Category Archives: Life

Wordsworth, This Holiday

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There’s a lovely line in William Wordsworth’s poem “The Prelude”:

“What we have loved, Others will love, and we will teach them how.”

There are still things worthy of our love. Honor, decency, courage, beauty, and truth. Tenderness, human empathy, and a sense of duty. A good society. And a commitment to human dignity. We need to teach others—in our individual relationships, in our classrooms and communities, in our book clubs and Bible studies, and in innumerable other settings—why those things are worthy of their attention, their loyalty, their love. One person doing it won’t make much of a difference; a lot of people doing it will create a culture.

Maybe we understand better than we did five years ago why these things are essential to our lives, and why when we neglect them or elect leaders who ridicule and subvert them, life becomes nasty, brutish, and generally unpleasant.

Just after noon on January 20, a new and necessary chapter will begin in the American story. Joe Biden will certainly play a role in shaping how that story turns out—but so will you and I. Ours is a good and estimable republic, if we can keep it.

PETER WEHNER is a contributing writer at The Atlantic and a senior fellow at the Ethics and Public Policy Center. He writes widely on political, cultural, religious, and national-security issues, and he is the author of The Death of Politics: How to Heal Our Frayed Republic After Trump.

George Washington’s letter to the Jewish residents of R.I.

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President George Washington and the letter he wrote, after a visit to Newport, R.I., where he was enthusiastically received by, among others, members of the local Jewish community. It was dated Aug. 18, 1790. (Hat tip to the Jewish Women’s Theater in Los Angeles, Dana Milbank of The Washington Post, NPR and all others who have referenced this letter in recent days.).

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Gentlemen: While I receive, with much satisfaction, your Address replete with expressions of affection and esteem, I rejoice in the opportunity of assuring you that I shall always retain a grateful remembrance of the cordial welcome I experienced in my visit to Newport, from all classes of Citizens.

The reflection on the days of difficulty and danger which are past is rendered the more sweet, from a consciousness that they are succeeded by days of uncommon prosperity and security. If we have wisdom to make the best use of the advantages with which we are now favored, we cannot fail, under the just administration of a good Government, to become a great and a happy people.

The Citizens of the United States of America have a right to applaud themselves for having given to mankind examples of an enlarged and liberal policy: a policy worthy of imitation. All possess alike liberty of conscience and immunities of citizenship. It is now no more that toleration is spoken of, as if it was by the indulgence of one class of people, that another enjoyed the exercise of their inherent natural rights. For happily the Government of the United States, which gives to bigotry no sanction, to persecution no assistance, requires only that they who live under its protection should demean themselves as good citizens, in giving it on all occasions their effectual support.

It would be inconsistent with the frankness of my character not to avow that I am pleased with your favorable opinion of my Administration, and fervent wishes for my felicity. May the Children of the Stock of Abraham, who dwell in this land, continue to merit and enjoy the good will of the other Inhabitants; while everyone shall sit in safety under his own vine and fig tree, and there shall be none to make him afraid. May the father of all mercies scatter light and not darkness in our paths, and make us all in our several vocations useful here, and in his own due time and way everlastingly happy.

G. Washington

Staring Down Dragons

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Every crisis chooses its heroes. The heroes do not volunteer for the role. Brave souls do not rush to the front line to save us. The heroes, ordinary folk until now, are plucked from their previous lives without warning, whether they are willing or not, whether they are ready or not. In this crisis, there are many heroes (see Heroes in Masks with Mops). Everyone who shows up for their shift—whether they be nurse, houseman, security guard, food service worker, physician, or one of the countless other individuals needed to care for the tsunami of sick COVID-19 patients overwhelming our hospitals–is truly performing an act of courage each and every day. The heroes for the history books, though, the heroes who will be remembered by their colleagues long after this plague passes, are the anesthesiologists, nurse anesthetists, respiratory therapists, and ENT surgeons who find themselves staring down this monster every day–some many, many times on a really bad day. These are the special people whom we will always remember with an admiring nod and a tear of appreciation.nurse-anesthetist-vs-anesthesiologist.jpg.5c6db5df59cf2f07619cd04bbc39f0c1

