Category Archives: Musings

“A soft answer turneth away wrath…

…but a witty one can silence a fool.”

Living in New York City means living in close quarters with people who are at times cocky, arrogant, brusque, dismissive, and overbearing.  People do not sit on the front porch sipping lemonade here; they do not bring casseroles to new neighbors.  No, they run over others who happen to get in their way, they insult those in proximity who happen to annoy them, and they often have no regard for others they may be inconveniencing.

Thankfully, the hospital atmosphere usually smooths out the rough edges.  Usually.  I remember vividly when I was interviewing for residency at NYU, I stopped at the security desk and asked politely for a visitor name-badge.  That simple request at 7:30 in the morning apparently ruined that security officer’s day.

The other day, I was going to bring a patient back to the operating room.  One of the nursing assistants had already started an IV on the patient–a bit of a luxury at my institution.  I usually will just carry the bag of intravenous fluids as I escort the patient, but this time, without thinking, I started to push the IV pole with the patient as we headed toward the door of the preoperative holding area.

“I knowyou’re not taking that pole!” one of the nursing assistants said in a condescending tone.  I stopped, instantly feeling annoyed.  I usually don’t think about the medical hierarchy, but there definitely is one.  Attendings > Fellows > Residents > Interns > Medical Students.  Nurses have a bit of a different ladder, but I would generally place an average nurse somewhere between an intern and a medical student.  Interns write orders that nurses follow, but they are still credentialed professionals; medical students are not.  Otherwise, the nursing hierarchy is something like Nurse Manager > Charge Nurse > Nurse > Nursing Assistant.

As a senior resident (a chief resident at that) I intuitively feel I’m perhaps a couple rungs higher than this nursing asssistant.  And while rudeness (in the sense of condescension) is never professional, it seems particularly egregious when it’s directed up the ladder.

And so, I turned, and I said in the most neutral tone I could muster, “Are you asking me to leave this IV pole here?  Because if you ask nicely, I would be happy to.”  This was met with absolutely no reply, so I unhooked the bag from the pole, and escorted the patient out of the room.

On a different day, I happened to have a medical student on an anesthesiology rotation assigned to my room.  We were doing a complex case–a resection of a lobe of the liver for a living-related liver transplant.  The surgeons like the patients dry so the liver doesn’t bleed as much, and I was trying to accommodate, though the risk would be hypotension.  Throughout most of the case I was successful in walking the fine line of hemodynamics, though at one point the patient seemed a bit bradycardic (heart rate of 46, baseline of 60, running most of the case in the 50’s) and hypotensive.  I gave a dose of ephedrine and a little fluid, and explained to the medical student my rationale as we watched the monitors for the response.

Just then, I heard a voice say, “The patient is bradycardic.”  I turned around.  It was a woman who had been one of the two or three people floating mysteriously on the periphery of the room; she was now standing immediately behind me.

Rather than answering her, I asked, again with a neutral tone, “Excuse me, who are you?” “I’m with the liver transplant team, but I used to be an ICU nurse,” she replied.

I then asked her, “Are you asking me or telling me that the patient is bradycardic?”  She said nothing, so I turned around and went back to my job of taking care of the patient.

I think the thing I found particularly insulting is what this former ICU nurse’s interference with my work implied.  If I’d been sitting there working on a crossword puzzle while the patient was on the brink of death, that is one thing.  But I was clearly monitoring the patient, so this woman’s comment suggested that I was not qualified to recognize a problem.  This I found highly offensive.  This is my job.  I monitor patients.  I keep them alive while the surgeons hack out major organs. Not only did I already knowthe patient was bradycardic (not so worrisome) and hypotensive (more concerning), I had already treated it by the time this woman thrust herself into my area of sanity on my side of the drapes.

I will spare my gentle readers the story from the same day of the animal, er, older man, who resorted to pushing on the subway when people were in his way, rather than walking around or *gasp* saying “excuse me.”

I don’t know…maybe I’m the arrogant, dismissive one.  But better to be clever and arrogant and dismissive, than foolishly arrogant.


