My biggest regret about this opera is that I was dreadfully tired, and ended up sleeping off an on.  At 90 minutes, it’s a very short opera.  All I can say is that I enjoyed the early classical instrumentation and orchestration, and the singing was on par with the Met’s high standards.  The creative set with the maqueraded chorus set on tiers was effective.  Sadly, I slept through the climax of the opera when Orfeo looks back at Euridice, sending her back to Hades.

Also noteworthy is that I brought the intern who’s been working with me for the week, David.  Not only has he had the misfortune to spend all day with me in the operating rooms all week, but he went to the applicant dinner I hosted on Tuesday evening, and went last minute with me to the Met so that my extra complimentary ticket didn’t go to waste.  He’s truly been my protege for the week.

The thing I was most looking forward to was hearing Ben Heppner on stage.  I was a little disappointed.  Although his artistry was evident in his role of Ghermann, his voice seemed a bit small, at times swallowed by the orchestra.  It also had a slight nasal character without the open resonance I’ve heard on a number of his recordings. Yeletsky sang a fine aria in Act II.  Maria Guleghina, as one of the leading sopranos, had a powerful voice that filled the hall, but her singing was unrefined, even clunky.

The set was impressive.  With seven scenes spanning three acts, the director creatively explored the picture-framed stage with a sloping floor.  The first scene featured a Russian street scene with a simple but beautiful backdrop of winter trees against a turquoise blue sky.  Lisa’s room was feminine yet impressive with twenty-five foot French doors.  Everything in the ball scene in Act II wowed the audience, from the three enormous Corninthian columns to the elaborate costumes of the Russian nobility.  There was even a rather confusing appearance by the Empress, Catherine; although it had nothing to do with the plot, it captured the grandeur that only the Met can do when it pulls out all the stops.  In contrast, the second scene of Act II was much simpler, having only a chair and an enormous painting of the Countess, which Ghermann revealed by flinging open a series of gigantic sliding doors.  The first two scenes of the third act were stark as well, with minimal set, making for a contrast with the elaborate gambling house and huge male chorus in the final scene.  Throughout, the director/designer made an effective use of light and dominating shadows.

The music very enjoyable.  Tchaikowsky accomplishes a score that’s at once rich and graceful, at times even Beethovenian, like the opening of the second act.  He provides a couple impressive piano and cello solos.

In the end, however, the opera failed on the psychological level.  Even if personalities aren’t entirely believable in opera (are they ever?), a successful connection requires that the audience care about the characters.  This didn’t happen for me.  I found the double suicide more tiresome than distressing.  The Countess’ character was as one-dimensional as the shepherd’s staff.  I can only hope that Tchaikowsky found better librettos for his other operas.

I took my first pediatric anesthesia long call on Friday.  I went in expecting to anesthetize a three-day-old neonate for a Norwood procedure (palliative surgery for hypoplastic left heart syndrome), only to find out the case was cancelled.  Instead I did a central line on a 1 year old and a pyloromyotomy on a 3 week-old, before helping with sedation for a 7 year-old in the MRI.  This child had “single ventricle physiology” having a hypoplastic left heart as well, now having undergone the Norwood, bidirectional Glenn, and Fontan procedures.

I then did brief afternoon rounds with the pediatric pain attending, as I was covering the “OUCH” pager that night.  Circling through the list before I left the hospital, everyone seemed comfortable enough, and I went home.  This is one of the few rotations where we can take home call, or “pager call.”

I was awakened by my pager at 0100.  There was a 7 year old with a ruptured eyeball, and the ophthalmologists wanted to take him to the operating room within the hour.  I quickly paged my attending to notify her of the case, dressed, and caught a cab to the hospital.  No telling how long I would have waited for the subway at that hour, and ten dollars seemed like a small price to pay to avoid the cold and get there quickly.