The AIDS epidemic was the last plague that truly threatened US medical workers. While Ebola and H1N1 challenged us, neither of these crises presented a general threat to the health of our practitioners in this country. AIDS, however, during the terrible years of the late Eighties and early Nineties, killed our practitioners as well as our patients. We forget now, because of brilliant scientists like David Ho and countless others, who have given us effective treatments for HIV. But for several years, AIDS actually was the leading cause of death of people under age 40 in this country, the only time any disease displaced trauma from the top of the list. AIDS killed EVERYBODY it infected. And if the medical professional caring for the critically ill AIDS patient suffered a significant exposure, there was a definite possibility that they would die–horribly, because everyone with AIDS in those days died, horribly. Whole wards were filled with young people dying, horribly. Many AIDS patients developed severe intra-abdominal crises that required urgent surgical intervention. Surgery on these patients was fraught with the possibility of killing the surgeon, because these patients generally had extremely high viral loads at the time of their surgical crisis. This was the first time in memory when we had a national discussion about whether a doctor or nurse was morally obligated to care for an ill patient.

Doctors and nurses were dying. General surgeons, resident surgeons in training, orthopedic surgeons, surgical techs, and scrub nurses were at risk from needle sticks, blood splatters, intra-operative incidents of all kinds; significant or seemingly mundane, but now mortal injuries. Some surgeons refused to operate on HIV positive patients, hiding behind the argument that the patients were all dying anyway. This left the rest of us scrubbing on more and more of these dangerous procedures as others subtly deferred consults. Scrub techs and nurses willing to operate in dangerous conditions were increasingly called upon to fill in for those who declined. NY state entertained a law requiring surgeons who seroconverted to notify all patients of their status in the never-proven concern that a patient might contract the disease from the practitioner. So we stopped getting tested after every needle-stick, we even stopped donating blood, because we were not only risking our health, but also our ability to practice. It was a double-edged sword, with both edges pointed toward the practitioner. We stopped telling our spouses and colleagues about every torn glove or needle stick during an AIDS patient operation, because we stopped thinking about it as soon as we left the OR. But we kept operating on HIV patients, trying blunt-tip needles, extra-thick latex gloves, even chain-mail gloves—none of which helped in the least. Be careful, assume every patient is positive, universal precautions, we were told—all of it went right out the window with the next trauma patient in shock.

This plague has picked a different hero. Now, the riskiest moment for the health care practitioner is the intubation of a deteriorating COVID infected patient. In every hospital, anesthesiologists, anesthetists, and respiratory therapists, as well as many emergency medicine physicians and ENT surgeons, are placing their heads in the maw of the dragon as they insert an endotracheal tube needed to save a patient’s life. There is not a more dangerous maneuver in our current practice. Even worse than the surgeon operating on the AIDS patient, our modern knights staring down this dragon are not protected with chain-mail gloves, cannot even see the enemy, because it attacks—not in a spray of blood or with the pain of an errant needle—but in an invisible miasma. The risk of each individual intervention may be less, but the anxiety so much greater, as no one knows as they pull off their mask if, on this occasion, the dragon’s breath got past their shield. There is no choice but to take a deep breath, say a little prayer, and go on to the next patient.

When our anesthesiologists, anesthetists, ER docs, and respiratory therapists applied for training, none of them took a moment to ask themselves if they were brave enough to do this work. The job interview didn’t include a question about courage. No one signed up for this. They just do the work we need them to do to save our lives. When this is finally over, we will not forget that.

