast, my sons have lived their entire lives with the cruel genetics of cystic fibrosis, and all the pills and therapies and hospitalizations that go along with it. They've never known life without concomitant disease or what it's like to be completely healthy. For them, adaptation hasn't exactly been a choice.
    Doing what I do, and knowing what I know, am I a hypocrite or am I simply being non-judgmental?  Isn't acknowledging that what's right for me isn't necessarily right for everyone else, and vice-versa, the hallmark of self-determination and autonomy, the most inviolable principles of both medical ethics and humanity? Is supporting others who are sick, but not wanting there to be anything wrong with me really such a paradox?  Would any of my feelings change if I suddenly became incapacitated or terminally ill? And, now for the question of the moment: Should I have that colonoscopy?..."Big. Deep. Breath."

*name changed

Physician, Heal Thyself! (a related post)

Sunday, October 21, 2012

The Weirdness of Me

     Fifty. The big 5-0. Half a century. That's gonna be me in just a couple of weeks. For some reason, I thought that by fifty, I'd have my shit together, be a "real" grownup and all, but that just hasn't panned out. On any given day, I feel five or twelve or eighteen or thirty-two. To an observer, my life's curriculum vitae might seem impressive--there's that whole "doctor" thing sticking out like a sore thumb--but that's never been what I'm about. I still don't know what I want to be when I grow up, and lately, that whole idea of "Be all that you can be" doesn't seem incredibly necessary or important.
     Because I keep running into problems with a little thing called society, I've spent much of this last year examining the weirdness of me. Funny thing is, I keep coming up empty-handed. Although I've dabbled in the mainstream from time to time, being a sheeple has never really held much of an appeal. I'm not marching to the beat of a different drummer: I am the drummer. For some reason, this lack of conformity seems to bother people, especially those are overly concerned with superficial appearances and projecting a certain image. Who do they think they're kidding?
     I've never been a good liar. What you see is what you get, and for that, I remain unapologetic. I don't worship the God of Expectation and Disappointment, the one that hypnotizes the susceptible into thinking there's always something else to be achieved, something bigger and better and new and improved, that what we already have to give will never be enough. By definition, isn't enough enough? This consumeristic mentality just isn't my bag; I don't relate to people in terms of what I can do for them or what they can do for me, and for that, I'm labeled selfish, uncompassionate, egoistic, anti-social, and a failure at capitalism. Since when did being interested in people on a deeper level become such a crime?
     Fifty. It's an age that's always sounded so mature and matronly, but I feel more wild and free than ever. Living dangerously is all it's cracked up to be. Although I've learned to tone down some of my more subversive tendencies by flying under the radar, I still don't give a damn what the neighbors think. Life is good, even when it's sucky. Self-acceptance is key to my happiness; at the end of the day, what I think about me matters most, obviating any need to stereotype myself as "weird" or "normal." Sometimes, weird becomes normal. If weird is to normal as eccentric is to boring, though, it looks like I'm in for a few more decades of weirdness.
I see nothing at all weird about using this spoon to stir my Brussels sprouts.
What almost 50 looks like.

