A Unconditional Guarantee

There are few absolutes in medicine. But there are some. Like if you get on the bad side of the nurses, they WILL make your life miserable. And if someone in the medical profession, or an immediate family member, is admitted to the hospital, something major will go wrong.

And another unconditional absolute is this: Folks that have more than three drug allergies or that own more than three cats, certainly have been, or should be, assigned a diagnosis from the most recent edition of the DSM (catalog of mental illnesses).

Additionally, if they need surgery in Roanoke, Virginia, I WILL most certainly be their anesthesiologist.

Just today I had one who wouldn't allow the nurse to start an IV on him. Nor would he get into bed or even don a hospital gown. So I had to sneak up behind him and shoot him in the ass, through clothes and all, with a big syringe full of ketamine. Not one of my more graceful moments as an anesthesiologist.

He growled and hissed and I almost lost an eye. But I got the job done. Now, I didn't get paid, because he was uninsured. But there is one more crazy man from southwest Virginia with teeth that shine when he bares them.

The Problem with Mall Santas

All three of my children despise mall Santas. We have $35 photos of all of them as little ones, struggling valiantly to escape their clutches, mouths wide open in blood curdling screams, snot and tears smeared across their red-purple faces.

And as they've gotten bigger, they aren't any more willing to pay these Santas a visit. And, you know, I really don't blame them. They smell bad, like a combination of the urine of other terrified children and sweat that forms from sitting in those suits under the glare of camera flashes all day. They are often in pissy moods, as I would be if I had to do that for eight hours straight. And they know that these figures are imposters, or rather "Santa's helpers" as we call them, because really, they're in EVERY mall. And truly, I'm happy that my three inherently feel uncomfortable sitting on a strange man's lap. They should!!

So we don't force the issue in our house. Now, they tolerate the Santa Claus at the annual Chrismas brunch at the Club...from a distance. But we do not require the mall trip, the wait in line and the forced smile.

I guess my photo albums will be less complete. That's o.k. But the real tragedy is that I'll never acquire a collection of supremely awesome photos like the ones above.

Tiny Baby Girl Twins

I am so excited about this weekend. Ashley and I are going to Raleigh to spend time with Allison, Matt, Jackie and our new babies, Stella and Scarlett.

They came home from the hospital yesterday and everyone is doing so well! Allison seems really happy. The breastfeeding is going well. And everyone is managing on one and a half hour stretches of sleep at this point. I am contantly amazed at the power of endogenous catecholamines and how they enable our bodies to rise to pretty much whatever task needs to be done.

It's amazing the rush of feelings that her experiences are bringing back. Concrete rememberances of time with our tiny newborns seem to exist in a distant fog at the back of my mind. I was so sleep deprived and hormone-crazy. But I do remember specifically holding their tiny hineys in the crook between my thumb and first finger.

Seems funny to remember that! I guess I was amazed.

The Profofol Shortage

Thanks to contamination by endotoxin or particulate matter, or Michael Jackson's overuse, or whatever, we are in the midst of an international shortage of the one anesthetic induction agent we use most. Propofol.

Most of us are doing mask inductions. The old folks we anesthetize are pros at this and are just thankful its not ether they're breathing. And we're substituting intravenous induction drugs that are clearly not as good when patients can't go to sleep with a mask. Patients are suffering more nausea and hemodynamic instablity. Luckily, we can deal with these side effects. But things are messier in the OR these days. It feels sort of like trying to write with your left hand.

Dear Propofol Manufacturers,

Please hurry!

Sincerely,

Anesthesiologists of the World

Reasons to be Thankful...on the Occasion of Thanksgiving

Well, it's actually been four days since Thanksgiving, but I write when I have time. And judging from the date of my last post, I have not had much of that lately.

We have developed a family custom of naming, person by person, what we are thankful for each year while we are eating our Thanksgiving dinner. The children really look forward to this and are so proud and happy when it's their turn to take the stage.

It makes me so proud that each of the three children name their "family" as the one thing for which they are most thankful. They are such demonstrably loving children at this point in their lives! Now, I am fully aware that this will likely change with the scourge of teenager-hood. But I am so hoping that when the hormone-laden veil of evilness is lifted, they will remember what they were most thankful for. And, as is every parent's hope, that they will come home.