I was in scrubs and had the room set up by 0150. but the patient didn’t show up till nearly 0300 from the emergency room!  Somebody felt the need to order a CT scan before sending him up to the operating room.  Anesthetic concerns include the following:

• This is a trauma, and thus may put the child at risk for aspiration of stomach contents during induction of anesthesia.  Pain and increased tone from the sympathetic nervous system delays gastric emptying, and aspiration can occur as a patient is anesthetized and loses protective airway reflexes.  Aspiration, though rare, has a high fatality.  In order to minimize the risk of aspiration, anesthesiologists frequently employ the “rapid sequence induction” technique.  This involves ample preoxygenation of the patient to build up as large a reserve of oxygen as possible in the lungs, and a quick administration of a sedative and a paralytic–usually succinylcholine because of its rapid onset.  As the medications are pushed, pressure is applied to the round cricoid cartilage in the neck to help close off the esophagus.  This pressure is continued until the placement of the breathing tube is confirmed.  The breathing tube with its inflatable cuff protects the lungs from aspiration.  In this case, the child had not eaten for more than 12 hours, so this risk was probably lower.
• The eyeball (or “globe” in medical terms) is ruptured.  Succinylcholine can increase intraocular pressure, which could lead to greater extrusion of contents from the eye.  Most anesthesiologists get the willies when we think about jelly-like substances squirting out of an eye wound, so we prefer to avoid this.  Additionally, succinylcholine is avoided in children because of the risk of malignant hyperthermia (serious adverse reaction) in a child with an undiagnosed myopathy (muscle disorder).  Hence, we used rocuronium for our paralytic agent with an onset nearly as fast.
• General anesthesia, and eyeball surgery in particular, can cause nausea, and wretching can increase pressures in the eye.  We would like to avoid this post-operatively as it could damage the surgical repair, so administering ondansetron (a powerful anti-emetic commonly used for severe gestational nausea or chemotherapy-related nausea) is a must.
• Coughing and bucking on the endotracheal tube as a patient emerges from anesthesia is also suboptimal for the same reason.  We can treat patients with intravenous opioids and lidocaine to blunt airway reflexes, and we could topicalize the vocal cords with lidocaine, but in this case we opted for “deep extubation.”  This is a technique in which the patient is allowed to resume spontaneous ventilation, and the endotracheal tube is removed while the the patient is still anesthetized.  The airway is then supported and supplemental oxygen provided.  This provides for smoother wake-ups.

It was around 0600 when I dropped off the patient in the recovery room, leaving me enought time to check e-mail and change into street clothes before heading uptown for my moonlighting shift which began at 0700.  Thankfully, the day was as slow as it could be (not a single operating room case, epidural, cesarian section, or stat intubation) which meant I didn’t do much other than sleep, eat, and read.

November 28, 2008

Greyhound Corporate Headquarters

350 N Saint Paul St # 300

Dallas, TX 75201

~

Dear Sir or Madam,

~

If ever there was a time for a strongly worded letter to the management, it was not when the traffic on the turnpike crawled more like a sloth, or even like a well-trained poodle, than a racing dog.  For holiday congestion is reasonably beyond the control of the most respectable transportation institutions.

And the driver’s unscheduled stops by the side of the road, either for directions or a discreet moment of relief behind a tree, are surely understandable to the traveler from Manhattan, who has already braved sidewalk crowds and the spaghetti-bowl of a subway system and the labyrinthine Port Authority Bus Terminal, which is like the Metropolitan Opera House in some ways–not because of the gracefully aging architecture, the lofty arias, not even the red velvet and crystal, but because both can hold a goodly number of saintly souls whose virtue of patience is outshone only by their inner sanctum of tranquility.

And who could not slip into another’s shoes when the bus driver, a certain Larry Pendleton, driving bus 6200 and being “from the South,” announced he missed the exit and would have to circle back over the bridge–could we help him not miss the exit next time?

Indeed, it would be a thin-lipped crowd–a cranky coterie–which, being so close to Ben Franklin’s town–spitting distance some might say–would not relish the opportunity to take in the lights of Center City for a second time from high on the bridge.

And if a person can claim to have lived a full life without ever being lost on the streets of Camden at night, then please step forward.

For it was there, after asking his passengers for directions, that Larry From The South marched down the aisle to my very row and presented my seatmate with the kind invitation of being deposited on the dark sidewalk of Camden if she were to make one more remark that some consider less than polite.