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Doctors as professionals

I ran across this interesting post recently which contrasts physicians with other professionals.

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Maybe I should get a desk job…

Editor’s note: I wrote this post some time ago, but waited an unspecified length of time to post it to protect patient privacy.  It should be noted that the post portrays graphic medical situations in raw, unedited detail, so readers with a delicate constitution may wish to stop reading here.

Yesterday afternoon’s code was one of the…shall we say…earthiest I’ve ever been to.  My friend Jen, carrying the code pager for the day, had grabbed the orange “arrest bag” which was stocked with medicines, airway equipment, and gloves and was headed out of the anesthesia workroom.  “Code blue, sixth floor,” she said tersely, “Want to come?”  Given that I find participating in codes strangely rewarding, I tailed her.  It’s satisfying to make a huge difference in the acute trajectory of a patient’s health, and once an endotracheal tube is successfully placed, one can sense the rest of the medical team breathing a collective sigh of relief.  I’ve also noticed that walking into a crowded room, assessing the situation, and taking charge and communicating effectively seem to restore a bit of order to the chaos.  It’s good practice for learning to function well in highly stressful situations.

As Jen and I rounded the corner, we saw a small gaggle of medical students clustered around a door near the nurses’ station.  They talked quietly in intense conversation among themselves, their short white coats’ pockets bulging with reflex hammers, pocket references, and “to do” lists.  We immediately headed toward that door.

We strode into the room that was packed with physicians, nurses, pharmacists, respiratory technicians, and the code cart.  Being nearly 6’4″, I had a decent view of the situation, but rather than seeing a patient, all I saw were white coats clustered around the bed amid a flurry of syringes and beeping.

“Anesthesia,” I announced loudly.  “Who’s the primary team?”

“Anesthesia, get in here and intubate this patient!” one of the surgery seniors commanded me.  A little taken aback by his tone, many thoughts quickly crossed my mind.  Why else were we here?  Tea and crumpets?  Of course we were going to intubate the patient, in the quickest and safest manner possible.  Jen and I were working our way to the head of the bed.

Rather than replying, “Can you communicate with me rather than barking orders at me?” I simply asked in a voice that carried across the crowded room, “Does he have any cardiac history?”  The surgeon didn’t seem to know.  Instead, in a more neutral tone, he said, “He aspirated.  He needs intubated.”  Aspiration is the medical term for when acidic stomach contents enter into the trachea (windpipe) and potentially cause grave damage to the lungs.  Most people who aspirate end up with in the ICU with lung injury; many die.

By this time, through the tight ring of white coats, I was able to see the patient at last.  They were doing chest compressions.  I looked at Jen and said, “Compressions.  We need to intubate.”  A true code–that is, a cardiac arrest–makes our job fairly simple.  No medicines are needed.  Just a laryngoscope and endotracheal tube.  And there’s really nothing worse than being already dead, so we don’t have to worry much about hurting the patient.  I’ve never heard of a patient saying, “Hey Doc, I wanted to thank you for saving my life, but I think you may have cut my lip in the process.”

The “fairly simple” task, however, became a bit more complicated as I got a better view.  The bed was only about two feet off the floor, making it more difficult to get a close view.  The patient had a huge stomach, which is usually associated with a thick neck and a difficult time performing adequate laryngoscopy.  In addition, he had a full beard.

“Move the bed out,” I ordered.  As the bed rolled forward, I noticed not puddles, but small lakes of brown liquid covering the floor at the head of the bed.  The white sheets covering the mattress were saturated with particulate brown fluid.  Donning gloves, I scarcely had time to process it before the respiratory therapist told me, “I’m having trouble moving air.”  With that, she removed the ambu bag and I saw the source of the effluvium.  It was erupting from the patient’s mouth with every compression of his chest.

“This’ll be tough, Jen,” I said, looking at my fellow senior resident.  “Do you want to do this?”  She shook her head no as I removed the head board and grabbed the suction tubing with the Yankauer tip.  This attachment quickly clogged with the particulate matter, so I removed it and placed the larger tubing directly in the patient’s mouth while the internists continued compression and rounds of epinephrine and atropine.