My list was abbreviated at dinner, but I've thought a lot since about what I am truly thankful for and why. And this is my list, in a very particular order:

1. Andrew. My husband of just about 15 years. He is the most caring, loving, beautiful person that I have ever met. There are not adequate adjectives in the languages I know to fully describe the person that he is or how I feel about him. When I think of him, I feel a fullness in my chest, a very expansive fullness that has a warm quality to it and is accompanied by a tightness in my throat. The love I feel for him affects me on a visceral level every day.

I have had such a charmed, easy life. I was born into a loving family with financial security. Educated at some of the finest schools in the country. I accomplished all of my career goals without too much hard work. Scored a fabulous job. Had my children easily. Live in the house of my dreams. Travel abundantly. But Andrew was, by far, the best thing that has ever happened to me.

When you rotate the obstetrician's wheel to August 10th, which is my birthday, you see that the date of my conception was nine months earlier, on November 17th, the date Andrew was born. During the times my scientist-mind is struggling with my belief in God, I just need to remember this and the doubts evaporate.

I am most thankful for him.

2. My children. Jack, Alice and Clara. I wasn't always sure that I wanted children. But several years after marrying Andrew I began to feel the biologic urge that many women describe and we started our family. We had Jack first, and I soon came to the realization that this son of mine was someone I needed very much in my life. I grew up with only sisters and had no use for boys. They were impertinent. And Jack taught me just how pertinent a boy can be. He is so smart and funny. And sweet and loving. He is wise beyond his years. And I see in him the person Andrew once was.

Just today he came home from school and told us that he has befriended a boy from India. A boy that the others make fun of simply because his name sounds different to them and because his skin is dark. Jack, at nine, actually sees the inherent wrongness in this. And he leaves his friends on one end of the playground and crosses the vast blacktop of fear and ignorance to play alone with the lonely boy. I am so proud of him.

I did, upon finding out he was a boy, have a slight twinge of disappointment. Not that he was a boy, but that I would never get to raise sisters. You see, we wanted only two children. The sister relationship is so important to me and, selfishly, I wanted to recreate it for two daughters of mine.

So, you cannot imagine my joy, which followed my shock, when I found out, three years later, that I was expecting TWIN girls. So I got my sisters after all.

And with my children came some more faith confirmation. How did God know I wanted and needed a son who has every wonderful quality I never knew a boy could have? How did God know I wanted a ultra-sweet girly girl who is happiest watching me apply makeup, serving as my sous chef and drawing pictures of, well...anything pink? How did God know I wanted a strong, athletic, determined daughter who reminds me so much of myself as a child?

They are the three I got; one more than I wanted. But I absolutely could not live without any of them. I am so thankful.

3. My girl posse. My mother and my sisters, Allison and Ashley. I have plenty of girlfriends. Work girlfriends, social-circle girlfriends, old girlfriends. And maybe it's because I grew up in the Navy and moved every two to five years, but my main girlfriends are those three. Especially now that we are adults and the age differences have been minimized. The three of them would do anything for me, and I for them. Through good and bad, thick and thin, it's these girls I want most by my side. I am thankful that they are my BFFs.

4. My father's health. Twenty years ago he was diagnosed with melanoma and had it resected. Last year, nineteen years later (!!!), it came back in his axilla. He's had surgery, radiation and a hellish year of interferon. His last two PET scans were negative. So we are cautiously optimistic. Its a nasty, stealthy disease. But he is on the winning side right now. And for that I am very thankful.

5. My new house. Or rather the addition we put on our old house. It took 14 months, more than twice the expected time to complete it. And it was nutty to live through. Especially our time in the basement. But it is done and I LOVE IT!! I love cooking in my new kitchen. I love the togetherness it provides us. I love entertaining in it. I love to steam in my shower and step out onto my heated bathroom floor. I love how organized it allows me to be. I love how its decorated and I love my designer. I LOVE, LOVE, LOVE it and I can't help gushing. I am very thankful for my new house.