And it was then that I learned, in such a short time, the sundry Spanish expressions that add a splash of color to circumstances such as these.

So I offer exuberant praise and thanks, dear Sir or Madam, for enriching my travels this Thanksgiving.  I continue to have nothing but the highest regard for the service your company provides.  And this journey remains lodged in my memory, as a bullet becomes lodged in the rib, as a reminder of the excellence one can expect on the Greyhound bus route from Manhattan to Philadelphia, for only twenty-four dollars, round-trip.

~

Thankfully yours,

Jonathan

Early the next morning we were off.  Before leaving Dingle Town we’d picked up some sandwiches, post-cards, and woolen souvenirs. The highlight of the trip to Galway was a thirty-minute ferry ride in the crisp, cool sunshine.  The cold wind blew across the sound as we huddled on the upper deck of the ferry to enjoy the view.

The next stop was the Cliffs of Moher.  I properly waited behind the fence while David ventured with others onto private property for better photographic opportunities.  The sun shone brightly on the green hills and turned the water into silvery waves lapping at the foot of the cliffs far, far below.  We ate a picnic lunch on some steps before admiring a tower and continuing our drive through the rugged and barren “The Burren” with its treacherous roads to Galway.  (Cliffs of Moher picture belows, and my masterpiece panoramic in the blog’s header.)

We arrived at Galway during rush-hour traffic and checked in to Eddie and Helen’s Four Seasons Bed and Breakfast near Eyre Square.  We wandered down to the town center, had dinner of sub-prime lasagna and sub-prime Chianti (David, on the other hand, had excellent roast duck quessadillas), explored the waterfront, and then enjoyed a pint at a crowded pub which featured a piper, three violinists, and an accordian player who might have been carrying a staff and garbed in a grey woolen cloak on a normal basis.  Eddie had told us we’d have to “find the crowd,” and his one piece of advice had been to “follow the short skirts, lads.”  Well, I didn’t see many short skirts in the warm, jolly inn, but there were many a person enjoying the folk music, fellowship, and satisfying drink.

Tuesday, April 15, 2008:

I could tell David was slowing down as he pushed his sausage and hash around his plate.  We were downstairs the following morning enjoying a big breakfast–an omelette for me, and a full Irish breakfast for David.  He’d already supplemented his with a wedge of cheese, toast, tea, and fruit salad.  Partially not wanting to waste food, and partly wanting to see if he’d really do it, I challenged him to finish everything on his plate.  He did, surprisingly and nauseatingly enough, and I gave him the 10 euro as promised in our bet.

The day was spent reading and relaxing–at a tea shop, near a 1960s stone cathedral, and on the quay.  We had a light supper of sandwiches and then a pint at the sophisticated and masculine Skiff Hotel with its dark wood paneling, fireplace, and numerous staircases and balconies, right on the south side of Eyre Square.

This picture is either at the tea shop or at the sophisticated and masculine Skiff Hotel, I can’t remember which.

Sitting on the quay in Galway in the late afternoon sun.

And steady soft breathing are all I hear

This dark night. My tired eyes

See nothing in the thick blackness of the room

But the glow from the alarm clock

And the pale yellow light that crawls

Beneath the drapes.

~

And the ache that set root

In the pit of my stomach

Slowly grows again, twisting its vining branches

Around every rib, until once again

My breaths are shallow

And painful, and salty drops of sadness

Roll down onto the pillow.

~

In the morning there will be time

To put away our tender dreams,

As one might put away dishes

In the cabinet of loving expectation.

But in this still moment I think of

The little saucer face,

A chipped teacup tooth

A round bowl filled with laughter.

~

And then, in the camera of my memory,

We slowly tuck the small lifeless form–

Dressed in soft cotton and

Fingers smaller than I’d imagined–

Into a floating cradle warm

With the linen and blanket

Of my swaddling love.

~

Like the dew outside,

Sleep descends mercifully.

And gently rocking like Moses’ basket,

The vessel drifts away.

Here’s a good arrangment I found on YouTube.  Sit quietly for a minute in a comfortable place, take a few slow deep breaths to recenter yourself, click on the link, and close your eyes for five minutes.  You will be a better person for it.