After thirty seconds, I realized that whatever I suctioned out was being replaced with more fluid from deep, deep inside this poor patient.  His mouth was like a storm sewer overflowing after an afternoon deluge.  If we didn’t get oxygen into his lungs soon, there would be no hope of resuscitating him.  I tried to think about my options: a fiberoptic scope would be useless with all the liquid, and it was downstairs anyway.  A laryngeal mask airway might help get oxygen in, but it wouldn’t prevent more fluid from entering the lungs.  I don’t feel qualified to do a slash-tracheotomy, and a needle cricoidotomy would be silly in this setting.  He needed a definitive airway–an endotracheal tube–and our main way of placing it–by direct sight–was impossible with the copious runny stool being forced up by the impossibly large gut.  My sense of smell, taste, and hearing didn’t seem to help me here.  This left me with one obvious answer.

“Jen, could you hand me a bougie?”  This somewhat rigid yet flexible tool saves lives daily in the operating room.  Its curved tip is designed to bounce on the cartilaginous tracheal rings, providing tactile confirmation that the bougie is within the trachea and not the esophagus.  Once in, an endotracheal tube can be slid over the bougie, the cuff inflated, and the bougie removed.

I grabbed the laryngoscope and pried open the patient’s mouth, while brown chunks seeped out the corners of the lips.  Advancing the laryngoscope by feel rather than sight, I knew that it would help me by lifting soft tissue out of the way, rather than providing a line of sight.  I took the bougie in my right hand and plunged it into the small pool in the patient’s mouth.  It met some resistance as I advanced, so I twisted and redirected a couple times before it finally sped forward.  I felt a subtle bump or two, suggesting tracheal rings.

Raising my eyebrows at Jen, I steadied the bougie while she advanced the endotracheal tube over it.  With deft hands, we inflated the cuff, pulled out the bougie, attached the carbon-dioxide sensor, and applied a few breaths with the ambu bag within seconds.  The sensor turned a reassuring yellow, and one of the keen internists called out, “Bilateral breath sounds!”  The tube was miraculously in place.

I called for a soft suction catheter, knowing if the patient stood any chance of survival I’d have to remove as much fluid as possible from the lungs.  As I removed the ambu bag, however, I didn’t anticipate the geyser of fluid pumped from the lungs, up the tube, and out onto Jen’s scrubs and a nearby internist’s white coat as another medicine doc continued forcible compressions.  We quickly suctioned and continued ventilating while rounds of epinephrine, atropine, lidocaine, and calicium were poured into the femoral line.

The story ends, sadly, as many codes do.  We were unable to restore a heart rhythm.  The code was “called” as no pulse was attained.  The room emptied in what seemed like seconds leaving Jen and me, with spinning heads, alone with the patient and our orange bag.  We wandered back downstairs to change scrubs and sit down for a few minutes of peace to restore our sanity.

In retrospect, I cannot think of much we’d do differently.  Attempting mask ventilation can force more fluid into the lungs in a patient with such copious gastrointestinal regurgitation.  We should have put on masks with face shields first thing for our own protection.  But in reality, I knew that our chances of bringing this fellow back were next to nothing with such massive aspiration.  Here is a situation where the patient is clearly objectified, as he should be in that moment.  He becomes a task, a problem, a challenge.  We solved it.  And even if saving his life was practically impossible, by restoring oxygen to the lungs, we at least gave a sense of closure to the medical professionals.  Everything that could be done had been done.

Images of those minutes kept coming into my mind during the remainder of the afternoon and as I tried to go to sleep last night.  Nearly every sense was saturated with input: slippery floors, shouted orders, red blood & brown stool, ringing pages, splatters, needles, cracking ribs.  And I wondered, “What kind of job do I have?  What would it be like to sit behind a desk, sip coffee, and sort through e-mail and messages?”  In medicine, we tweak the inner workings of an amazing machine, our finesse guided by thousands of years of experience, by the scientific method, by love, by art.  But in the crucial times, practicing medicine rams together the raw, animalistic, sloppy, dirt-under-your-nails sort of gritty survival instinct with placid, cerebral, transcendent rationalism.  And I marvel that this is all starting to become normal.