Sunday, October 14, 2012

From Poop To Nuts

     It's raining nuts around here, literally and figuratively. I'll try to explain. I live in the former library of a very old elementary school that's been converted into lofts. The library is separate from the rest of the school building: 2500 square feet of open space, 14 foot ceilings with exposed ductwork, huge windows, polished concrete floors, and a metal roof with two large skylights, a visionary repurposing of otherwise ugly industrial materials.  When we found this place back in January, the karma was almost too good to be true. Aside from being the perfect place to start life as a writer, this old schoolhouse is located in an uber-cool East Atlanta neighborhood, one that's currently undergoing the process of gentrification. It's trendy, but still replete with original ghetto charm.
     For the last week, the acorns from the oak trees in the schoolyard have started plummeting incessantly across this metal roof in a maddeningly nutty hail that shows no sign of letting up anytime soon. With the acorns have come the squirrels, whose thunderous rooftop scampering has jangled my last nerve so badly that I'm thinking of taking up residence with any of the mixed bag of human nuts that populate our neighborhood. Let's see...there's the angry sweaty lady with the big hat and pendulous belly who, when she isn't wandering around observing telephone poles and recording her findings in a black notebook, parks herself out on our front stoop, giving F-bomb filled Sunday sermons any given day of the week, completely oblivious to the dog-walkers, bike-riders, and parents pushing baby carriages passing her by. Another lady wearing a hair net rides around on her bike, yelling and screaming into her cell phone, which I'm not sure even has a person on the other end. There's the young guy with dreadlocks and a trucker hat who can be seen either standing on the corner with a baby, or pushing a grill or an empty stroller up and down the street, stopping you on a regular basis to ask for (crack) money. Then, there's the drunk middle aged woman, decked out in Tennessee Volunteers attire, who amuses herself by barking at our dogs.
     I've had my hands full of nuts the last few days, and I'm not referring to the ones here in the 'hood. A couple of weeks ago, I had a patient who presented 30 minutes after her scheduled appointment for esophageal endoscopy and colonoscopy, due to a complaint of abdominal pain. She seemed to be of reasonable intelligence, but come to find out, appearances can be deceiving. In order for a colonoscopy to be performed successfully, one's bowels have to be clean as a whistle. Makes sense, right? It's self-evident that a colon full of poo will obscure a camera's view. Patients are given explicit verbal and written instructions for prepping the colon, which involves a two day ordeal of clear liquids, various cathartics, and enemas. For 24 hours prior to the procedure, there is to be no intake of solid food whatsoever. Doesn't leave much to the imagination, now, does it? After denying that she'd eaten the day before, we took this patient back to the procedure area, got her sedated, and placed the scope in her throat, only to be greeted by an esophagus full of undigested pasta. The procedure was immediately aborted, given the fact that a full stomach in a deeply sedated patient is a potentially lethal combination.
     Because sedation and anesthesia impair the protective gag reflex which prevents food from being upchucked into the lungs where it can cause catastrophic aspiration-induced respiratory failure, NPO (nil per os or "nothing by mouth) guidelines are strictly enforced. Unfortunately, many patients don't seem to take them very seriously. It's almost as if they think they're pulling one over on us, but what they don't quite grasp is that we're going to be looking right into their gullets and bowels with a video camera where all will be revealed. In other words, if you've consumed anything other than plain Jello, apple juice, or