Other things I am thankful for are my great job and smart colleagues, my church for providing a loving community of faith for my children, my sister-in-law with whom I have developed a satisfying, close relationship as of late, for a secret that is going to knock the socks off my children in January(and the fact that we get to share the awesome secret with my parents) and for Goose, the stray we took in almost two years ago, who has reminded all of us not to judge a book by it's cover and to bloom where we are planted.

I am one lucky, thankful girl!

It's Crab-Picking Night!!

The high tides caused by a combination of Hurricaine Bill and the full moon brought us a bounty of crabs in our pot.

We're breaking out the steamer, Old Bay, newspapers and mallets. It's time to get dirty!

This Boy's a Changin'

In some ways Jack is the same as he's always been: funny, sweet, lazy, clever. But some things about Jack are changing, and I get the feeling these changes are here to stay. He is now capable, gruff and less forthcoming with his feelings. He shuns things, games or activities that he deems too childish. He closes the door when he is in the bathroom, and turns away from me when he is unclothed.

He is 9 1/2 and I think I'm saying "farewell" to my little boy. That was so fast! Everyone said it would be and to savor every moment. But I'm afraid I didn't listen well enough. It is so easy to let the best times of your life pass by without realizing you are in the thick of them.

I no longer have the little boy who came into my life late one March evening. The boy that fulfilled my husband's desire to have a son. The first male offspring of my grateful father. The boy I never knew I wanted but became, and remains, the light of my life.

I am proud and devastated.

And a Storm Rolls In

There's nothing better than watching a storm roll in from the mainland. It usually happens after lunch, just when everyone needs some down time. Today's was loud and powerful and made us all feel really, really tiny here in our little cottage on the sound.

I'll take an afternoon boomer every day, as long as Bill stays way out in the Atlantic...

The Fear of the Fish

All finned creatures off Topsail Island are officially in hiding as the fish-slayer has arrived!

Summertime Sisters

Sometimes I wonder what it would have been like to grow up with a twin. Allison and I were five years apart; a lifetime in child-years, although more and more insignificant now. And I turned 14 twelve days after Ashley was born. And as such, she and I have never had a traditional sister relationship. However, that relationship, too, is evolving into a much closer one. (Gaining another sister at this point in my life is an unexpected thrill.)

So to watch these twin girls of mine grow up together, as two lives so intertwined that sometimes neither they nor I can sort out the individual joys and anguishes, has been a fascinating privledge.

Today I found them on the hammock, stroking each other's faces and cooing together. It was not for show, although they will perform cute twin tricks on occasion. They were alone and simply enjoying each other's company. The company that I suspect they feel incomplete without. The company that they have enjoyed since they became capable of enjoyment. The company that they have had since conception.

I feel so, so lucky to be the mother of twins.

A Visit to the In-laws and the Wisdom of a Five Year Old

With Jack packed off to Hilton Head with my side of the family, Andrew, the girls and I went to Chapel Hill to spend the weekend with his family.

The four little girls (our two and Andrew's sister's two) all had a blast, as usual. There is something about that foursome that just works. Alice and Clara, alone, rarely make it a half of a day without some sort of physical or (because it's what girls do REALLY well) mental battle coming into play. And according to their mother, the cousins are constantly at each others throats during these long, steamy summer days.

But put the four of them together and it is just bliss. No fighting, picking or tormenting. It is all laughing and games and giggles. They share, they respect boundaries. They express their affection physically and with loving banter. They are just happy to be together.

And I usually learn something every time I am with these wonderful children. On Saturday they were all skinny dipping (don't we all love the feel of water on parts where the sun don't shine?), and one girl said to another, "I'm skinny and you have a fat tummy." Now, all four of these girls are lean and gorgeous. One just has a BIT of a pot belly. A remnant of her adorable pudgy toddler body. (Albeit supplemented by a generous helping of her grandfather's delicious blueberry pancakes that morning.)

And even though the offender said something that in her opinion was true, she certainly shouldn't have said it in front of her cousin. But the cousin stopped for a minute, thought about it (I could really see the wheels turning in her pretty little head), and then jumped back into the water and went about her business.

She made a conscious decision that what was said, although potentially hurtful, came from someone who has loved her since she was born. And she was not going to make an issue of it. The history of their relationship was more important than a bruised ego.

Smart, smart girl.