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Guilty pleasures

I had an epiphany of sorts on the train today.  I was riding in relative peace–as much as was possible wedged between two strangers in a car whose air-conditioning was a bit like a gentle breeze in Death Valley–when a nearby two-year-old began to cry.  This was no “I’m scared” cry, or “I’m hurt” cry.  No, it was an angry cry, one whose screeching pitch rose and fell like the tides, one whose tantrums crested with piercing squeals as the child arched his back and kicked his legs in convulsive fits.

A pleasant middle-aged black man riding across from me smiled at the struggling father and asked, “How old is he?  Two?”  The father nodded.  In that moment, I could think of no other age that so deserved the modifier “terrible.”

In fact, the cries brought me back to my time doing pediatric anesthesia.  For those rare children whose parents refused oral premedication on their behalf, a trip to the operating room may have well been like checking into a nice stay at Abu Ghraib.  And for these children–a particulary wiry and surprisingly strong eight-year-old getting a questionably medically necessary circumcision comes to mind–gently inducing anesthesia was a two-, or sometimes three-man job.  More than once, I’ve stood behind a child who sat on the operating room table facing his mother and wrapped my boa-long arms around his body, pinning his arms to his side, while the attending held the cherry-flavored mask to the little head which was frantically flinging itself left to right, left to right.  With every deep, visceral shriek, I could just imagine the little molecules of sevoflurane being whisked from lung to capillary to heart to brain.  No child can withstand a compelling inhalational induction of anesthesia.  Grisly, but strangly satisfying.

And so it was, as the cries brought me back to the rattling subway car, I slowly opened my bag and pulled out the pink bubble-gum mask.  The father, seeing this, grimly nodded and handed the child to me.  His dark, confused eyes surveyed the new face before him while his shallow panting afforded our ears a brief reprieve before the fierce wailing resumed, the back arched, the little fists pounding against the orange plastic seats.  As I pressed the mask against the child’s face, the sobs became muffled and shorter, and then, eyes rolling back, blessed, quiet sleep came.  I handed the little one back to his father as the subway ground to a stop and the doors opened.  A last glance at the car before exiting showed every beaming face raised, every mouth upturned in a thankful smile.

Okay, so I made up that last paragraph.  But oh, what I would have given to knock that little kid out (anesthetically, of course).  It was startling, though, to realize that I wouldn’t have done it only for the sake of my hearing.  No, when those situations arise–not that I would ever choose to be in them–there’s also some element of primative power struggle, and it’s gratifying to win…even against a two-year-old.

Addendum–ethical analysis

In my defense, I don’t believe I’m a horrible doctor and a horrible person.  Just reflective.  The same essay could probably be written about law-enforcers, or CEOs, or even a flight attendant dealing with an unruly passenger…  With many (most?) jobs, there’s a difference in power, and when individuals’ goals are in conflict, that power advantage–be it physical, mental, social, or rhetorical–can be, shall we say, compelling.  The intentions and the circumstances may determine the moral and social acceptability.  Anyone remember Rodney King?

What I realized is that unpleasant as it is to put a fighting child to sleep (“Disgusting,” I remember my attending muttering after the aforementioned eight-year-old was anesthetized, referring to our brute force, not the child’s lack of cooperation), it’s generally regarded as necessary in some circumstances, and it accomplishes a greater good, so it’s okay.  But if I’m honest, I have to say that a primitive part of me actually finds it satisfying.

Obviously, the hypothetical scenario I described on the subway would have been a display of power not out of necessity or because it was accomplishing a greater good for the child, but simply because it would have given our ears a rest from the painful cries.  The epiphany was that I would have definitely enjoyed putting that child to sleep for the good of everyone on the subway.  Clearly this is ethically indefensible, and so those motivations were filed away to some hidden part of the consciousness, and I continued reading my magazine in a socially acceptable manner as other nearby riders rolled their eyes and the wheels continued clicking along the steel rails.