broth, we're going to see exactly what you've been eating! Needless to say, upon further questioning, the patient admitted to having eaten a Lean Cuisine the night before. Her inability to comply with simple instructions could have cost her her life. Once again, this patient was given clear and concise instructions for repeating the bowel prep, and this time, she was placed on a clear liquid diet for two full days prior to her rescheduled colonoscopy to ensure that she'd be extra clean. On Thursday, she returned for her procedure, forty-five minutes late. This time, she admitted up front to eating peaches and cream of mushroom soup the day before, so she was immediately cancelled. Whatever belly pain she's been having obviously wasn't sufficient enough motivation to keep this Holly GoLYTELY from indulging in breakfast at Tiffany's (or Waffle House), ruining her second chance at a diagnosis.
     On Friday, I checked into my blogger forum where there's always sure to be an interesting discussion taking place. Medically-related posts never fail to catch my eye. I don't consider myself a censor per se, but with all the nonsense floating around on the internet which lay people misconstrue as science, I feel a bit of responsibility in busting the myths that routinely complicate my clinical practice, the primary example of which is Michael Jackson's illicit use of propofol. Every single day, I'm confronted with some anxiety-riddled version of, "You're gonna give me the Michael Jackson drug?!" I explain that propofol didn't kill Michael Jackson--his own addiction and his doctor's negligence did. I then reassure the patient that propofol, which is an intravenous anesthetic, not a sleeping aid,  is safe when administered by anesthesiologists and anesthetists in a monitored setting. These conversations tack an extra two or three minutes onto my pre-op assessments, time that could be better used in other ways. Thanks a pantload, Michael Jackson!      
     Anyway, I was trying to get my mind off of work, when I noticed a discussion entitled "What Good Is A Cortisone Shot?" Without going into details, it was a wealth of misinformation regarding steroid epidural and joint injections by a Hitler-obsessed conspiracy theorist claiming that patients are misled into thinking cortisone shots are beneficial, when it's really "cocaine derivatives" producing the analgesic effect. I'd never seen this author on the forum before, so I wrote a reply clarifying that although local anesthetics are sometimes used diagnostically in these injections, none of those currently in use are derivatives of cocaine. This guy is a great example of a little bit of knowledge being a dangerous thing. Although some of what he said was valid, namely that the long term use of corticosteroids is associated with immunosuppression, bone demineralization, and derangement of intrinsic hormone homeostasis, his conclusion that these injections have no clinical utility was based on an incomplete understanding of steroid synthesis and pharmacotherapeutics, as well a frightening arsenal of evangelical paranoia-fueled pseudoscientific propaganda. After realizing that he was just another disturbed nutcase, I left the conversation. My guess is that anyone who follows his blog is probably as bonkers as he is, too brainwashed by hogwash to question the verbal diarrhea he's spewing as the truth.
      From poop to nuts, it's been one of those weeks. I'm emerging from a funk of aggravated frustration, heavily infused with snark, which I have to admit I've rather enjoyed indulging in. I'm tired and grumpy, but at least I feel validated. For now, the acorn showers have abated, and the lunatic fringe is strangely quiet, like a knife cutting through peanut butter. Sometimes you feel like a nut, sometimes you don't. Neighborhood eccentrics are whimsical and endearing, militant fanatics and NPO violators, not so much. Life's already a tough enough nut to crack, isn't it? I think I'll be much better off without further help from the peanut gallery.