On Cost and Healthcare

Here are some things I'd love to have:

College tuition for each of my three children, sitting in interest-bearing accounts.

A larger sedan as the children have to uncomfortably smush themselves in the back seat now.

A nice swimming pool in the back yard. Public pools gross me out but I love to swim.

The ability to take a year off work so that Andrew could focus on his career.

A house at Smith Mountain Lake, for convenient weekend escapes.


I want each of these things, but I can't afford them. So I don't get them. Obama wants a $1.5,000,000,000 reform package. It would be nice to be able to afford this, but we are not enjoying high financial times. Can't afford = don't get. Why doesn't the government have to abide by simple economic principles like the rest of us do?

Getting Acquainted

How cute is that?

Goose would love to meet a dolphin!

All Bad Things, Too, Must Come to an End

As of today, we 5 have been living in a single bedroom suite in our basement for 5 1/2 months. Along with Goose, our 70 pound dog, and two night-fighting cats.

There is one tiny bathroom and a refrigerator. We eat out 5 nights a week (fun for the first week).

Things I have become accustomed to are as follows: coming to the realization that someone is pooping while I am showering.

That my toothbrush, unless hidden behind my shampoo bottle in the shower, is community property.

Workers who traipse down unannounced no matter what our state of undress or wakefulness happens to be.

And that one day I'll no longer be startled by two little eyes staring down at me while Andrew and I try to work out our tensions in a carnal fashion.

I am told that one day, we'll all look back at this with fond memories. But right now, I am here to say: that day is a long time coming.

She's Having Two Babies

After nine years of being the only sister with children, Allison is finally expecting some of her own. And much to our delight, she will be the second sister in the family to have twins! Happily, this will finally put to rest the burning question posed to me nearly daily: Do twins run in your family? Well...clearly.

So far she is having an extremely breezy pregnancy. Not the first wave of nausea, no fatigue, no heartburn. Nothing, nada, zilch. She looks amazing and her mood is great. She is the Pregnancy Goddess.

Except for one thing. She is completely and certifiably insane with regards to her post-pregnancy expectations. She thinks that when the babies are three months old she will be ready to go to Ireland with her husband for a vacation. And when they are four months old she plans on running in the Boston Marathon.

As my 92 year old grandmother likes to say: "I'm just going to sit back and pat my foot."

The Page From a Partner

Every now and then, when it is my turn to be the doctor in charge of coordinating anesthesia efforts in our 35+ operating room system, I recieve a page from one of my partners.

Typically it's one of my middle-aged male partners, who, after drinking their morning cups of joe (an absolute requirement for anesthesiologists), and never being able to fully empty their bladders due to aged-induced benign prostatic hypertrophy, begin calling at about 9:15 AM. This is a predictable scenario; it happens every day. And it's very easy to deal with. I just stand at the head of the bed and chat up the surgeon for a couple of minutes. Usually the surgeon has a thing or two to say about how it seems that my partner isn't quite old enough for prostate issues and how he must just have a weak consititution, and how common that is amongst anesthesologists. Thick skin is also a requirement. The gas doc returns happy and thankful.

The second most likely scenario is a call from a partner who was running late that morning and didn't have time for that 1st, 2nd or 3rd cup of coffee, that one cup that is required to relieve head tension and to focus concentration. This is also easy to deal with. Stand at the head of the bed and chat up the surgeon. The surgeon usually has a comment about how easy our jobs must be that we can take coffee breaks whenever we want. Again, the gas doc returns relieved and thankful.

And then sometimes, not very often, but sometimes, I recieve a call from a partner asking me to come and help them with an airway. I can immediately sense a difference in the tone of their voice. Typically, they try to act casual and calm. That is how we must act to maintain a sense of order in the room during difficult airway scenarios. But I can usually hear an edge that most people wouldn't be able to discern. All anesthesiologists can hear this edge.

Last week it was Dr. M. He said, "Um, Christy, would you have a moment to stop by room 2? I'm having a bit of trouble getting this tube it." And there it was: the edge.

I immediately dropped what I was doing. My conversation with a pre-op nurse ended, the orders I was writing were left undone, my coffee cup, unattended. And I ran-walked to OR 2. Why the hurry? Because when airways go bad, they go bad fast. And without oxygen a patient can die in minutes. And if my intelligent, skilled, board-certified anesthesiologist partner is calling me for help, then he needs help quickly.