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Pain and palliation

Today was a rewarding day.  I was called by a primary care team to assist with the care of a 25 year-old girl who is dying of cancer.  This was a situation that, as unfortunate as it was, had been made more complicated by growing distrust on the part of the family.  As the resident told me her story, he mentioned that the patient was being seen by the Palliative Care Service.  This was unusual, since the same pain specialist oversees both the Palliative Care Service and the Chronic Pain Service.

I agreed to come, not as a formal pain consultant (since my boss was already technically on the case), but as someone that might visit with the family and offer another perspective.  This was mainly a psycho-social consultation.  I did meet briefly with the patient, but spent most of my time in the family room with the father, the rabbi, and the primary care physician.  When I arrived, they were on the verge of signing Do Not Resuscitate/Do Not Intubate orders, and the father wanted to make sure that in spite of signing the paperwork, the family would still have a voice in the medical care.

This, of course, was easy.  I assured him that these measures simply meant we would not take aggressive measures to unnaturally prolong his daughter’s life.    They absolutely would not change the quality or quantity of their interaction with their physicians.

I spent the next thirty minutes asking about their goals and expectations, listening to their fears and frustrations, and assuring them that we would in no way abandon them in the face of the daughter’s rapidly deteriorating health.  I say “them” because in this case, my role of physician seemed to explicitly extend to include the patient, her parents, and the rabbi.  We clearly definited several goals: comfort & pain control, avoiding sedation, tolerating oral medications, being able to go home.

Tangibly, I was rewarded by being able to accomplish what the primary team and the regular Palliative Care Team had been unable to do, that is, to adjust the pain regimen that might facilitate comfort and be a step closer to home.  I attribute this not to any special skill, but to being willing to take the time to build a “therapeutic alliance” which involved the family’s trusting me that I had no interest in pushing the patient out of the hospital.  I clearly expressed that in the setting of rapidly progressing cancer, avoiding sedation might conflict directly with comfort, but that we would do everything possible to accomplish both.

Practically, this meant increasing the transdermal fentanyl dose, changing the intravenous pain medicine to avoid some untoward side effects, and supplying some potent non-intravenous medications as a trial run for out-of-hospital care.

But I felt most satisfied when I rose at the end of the conversation and the father and the rabbi both stood and eagerly shook my hand and, with damp eyes and choked voices, emphatically thanked me.  Here I was, telling them that yes, the daughter was dying, and that I could keep her comfortable but maybe not awake and she may never leave the hospital, and they were thanking me.  That’s ironic.  But I also told them that I would walk with them, that I wouldn’t abandon them, that I cared about what was important to them, and that I understood them; and they responded to that.  It was here, in practicing the art of medicine, that I connected with the family’s experience at the same time that I connected with physicians who, through the millenia millennia, have eased suffering and done no harm.  And that made my day.

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Random thoughts from the big house

Whenever the “Ouch” pager clipped on my belt this week goes off, I’ve found myself standing quickly and informing others in the room, “I’ve got to go. There is a child in pain.” I’m not sure they can always tell the comment is meant to be tongue-in-cheek. Often it’s the hyperattentive parent, not the child, that makes me most uncomfortable. Of course I want to help these kids (many of whom are post-surgical or have sickle-cell vaso-occlusive crises), but wow, some of these parents need to tone it down.

For instance: venipunture. If there were a magical way to draw blood without using a needle, of course we would do it that way. Or if we could make do without labs, we wouldn’t drawn them. Naturally, no toddler is going to relish the thought of a vaccine or a needle-stick. But I feel that when we make such a big deal about it, it makes the experience for the child that much more traumatic. Surely there’s a cultural component. I wonder if the African children I saw in Cameroon would be so upset by the mosquito-bite sensation of a blood draw?

On the pediatric pain service, we aim to use multimodal therapy. For one child recovering from a Chiari malformation surgery, today’s plan was opiates, adjuvant medications, physical therapy, and a visit by the clowns.