Sunday, October 7, 2012

When "g" Inadvertently Became a "ɋ"


     She couldn't have been more than six years old at the time, given the conspicuous absence of both bottom incisors, her school uniform itchy and tight about her waist as she sat at her desk, folding a piece of paper over and over on itself, marveling at how it kept getting smaller, wondering if folding it enough times would eventually make it disappear. Defiantly shoved beneath her Big Chief tablet, barely obscuring her assignment's tell-tale red star sticker, lay the ruins of a job almost well done. For a left-handed girl who still wrote her name backwards, penciling row after row of lower case "g’s" without besmirching the sheet of paper had proved an impossible challenge, especially given the fact that Sister Mary Nicholas did not permit the use of erasers without prior special dispensation.
     Only moments before, she'd set about the task of making “g’s,” concentrating intently, determined that today's effort in penmanship would be rewarded with a gold star, not the usual blue or green one. She glanced over longingly at Perfect-Sharon-Carmichael's desk. The tip of Sharon's tongue was already deliberately affixed to the corner of her mouth in typical studious fashion, marching her “g’s” almost mockingly across the page, each letter as crisp and pristine as the typeset in their "Fun with Phonics" workbooks. Pretty, bright, and obedient--the sugar and spice embodiment of a teacher's pet--Sharon was her unsuspecting nemesis. From her stylishly coiffed glossy brown hair to her meticulously polished saddle shoes, Sharon had all the right stuff, including right-handedness. Unfazed by the dreaded yellow subtraction flash cards, Sharon would enthusiastically raise her right hand, righteously illuminating the rest of the class with all the right-minded answers. It just didn't make sense that she was the one who got to use an eraser.
     Two rows of “g’s” down, three more to go. She'd been careful to elevate the sooty pinky-side of her hooked left hand ever so slightly to keep it from dragging and smudging the paper, taking her time to scribe what was certain to be the most exquisite array of “g’s” Sister Mary Nicholas had ever seen. Distracted by the sudden violent scrubbing of Sharon's coveted eraser, her next “g” inadvertently became a "ɋ." Just as she was completing the "o" part of a particularly troublesome “g,” her adversary's convulsive fit of erasure trembled her desktop, peppering it with pink shrapnel, the detritus of which she was tempted to scavenge and roll surreptitiously into a tiny eraser of her own, a delightfully naughty fantasy indeed. Captivated by this wildly provocative thought, she carelessly transposed the "j" which was supposed to turn her "ointo a “g.” Now, she was stuck with “ɋ.”
     Deprived of eraser privileges, and impoverished by her own awkward chirality, she deftly resorted to other means of correcting her sinister slipup. Surely Sister Mary Nicholas, who was thickly bespectacled and had eyes in the back of her drab grey veil, wouldn't notice the little bit of saliva she'd used to coax the “ɋ” into an "α" and finally, into a magnificent “g,” as flawless and unadulterated as one of Sharon's scuff-free shoes...