On the table was a 72 year old woman with ovarian cancer and metastatic disease to her cervical spine. Her neck bones were so painful that she decided, despite her limited life expectancy, to have them fused. This operation would eliminate her pain.

And she was a relative of one of our anesthesia techs. The sweetest anesthesia tech in the world and babysitter extraordinaire for my children. Damn! Damn! Damn! The lady on the table had the curse! An unwritten but 100% infallable rule: there will be some sort of complication with your surgical procedure, anesthetic or hospital stay if you are a nurse, doctor, tech or related to one.

The woman on the table was an eggplant shade of purple. I could hear the ominous baritone beep of a pulse oximeter in the background. 38%. Very bad. O.K. Time to act. I helped Dr. M bag the patient up. I held the mask on her face with two hands while performing a two handed jaw thrust, as Dr. M inflated her lungs with 100% oxygen by squeezing the bag on the anesthesia circuit. Over the course of two tense minutes her sats were in the 90s. Whew. During that time Dr. M told me what he had tried, so far, to get the tube in.

Mac 3. No view. Mac 4. No view. Miller 2. No view. By this time it was likely that some mild bleeding was developing in the back of the throat from repeated laryngoscopy trauma. LMA inserted. No ventilation possible. By this point edema was probably setting in and the sats were dropping. That is when Dr. M attempted to bag the patient back up. Due to edema and secretions, he was unable to do it himself, and then called me for help.

Now, with a two-man technique, the sats were up and we needed to figure out what to do. The surgeon was sitting in the corner; a common place for surgeons during airway crises. They are deathly afraid of lost airways. Simply because they have no idea what to do but to call an anesthesiologist. And we were already there, meaning he was out of options. The surgeon suggested cancelling the operation and waking the patient up. But the paient was now stable and desperately wanted this surgery to have the chance to die in peace, whout the debilitating neck pain she had been having.

Dr. M passed a fiberoptic bronchoscope into the patients nare and tried to visualize the vocal cords directly. All he could see was blood and mucous. We passed a suction catheter. Looked again. Blood. It was accumulating as fast as we could suck it.

I asked Dr. M if he'd tried a Mcgrath laryngoscope. No. I asked the anesthesia tech to prepare one for me. It was apparent that Dr. M wanted me to lead the effort. He was exchausted and a fresh algorithm was a good idea for this patient. I placed the Mcgrath. No view. But wait. Were those tiny air bubles that I could see? Could that indicate the path to the lungs? Air bubbles being passively exhaled as I performed a largngoscopy? "Eschmann stylet please." I passed the stylet into the dark area where I had seen the air bubbles. As I passed the stylet I saw a thin white stripe to the side of the dark hole. It was a vocal cord! So close. Dr. M passed a 6.0 endotracheal tube over the stylet and I guided it into the air bubble hole under direct visualization with the Mcgrath. Balloon up, stylet out, scope out. Big breath, chest rise, positive end-tidal CO2, equal breath sounds. We're in! Thank you God.

Dr. M and I locked eyes. He said, "Thank you, Christy."

He and I both know those words, when passed from one anesthesiologist to another after such a scenario, when the life of his patient hung in true limbo, mean far more than just "thank you." It's the same two words and eye lock that I have given to many of my partners, many times. A look that only an anesthesiologist can fully understand. We usher our patients in and out of waltzes with death every day. We literally take them as close to death as they'll ever be, until they die. And we almost always bring them back effortlessly. But when we don't we are dealt a blow. A blow of grief, embarassment, self-doubt and fear. We experience nausea, insomnia, saddness. It is not easy to feel somehow responsible for the death of someone who trusted you with their life. Whose parents and children and husband trusted you, too. And for your partner to help you avoid that gut-wrenching blow instills in you tremendous gratitute. But you only say, "Thank you."