Heroes in Masks with Mops

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The physicians and nurses facing the onslaught of this pandemic are undoubtedly heroes. We salute them for leaving their homes and families every day to face the risk of personal illness and death. Their bravery is an inspiration. That bravery is a product of the oath that each swears upon entering this profession. There are others in this struggle, however. Others who never swore an oath to use their skills to care for the sick and injured. Others who are every bit as critical to these efforts, but who are not receiving accolades and applause as they make their way to hospitals every day, to work another shift at great personal risk. I am speaking of the janitors and housemen and women who work in our hospitals all day, every day.

These brave individuals serve an indispensable role in caring for patients and keeping the medical system working. They transport the patients to the ICU’s, and in so doing, are exposed to the same risks as the treating physicians and nurses. During the painful learning process of caring for the sickest of the COVID-19 patients, it was discovered that the technique of prone ventilation, in which the patient is positioned on their belly while on a ventilator periodically every day, is the only consistently effective therapeutic intervention so far. But this treatment requires the careful repositioning of a sedated patient in critical condition, a process that requires a team of nurses, physicians, and other health care workers to effect safely. Those other health care workers are often Physician Assistants, or Surgical Techs displaced from the now-idle operating suite, and Housemen and women. This oft-repeated therapeutic maneuver puts all members at an equal risk of infection. And while nurses and physicians, PA’s and NP’s are carefully trained and experienced in how to minimize their risks, these other critical team members have–until this moment–not prepared professionally for this effort. Nonetheless, we expect this, and much more, of them. They have stepped into the battle without hesitation.

Janitors also are unsung heroes in this crisis. They are required, just as the physicians and nurses, to don PPE and masks to perform the critical duties of cleaning the rooms and care spaces of the contagion which is pervasive in their work. Our janitors are no less courageous in their efforts. Indeed, maybe more so, as the physicians and nurses are almost always working as a team, with particular monitoring for the proper removal of protective garb and other concerns to minimize risk. Janitors, however, are often working on their own, with no such assistance. Every ICU room, every ventilator, every ER bay, must be cleansed and prepared, else risk injury of the next patient. Without the critical services of the janitors, the system cannot provide care.

These brave health care professionals, the janitors and housemen and women in every hospital, are working just as hard and at just as great a risk, as our physicians and nurses. They never swore an oath. They don’t get the same benefits, or the same pay, or the same accolades. But they deserve at least as much of our gratitude.

 

Please Ring Your Callbell

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Ten minutes into a redeye on JetBlue to JFK, I pull out my earphones in the middle of Nathaniel Rateliff and the Nightsweats’ “Son of a Bitch” to ask my wife why she’s reaching over to ring my call bell. “They just asked for any doctor on board,” she explains. “You’re a doctor,” I point out. “Yeah, I don’t think any of these passengers is looking for an emergency mammogram,” she explains.

The senior flight attendant appears at my elbow. “You’re a doctor?” I nod. “What’s up?” I ask. “Do you have some proof? An ID of some kind?” Geez, this guy is pretty demanding. He scans my surgeon’s club card like a Manhattan bouncer. “Great,” he pronounces. “Follow me.” No problem, I think. I’ve done this drill a few times before. Almost every time, it’s a hyperventilating passenger with more anxiety than pathology.

Senior flight attendant introduces me to my fellow passenger, who is standing and clutching the seats on either side of the aisle in obvious distress. Oops, I’m thinking, this lady looks like a real sick person. She’s trying to breathe at about thirty times a minute, shrugging her shoulders with every breath. She looks scared; like a person who can’t breathe, scared.

“Hi,” I say. “I’m a doctor. What’s the problem, ma’am?”

“I–Can’t–Breathe!”

Got it.

“Let’s get you sitting down,” I suggest. Before you fall down, I don’t add. Because if this lady passes out in the aisle, it’s going to take me and about twelve of my fellow passengers to pick her up. Not gonna be a pretty picture.