Many children treated with opiates develop constipation, leading to the necessity of routine and often aggressive bowel regimens. One of my favorite quotations of the day was instructions to the nurses from my attending, regarding a constipated child. “Cotinue the stool softeners and go ahead and try another suppository. If that doesn’t work, then try an enema. Those are more intrusive.”  “Intrusive” puts it mildly.

On a creepy note, one of my fellow residents, while reading a chapter in a basic textbook today, asked me, “Who said ‘Practicing anesthesia is practicing medicine of the autonomic nervous system.’?” My response, “I did. I coined that phrase in 1986 while giving a lecture in Chicago.” We both laughed, and then my colleague said, “The quotation has a 1 beside it.” I directed him to look at the endnote at the back of the chapter. Reference 1 was another book produced by publishers based in Chicago, copyrighted in 1986. What are the chances?

Another fellow resident related to me the story of his patient who caught on fire several months ago. The patient was crumping before his heart surgery, so the surgeons sloshed sterile prep on the patient, cracked the chest, and “crashed” onto cardiopulmonary bypass. It’s unclear how the fire started, but in the process of sawing through the sternum, perhaps a stray spark ignited the still-wet alcohol-based cleaning solution. The fire was quickly dowsed with saline, but the patient (already intubated and under general anesthesia) had a couple blisters on the neck and chest. Given the, uh, unusual circumstance in the operating room, an intra-operative dermatology consultation was requested.

The instructions were simple, as the burn was very mild. “Put some silvadine on the blisters….and oh yes, give some extra fluid.” We thought the last piece of advice, though generally appropriate, was cute . Here is a patient on cardiopulmonary bypass, during which we’re continuously draining the patient’s entire blood volume approximately once per minute and pumping the anticoagulated blood back in, carefully maintaining temperature, pressure, volume, anesthetic depth, and anticoagulation parameters. And we’re told to give a little extra fluid.

This is akin to getting a car’s engine replaced, and asking the mechanic to make sure there’s enough windshield wiper fluid.


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A couple more interesting spaces

In yesterday’s post I included a couple photos of the new New York Times building.  This weekend I happened on a few other noteworthy spaces.

Here’s a photo of Juilliard taken from 65th Street looking east toward Broadway.  The addition takes advantage of the space that used to be open plaza on Broadway between 65th and 66th Streets.  I think the most interesting architectural feature is, of course, the overhanging corner slanting up over a curtain wall of glass.  (There’s black mesh hanging down which will eventually be removed.  The verticle white column is just inside the corner of the curtain wall, which is obscured because of the mesh.) When finished, the heavy stonework will appear to float over the glass windows and over nothingness.  In this image, we can clearly see the support column which rises to brace the horizontal girder, not the slanted beam.  I expect that this structural feature will be obscured once the limestone exterior is placed.

And here’s a view of an alley on Claremont Avenue, around the corner from where I live.  In contrast to most of the New York City alleys, this one actually looks well-kept and pleasant.

I apologize for how blurry this last photo is.  It’s taken from the back of my church, Emmanuel Presbyterian Church, on Sunday, June 8, 2008.  Jane and I were assigned to usher that day, and we adopted a more proactive and aggressive stance (yet still warm and friendly, of course) when it came to seating people.  Notice the masking tape discouraging use of the back rows.  From past experience, we know that this tape “keeps the honest folk honest”, but it’s a weak deterrent for the determined backrower.  So on that Sunday, we smiled when welcoming people and said, “Come with me; there’s some space at the front.”  Finally, the key ingredient was that we waited to hand people the bulletins until we arrived at the row in which we wanted them to sit.

This, truly, is effective ushering.  Instead of spending half the time setting up chairs in the back and trying to seat people here and there in pockets of empty seats, we were able to fill the sanctuary rather efficiently from front to back.  In church, it’s not a bad thing if the desires of the individual take second place to the good of the whole.  And despite the projection screen at the front, it’s not a movie theater: early comers don’t always get their seat of choice!

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