The Subtle Beauty of Chirality: A Related Post



Saturday, September 29, 2012

The Inherent Depravity of Peanuts: An Inquiry Into Blind Faith

     As someone who firmly believes that life's too short to adhere to convention, the notion of conformity, especially for the sake of religion, has always been a bit problematic for me. It's not that I'm particularly difficult or unusually strong-willed, it's just that I can't envision a worse existence than that of selling myself out to an ideology--following someone else's rules--instead of going with my own flow. Being who I already am means everything to me. Content to fly insubordinately beneath the radar of societal norms, I live life on my own terms, not anyone else's. Although I consider myself open-minded and quite tolerant toward other viewpoints I don't necessarily understand, every now and then the lack of common sense which accompanies rigid traditionalism leaves me dumbfounded, nearly at a loss for words. Perhaps I'm in need of enlightenment, but why would anyone want to trade dogma for free thought? That's a way of life I just can't get my head around.
     Yesterday, my son, Nick, came home from work, looking troubled. He said, "I found out I messed something up at work two weeks ago." For the last 10 months, he's worked at a natural foods store, a job he was very excited about taking mainly because of his interests in Ayurveda and alternative healing. The store is located in a diverse neighborhood with a large orthodox Jewish contingent. Although the store itself is not strictly kosher, it receives lots of business from the local Jewish population, and part of Nick's job is stocking and organizing kosher foods. Here's where I have to plead ignorance. When I think of kosher foods, I think of items like meat, fish, dairy, and eggs, and I totally "get" the whole concept of kosher and Halal laws pertaining to the ritual slaughter of animals. But, who would ever have thought that something as benign as a peanut could cause such a stir? I mean, what exactly is the point of kosher peanut butter?
     Well, apparently freshly ground peanut butter made from kosher peanuts is a big seller at the store, so there are separate machines for holy and unholy peanuts. A couple of weeks back, Nick was charged with refilling the machines. By some accident, he unintentionally and unknowingly placed "tainted" peanuts in the kosher machine, an honest mistake that his boss discovered yesterday. I sat in disbelief as Nick told me that because of his human error, the store had lost all its kosher peanut butter sales. "We either have to get a new machine or take the old one apart and boil all its components." I'm sorry, but this is nothing short of ridiculous! First of all, every peanut in that store is organic, and as Nick puts it, "They've already been blessed by Nature." Secondly, if there is a God, does he really care about whether peanut butter is kosher? It seems he might have more pressing issues on his agenda. People have been buying and eating that unorthodox peanut butter for the last two weeks, yet there have been no reports of anyone in the community being struck down by the hand of God for inadvertently disobeying Halakhic law. Gimme a break! We're not dealing with allergies, GMOs, or a salmonella epidemic here; it's simply a matter of a few unconsecrated peanuts. Why not just run a few batches of kosher peanuts through the machine with a rabbi standing by to bless it? Wouldn't that be more common sensical? Frankly, I fail to see how the inner workings of this peanut butter machine could have been so drastically altered by a gallon of unanointed legumes as to render it unacceptable for future use. I have no doubt that God would also approve of my plan for absolving this defenseless machine of its iniquity.
     It's all a matter is perspective, really. My work as an anesthesiologist involves life and death on a daily basis, and this tempers my philosophy about people who take themselves, their jobs, and their religion too seriously. Piloting an aircraft is one thing, whereas working in a grocery store is quite another. Theoretically, one could argue that stocking groceries carries the potential risk of selling expired or contaminated food, directly threatening public health, and in this case, carelessness can certainly be deadly. Nick's dilemma is less clear cut; he's unwittingly and unfairly assumed responsibility for the spiritual health of an entire community. What should have been a blip on the radar might turn into a big hairy deal. I'm willing to bet that the people making a mountain out of this molehill are also the biggest hypocrites in the bunch, the "holier than thou" whose sense of moral superiority and self-righteousness is thinly disguised beneath a veil of piety and service.
     Does a depraved peanut taste any different or provide less nutritional value than one that's been sanctified? Can someone please explain convincingly how fresh organic peanut butter can be deemed unfit for consumption by some, while it's fine for everyone else, or why a machine that was perfectly good two weeks ago is now unclean and unusable? In other words, if consecrated peanut butter is really that different, why didn't anyone immediately suspect that's not what they were eating? Like Nick said, those peanuts were already blessed by Nature; isn't that enough? I find it difficult to appreciate how anyone's spiritual health was even remotely compromised in this situation.
     Is the abandonment of reasoning, judgment, and intuition an inherent aspect of developing faith? Is faith itself necessarily blind, devoid of wisdom and practicality, intolerant of inquiry or human error? More importantly, why don't we have more faith in ourselves? Herein lies the quandary: if God exists, and God made everything and everyone, and God is everything and everyone, then isn't everyone and everything also God? And, what's the purpose of a God who's external to ourselves? When someone figures that out, please let me know. I'll be in Aisle 9 along with the other infidels and miscreants, shamelessly sampling the subversive peanut butter, la dolce vita style. 