Some of the other YouTube videos had the theoretically pleasing addition of a harp, though the few harps I heard were tuned a distressing quarter-tone flat.

Amazingly, Faure wrote the piece when he was only 19 years old!

the little cube of a room

I’d raced into after seeing

them open on their own.

And once inside, the yellow ceiling light

and the polished warm-hued trim reflected

the small orange button I pushed

for floor 10.

Only when the miniature fires inside

buttons 3 and 4

lit themselves

did I realize I had boarded the

Sabbath elevator

and thought that seven extra stops

made for a nice number,

an unexpected rabbinical ride.

~

This vertical ride, I thought,

reminded me too of the subways,

just off by 90 degrees or so,

when the express train

snakes local,

and nobody bothers to tell me in advance

that the A train leaving Harlem’s 125th

would stop at 116th, and 110th & 103rd of course,

and fail to bypass 96th

before slowing at pleasant 86th Street,

and pausing at 81st to drop off

museum goers anxious to see the dinosaur fossils.

And what’s one more stop at 72nd

before reaching the usual Columbus Circle-59th?

I will never look at these

seven extra stations the same way

but will instead offer a quiet prayer of thanks

for their underground burrows

teeming with rivet and rodent and tile.

~

Indeed, life offers many

unexpected stops–many knots along its

coiled rope of time.

Perhaps if I could roll the paired dice

of urim and thummim,

I could always avoid the flight

with the unanticipated layover,

the homeless man around the corner

who will ask me for a quarter,

even the slow line at the grocery store

that looks deceptively short.

No, it may be better

to savor these little hiccoughs–

despite their sour taste–

and to realize that interruptions

are life,

even if it’s the M60 bus

hobbling from block to block,

its engine wheezing as it traces

its Parkinsonian route.

~

And so the elevator

groaned and shuddered,

yawning at every floor

with a breath as invisible

as every Cohen and Shapiro

that rode with me that evening.

And with the seven stops,

I thought of suffering and blessing,

of scrolls and incense,

and considered a wish of

“Mazel tov”

to my patient soon to give birth upstairs.

 Learning to enjoy the opera more has been a side-benefit of living in Manhattan.  Having strongly favored orchestral music in the past, playing in the pit in a few operas in college helped me to appreciate the genre a bit more, but it wasn’t until I moved here and made friends with several vocalists that the world began to open up to me.  That being said, I hope never to become that sort of freakish opera buff I overheard in Patelson’s the other week.  The kind that says things like, “Bartoli is to mezzo as Pavarotti is to tenor.  That woman is a machine, but a machine with feeling.“  Or, “The Zeffirelli production is creative, but it lacks the raw power and nuance of the staging I saw in the 70s.”

In between the opera, I’ve been working on the Labor and Delivery floor, placing epidurals for labor and doing anesthesia for cesarian sections.  This is my third call in a six-day period.  When I don’t get home before midnight from the opera, needless to say it’s been a tiring week.

The shows this week included Puccini’s Madama Butterfly and Verdi’s La Traviata.  Good, solid Italian opera.  Given that I have a few remarks for each, and given that I’d like to avoid a monstrously long post, I think I’ll post retroactively on each of those.

The new feature the title of this post alludes to is the tab at the top in which I offer a short review of the various cultural experiences I take in.  A bit indulgent and supercilious, I know, but the obsessive-compulsive part of me likes to make lists.

Nothing much needs to be said other than that Anja Harteros was amazing.  Her role anchored the opera, and the major problem was that her brilliant singing nearly always outshone the leading tenor, whose name I cannot remember and will not bother to look up.

Anja Harteros

Zeljko Lucic played a believable father who sang with decorum and impeccable interpretation, his rich voice finely balancing Harteros’ in their Act II duets.  And the final treat was the Baron, sung by John Hancock, whose chocolate baritone voice soared even during group recitatives.  This one performance was enough to inspire me to follow these three’s careers.

The exuberant party scene in Act II, complete with stremers, confetti, costumes, Gypsies, and a matador with five bulls.