“Can’t–sit. Can’t—-breathe.” She shakes her head. Okay then–let’s talk here. “What’s your name, hon? Marie? Great, Marie. Are you having any pain?” She nods vigorously in time with her rapid breathing. “Where is your pain?” She lets go of a seat to tap her chest, then grabs on again to keep from toppling over. “Okay, pain in the chest. Got it. Do you have heart  problems?”  She nods enthusiastically. “Diabetes?” She nods. “Emphysema?” She nods. Well, maybe she’s just agreeable. “Anything else?”

“Sugar.”

“Do you take insulin?” She nods. “Did you take your insulin today?”  She nods. “Did you eat anything before you got on the plane?” She shakes her head. Great. Not just  being agreeable, then. “Any other health problems, Marie?”

“Kidneys.”

“Kidneys?  Kidney failure? Are you on dialysis?”  She nods vigorously. “When was your last dialysis?”

“Weds–breath–day.”

Great. She’s probably on a Monday-Wednesday-Friday schedule. Today is Sunday. Which means her last dialysis was over 3 days ago. Which is a long time to go without dialysis.

So far I’ve diagnosed this lady as probably being in respiratory distress due to florid congestive heart failure, probably having an MI (heart attack), and likely to lapse into hypoglycemia at any moment.  I’m thinking anxiety is not the main problem this time around. I’m going to need to do some kind of real doctor-stuff, not just my usual professionally reassuring murmuring. Which is sort of a problem, because I’m a surgeon, not an internist. But I’m a general surgeon, and we all think we know everything about everything, anyway. So there is that going for me.

With flight attendants’ help we clear the back row and get my patient semi reclined and out of the aisle. Oxygen mask applied and helping–as in her lips are no longer purple. Reassurrance. But patient still expressing distress, feeling of impending death, invoking need for Jesus to save her; none of which are considered ‘good signs’ in this setting. Most important, she is still having chest pain. I break open the completely inadequate first aid kit.  The kit is composed of many, many sealed plastic bags with various drugs and things, poorly labelled and completely unorganized. A bag of saline with no catheter to connect it to the patient. Helpful.

I find the blood pressure cuff and get some vitals. It takes me three tries to convince myself that her pressure really is sky-high, as in ‘impending-stroke’ high. Her breath sounds are even noisier than the aircraft engines and her heart is going so fast I can’t tell if she has a murmur which is just as well because I was never any good at hearing murmurs anyway. My exam does reveal that she has a dialysis access fistula in her left upper arm which has a bounding pulse–which is good, I think.

So at this point I tear open all the little plastic bags and start giving drugs to my patient. Glucose gel under her tongue for hypoglycemia, nitroglycerin for angina, aspirin for the acute MI. I’d love to start an IV but, again, no angiocath in the kit. Great.

The patient looks better but not great–as in, she now looks like somebody who may die soon rather than at any moment. I call over the flight attendant and mention to him that this lady may die at any moment. She is almost certainly not going to hang on like this for the five-plus hours it’ll take us to get to JFK, not to mention the additional half-hour taxiing to the gate. Time to land, buddy. He gives me his shocked face and mentions that maybe I should talk to the pilot. Good idea. He gets me on the little intercom thing and I introduce myself to Captain Pilot.  He asks me about my patient. I explain the situation and tell him in no uncertain terms that she needs to get to a hospital as soon as possible. To my chagrin, the pilot is not enthusiastic about my recommendation. He’ll check in with “MedCon” and get back to me. Really?

More drugs, more oxygen and Marie is alive but still having chest pain. Not good. Blood pressure is better, though. And her breathing is much better. At this point, helpful flight attendant informs me that I’m only allowed to use one more oxygen cylinder. “I’m sorry, why’s that?” Turns out that the plane only carries three cylinders and if I crack open the third one, I’ll violate safety protocol since the attendants need oxygen in case there is a decompression emergency. I inform him that if we are that fucked to have a decompression on top of what’s going on here, he’ll have to hold his breath. He doesn’t find this funny. So maybe, I suggest, he should get the pilot to land this plane like I said twenty minutes ago.