Wednesday, September 26, 2012

My First Interview as a Writer!

     What an honor! Thanks to the staff at BlogCatalog (BC) for selecting me to be interviewed. Not only was it great fun, it's an excellent way to gain exposure in the world of writing. I've been a member at BC since January 2012, and have found this blog directory, the caliber of its writers, and its discussion board really superb. I've made some very good friends at BC!
There Is a Doctor in the House

Saturday, September 22, 2012

The Uncommonly Short Half-Life of Our Arrogance

     It's Saturday, and my fingers and arms are still sore from the vicelike grip I held on my ambu bag, furiously trying to push oxygen into my patient's lungs during Monday's laryngospasmic* moment-of-sheer terror, a complication that every anesthesiologist eventually comes to know and dread. There are no words which adequately describe the intense tangle of fear, desperation, and adrenaline involved in a resuscitative effort. What just happened? What IS happening here? Time orientation is the first of your capacities to crap out on you. Seconds and minutes feel like hours, no...eons. Everything in your immediate surroundings becomes surreal, and you feel strangely removed from the experience, as if it's all just a bad dream and you're not really there, watching Life circling the drain as Death--adorned in her signature cyanosis and pallor-- taunts you, shrieking with obscene delight at the folly. What are we missing? What should we try next? With a mind-numbing array of algorithms swirling wildly through your head, you realize you are praying to someone, anyone, Please don't let this patient die. You're vaguely aware of a nurse's voice. It's the same nurse you were joking with about a new-fangled CPR machine just an hour or so before this event, only now she's solemnly delivering ominous news about your patient's heart rate and blood pressure, both of which are bottoming out. Oh my God, this patient's gonna die if we can't oxygenate! "Would you like me to give some epinephrine?" she queries, as you're sliding a breathing tube into the patient's trachea. "Yes, that'd be great. Can someone push on this lady's chest to help the epi circulate?" In the meantime, helping hands are flying every which way, with everyone around that stretcher intently focused on thwarting life's premature exit, communicating only through objective observations and simple direct questions. It's a realm we don't often see in medicine, a place where egos temporarily evaporate, where we're all clearly on the same page, Please don't let our patient die. Circulation. Airway. Breathing. 
     Suddenly, the black clouds part, yielding a singularly auspicious ray of thank-goodness-I-think-she's-gonna-make-it. Dare I exhale now? Your monitor has abandoned its lento doloroso of constant physiologic alarming in favor of the reassuring allegro vivacissimo of restored ventilation and perfusion. O bless you, Almighty Oxygen! Lips and nailbeds that were blue are now pinking up. She's swallowing, and fighting the tube...YEAH!!!!! Once again, you've managed to triumph over death, but for physicians like you who remain unafflicted by the deceit of over-confidence, arrogance in the face of victory has an uncommonly short half-life. Did I just get lucky? After talking with the patient's family, you sort out and document the details of the code blue using a fine-toothed comb, thanking everyone again for their help before making the solitary, silent drive home. You beat yourself up pretty thoroughly in the land of Hindsight Is 20/20, thinking of all the things you could've-should've done differently, pondering this roller coaster ride that is your chosen profession, contemplating whether it's time to finally throw in the towel. What on earth possessed me to become an anesthesiologist?
     Emotionally and physically exhausted, you make yourself a grilled cheese sandwich, still coming down from the catecholamine-fueled sequence of hair-trigger decisions and interventions which enabled you to save your patient's life. Why can't I gloat about this? Am I being too hard on myself? You know it's going to be a while before you feel "normal" again. Maybe a nap will make everything better. I just want to forget. Before you lie down, you recap the whole scenario online with your good friend, Todd, who also happens to be an anesthesiologist. You trade mutual tales of disillusionment; he understands precisely why you want to quit. "We all get burned at some point in time," he observes. "What makes you a great doc and the precise reason you should stay in medicine is because you DO care. The same thing that is killing you right now is what makes you an ideal physician. Yep, it's stressful, but you're damn good. When our patients 'do this' to us, they need us and we need them. You're a damn good doctor, and you need to keep at it for their sake. You totally made a huge difference today because you were there...you were experienced and you knew what to do. Don't give it over to the other people in our field who don't care." Finally, I feel validated.
     Todd is absolutely right. It's not that we care too much: we can never care enough. This is what separates us from those "other people" who view medicine primarily as a means of making money, instead of an altruistic endeavor. Booksmarts and a God-complex will only carry us so far in this profession, whereas benevolence, intuition, and impeccably honed skills offer real redemption. Donning a white coat symbolizes our ethical obligation to our patients, but all too often, it's worn as a shield of conceit. Paternalism still runs rampant in medicine. My own son, who was just discharged from the hospital after being treated for a cystic fibrosis pulmonary exacerbation, remarked disparagingly, "None of my doctors really seem to listen to me." For someone with a chronic illness, that's a sad state of affairs, one that embarrasses me as a physician.
     We've chosen a difficult vocation, made even more so by the fact that people like Todd and I care so deeply about our patients. Doing the right thing hurts sometimes, and yes, we all get burned. It's strange to think that five days ago, I saved my patient's life, a feat which I still don't view as being particularly extraordinary, certainly nothing worthy of anyone's admiration or exultation. It's simply what I do, and believe me, I had a lot of help. I no longer sport a white coat, having traded it in for scrubs many years ago. Today, I'm clothed in a not-so-invisible armor of compassion and humility, outfitted with the accoutrements of patient advocacy, the true trappings of my craft. I sometimes just need to be reminded that I'm good at what I do.
(Dedicated to my friend and colleague, Jeffrey Todd Wheeler, M.D.)
Todd & me in 2005, at my surprise house-warming party. We survived Emory anesthesia residency together.