Unfortunately, this patient suffered a spinal cord injury during the procedure. Her disease-ravished crumbling vertebrae could not withstand the surgical manipulation, and she woke up a permanent, ventilator-dependent quadriplegic. A risk she understood and accepted prior to surgery. In keeping with her wishes, the family gathered in the ICU three days after her surgery. Everyone said their goodbyes. She wanted no end-of-life sedation. No morphine or valium to ease the pain and anxiety of suffocation. She wanted to be fully present in her death. Her breathing tube was removed and she died within five minutes, with her husband holding her hand.

Another day at the office.

Very. Well. Said.

http://www.glennbeck.com/content/articles/article/198/26742/?ck=1

Perspective

I suppose in light of the sham election/escalating threat of human rights meltdown in one country and a scary, bat-shit-crazy totalitarian leader threatening to shoot missles at us in another country, my worry that this addition won't be done in time for the start of the new school year seems pretty petty...

A Letter to My Children

To my children,

You probably wonder what I do when I go off to work at the hospital. This letter is to help you understand. First and foremost, what I do is this: I think of you all day and night. Before I leave, I kiss and hug you whether you are awake or asleep. And then when this most important thing is done, I go off to the hospital with the smell of your skin on my hands, the look of your faces in my eyes and the sound of your breath in my ears.

I work for many reasons. I work to provide for you. To make sure you have food, clothing and toys. I work so that we can take vacations together, because we love those so much. I work so that we can have a nice home to live in together. I work so that your daddy can stay home with you and take care of all that you need when I am not there. And I work so that one day you can go off to college and find your own calling in life.

Work is very important and very noble. I go to work because it is my duty to you and our family. I can tell you, as important as my work is to our life, it's always hard to leave you behind. When you look at me with those eyes and hold out your hands for me, I want so very much to stay behind, to hold you, so find some way to be with you all day and night. That would be amazing! I wish I never had to kiss you on the cheek and slip out into the cold, dark night and leave you under the warm covers.

On the other hand, you need to see me work, so that you will understand when you are older the necessity and satisfaction of work well done. If I could work, but did not, and if I stayed home while taking money from others who did work, I would be ashamed. Ultimately, you would be ashamed of me as well.

So there you have it. That is why I work.

You must wonder, children, what I do when I work. Well, when I go to work I try to keep other people and their children safe. I go to work because people wreck their cars and bicycles. They fall down and break their bones. I go to work because young people get in fights and the bodies of old people wear down and don't work as well as they used to. And because people become sad and try to hurt themselves. There are many more reasons; these are just some of them.

Jack, Alice and Clara, I go to work because sick or injured people need to have their bodies fixed so that they can go home and be with their boys and girls. And if boys and girls are hurt, so that they can go home to their parents to play, laugh and love.

I spent lots of years in school to learn how to help people who come to me with sick or hurt bodies. I have skills to do thing to help them. I like knowing that the people I help have a chance to get better. Doing these things makes me very proud and I hope you are proud of me too. As proud of me as I am of you. (I spend lots of time talking about you to the people I work with and sometimes to my patients, too!)

You would think, that with a job like that, I'd always be happy! But you children are smart and you know that sometimes when I come home I am not happy. And I'm sorry about that. It is never because of you. You are my three delights. It's just that people can be very difficult. They hurt their bodies by smoking and drinking and eating too much. They sometimes don't take their medicines like they should. They sometimes speak badly to me and make my job more difficult.

But here is a secret I've learned: most of the time, when people are bad, its because they are lonely or scared or hurt. Or maybe their mommies or daddies weren't good to them and didn't teach them how to behave. So I have to be patient with the people for whom I care. Sometimes I am able to show some sad or mad person that at least once, someone was nice to them. I hope you'll learn to do that in your life. You and I have to do our best to act in love toward the people we meet at work, at home, at play or in school.

Sweeties, the world can be a scary place sometimes, for children and adults. My job is to make it a little less scary for people in the hospital which is a place where almost everyone is afraid.

When you are sick or hurt or sad or afraid, you come to me and we hug and talk and snuggle. I'm the person you expect to fix things for you. Maybe when I go to work and have to leave you, I am being a kind of mother for other people who really need one for a while. You are sharing me when I go to work. I hope that is OK with you.

But just remember this. No matter what, no matter how busy or tired I am, no matter where I am, be it at the hospital or at home, I love you with all of my heart and no one else is ever going to be more important to me that you, the three lights of my life.

Love always,

Mommy