*laryngospasm: a life-threatening involuntary spasm of the vocal cords, usually triggered by mucus or saliva, which temporarily restricts airflow into the lungs.


Saturday, September 15, 2012

This Side Of Tomorrow

     Every now and then, I seem to have not just one of those days, but one of those weeks, the kind that leaves me bewildered, emotionally and physically exhausted, flirting with an old familiar despair that I normally ignore because it's too close for comfort. The whole week was kind of a shitstorm, really. It began at work Monday with an ethical dilemma, culminating in perhaps the most severe violation of personal dignity and autonomy I've ever witnessed: an elderly Alzheimer's patient being bullied into accepting a feeding tube by her own daughter. Because of issues surrounding informed consent, as well as the old woman's clearly stated objection to having the tube placed, I chose not to become involved in her case. The helplessness in that poor woman's eyes haunted me, though. She'd wondered aloud, "Why would I want a feeding tube? I'm in my late 80s!" to which her daughter replied, "Mom, you'll die without a feeding tube!" In a moment of extreme clarity, the old woman quietly said, "Well, people die when they're my age." Although I'm quite certain that neither she nor her daughter were aware of the data which demonstrate that feeding tubes don't improve outcomes, increase longevity, prevent aspiration, or enhance quality of life in patients with advanced dementia, this frail old woman had a gestalt about the situation. Yes, people die when they get to be her age, and many of those who are living without their faculties wish for an even earlier death. Why is our culture so opposed to death with dignity? I realize this sounds morbid, but the truth of the matter is, we start dying the moment we're born. The only guarantee we have in life is that one day, we're going to die. From that perspective, wasting away gradually and naturally when you're 89 because you're tired of living isn't necessarily a bad way to go.
     Twenty-two years ago, my three month old twin sons were handed a death sentence: cystic fibrosis. Although the pediatric pulmonologist who called to deliver the results of the boys' genetic testing hadn't intended for it to come across that way, their father and I knew exactly what it meant. Out of all the possibilities, it was the diagnosis we dreaded the most. Cystic fibrosis (CF), an inherited disease which progressively affects lung and digestive function, leads to a lifetime of crippling pulmonary infections and malnutrition, and until two decades ago, claimed the majority of its victims during adolescence or young adulthood. Today, the predicted median age of survival for CF patients is still only the late 30s. The year Nick and Rory were born, the gene mutation which causes the symptoms of CF was identified, and we were led to believe that a cure was just on the horizon. No one bothered to mention that this so-called horizon was actually a personal hell, especially designed for parents who'd unknowingly and unintentionally passed on bad genes to the children they created out of love. My sons will never see the cure--their lungs and pancreases have already sustained irreversible damage. The best we can hope for is more targeted therapy that will work at the cellular or molecular level, the pharmaceutics of which is currently undergoing agonizingly slow clinical trials. It's a process that can sometimes take years, and when you've got sick kids, each year is numbered. We've been fairly fortunate in that neither Nick nor Rory has had to spend much time inside the hospital. With the exception of just a few bumps in the road, such as Rory's three courses of home IV antibiotics over the past year, they've enjoyed reasonably good health. Now that they're adults, I don't have much involvement in their daily maintenance. They go to the CF clinic by themselves, deal with their doctors and therapists, manage their myriad medications, and perform their own breathing treatments. As someone who's spent a significant portion of parenthood silently grieving the very real possibility of outliving my children, I've eventually had to resign myself to that tired old maxim: "No news is good news." It's the only way I know to survive.
     As I drove home from work Monday, ruminating about the demented old lady and her pushy, condescending daughter, Rory called to let me know his CF clinic visit hadn't gone too well. "Mom, my lung functions are down again. I just haven't been able to kick this infection. Dr. Walker wants me to go back on IV antibiotics and have a bronchoscopy. I really don't want to have to go to the hospital, and I'm sure you'll agree that we can do the antibiotics at home." My heart sunk. "No, baby, this time, you're going to have to go into the hospital. This is the fourth time in a year that you've had to go on antibiotics. You're on a slippery slope right now...we've gotta get this infection figured out for good." Rory sounded defensive, "I've been trying so hard, Mom, doing everything right, all my treatments and everything!" My throat tightened, the bittersweet lump of lament quickening in my chest as I blinked to keep the hot tears from spilling out, but I could no longer contain the deluge. "I know, sweetie, I'm not blaming you, I'm just so frustrated and sad. I had a terrible day at work. And, I don't know what to do to help you...I feel so helpless and I hate that this is happening to you again." An uncomfortably long silence followed, interrupted by my choking sobs, the despair threatening to resurface once again: Is he going to make it to 40? Will his dreams come true? How could I live without him? "Mom, don't worry, I'm a fighter." Rory will be admitted to Emory University Hospital next week, and I'll be there with him Thursday morning for his bronchoscopy, an endoscopic procedure that's done under sedation to look inside the lungs.
     Last night, while Spartacus and I were eating dinner at our favorite outdoor pizza joint, a little tow-headed boy caught my eye. He couldn't have been more than five years old, and his tousled platinum blonde hair reminded me of how Nick and Rory looked when they were that age. With gleeful abandon and not a care in the world, he jumped up from the table where he and his parents were sitting, dancing barefoot in the middle of the walkway, gyrating wildly, almost purposefully, his sun-tanned limbs effortlessly twirling and spinning in perfect sync to an old Motown tune that was being played overhead. It was exactly what I needed to see, a welcome distraction. I thought about Rory, who's only known life with cystic fibrosis, and the poor elderly lady, who can no longer remember her life--he's fighting to live, she's fighting to die. They've both been dealt an unfair hand. It is what it is. For the old woman, her memory impairment is probably a blessing in disguise. To her, every moment brings a new day. Like the beautiful dancing boy, Rory lives on this side of tomorrow, the buoyancy of his spirit counteracting the physical imperfections he's done nothing to deserve, the ones that are slowly tiring him out. But for now, he's got good wind, and he's dancing like a fiend, like there is no tomorrow, and you know what? I'm dancing right along with him.
Nick, me, & Rory at one of their band's outdoor gigs, right before it got busted up by the police. And yes, that's a PBR in my hand.