The pilot calls back to inform me that MedCon doesn’t feel the patient’s condition merits diversion. They recommend I continue current therapy, monitor vitals, and report back in thirty minutes with an update. I am pissed. I don’t know who “MedCon” is but I’m no fan. I inform Captain Pilot that if he doesn’t land this plane soon he’ll have a corpse in the last row of his plane. He promises to get back to me. I crack open the third–and last–oxygen cylinder. Flight attendant gives me a very concerned look.

Captain Pilot calls back twenty minutes later to inform me we’re diverting to Denver. Hallellujah! We’ll be down in 40 minutes. Hold it–what? Forty minutes? Captain Pilot lectures me that this is “not easy”, that Denver has “weather”, that it’s going to be “pretty damn bumpy” and he needs to get off the intercom so he can do pilot stuff so I should take care of the patient now, Bye. I’m hoping he’s smart enough to call ahead for an ambulance. Attendant assures me he is.

Half an hour later, I look past my patient and see lights out the window which is the first good time on this whole damn flight. “You’re going to be fine, Marie.” Woo-hoo! Celebration is short lived as pilot instructs everyone to buckle up for an unscheduled landing because the doctor in the back row is making us do this and by the way it’s going to be pretty damn bumpy because there’s a thunderstorm over Denver airport where we’re about to make an unscheduled landing so good luck with that. I’d be pretty pissed at the tone of the overly detailed announcement except I’m busy trying to keep my patient breathing and the last O2 cylinder has been on fumes for the last 3 minutes. I strap in and strap in Marie next to me across two seats and position myself to keep my hand on her pulse as the gear and the flaps come down and we’re bouncing all over the dark stormy skies of Denver, a flash of lightning illuminates the plane and I see a few folks from the back rows looking at me like, “If we crash and die, it’s all your fault, asshole.” So I smile except at that moment I realize that I can no longer feel a pulse on my patient. I attempt to discuss this problem with Marie but her eyes roll up in the back of her head and she slumps over as she stops breathing and proceeds to die.

“Oh, fuck! Really, Marie? Now you pull this?”

I unbuckle and stand up so I can lay my patient across all three seats. Helpful flight attendant yells at me that I must remain seated, we’re landing. Yeah, right. I start doing CPR which of course causes everyone in the last four rows of the plane to start screaming, which makes it tough to hear the automatic external defibrillator announce that “No, your patient does not have a shockable rhythm so, sorry, I’m not going to be much help. Just keep doing the chest compressions. Click.” Which I do while alternating breaths with the Ambu bag hooked up to the empty oxygen cylinder when a very pleasant young lady appears next to me as the plane jounces onto the runway and she asks, “What the hell are you doing?” I explain that I’m doing CPR, are you a doctor?” “I’m a family practitioner, can I help?” “Well, yeah, lady, where you been the last few hours or are you an Leprechaun Family Practitioner that just magically arrived on this airplane?” “Sorry, I was asleep, I didn’t know.” So she starts doing compressions so I can give drugs. Of course, I don’t have a working IV so I shoot an amp of epinephrine transtracheally into her windpipe and shoot another one into her fistula followed by an amp of bicarb because, well, what the hell, it can’t hurt and just might help. Mr AED still isn’t going to shock anybody but there is a pulse which is a definite improvement. Late Arriving Family Practitioner and I alternate doing chest compressions as several of our fellow passengers helpfully record our efforts on their cellphones. A kid leaning on the back of his seat keeps asking if that lady is dead and I’m impressed by my colleague telling him to shut up and go back to playing video games. At this point, the plane arrives at the gate and quite suddenly a squad of EMT’s arrive and somehow get not-entirely-dead-Marie on a gurney and up the aisle to the concourse. Well-Rested Family Practitioner and I follow and see that Marie really does have some type of rhythm on the monitor just before they package her up and speed away towards Denver General. Vaya con dios, Marie!

Well, that was fun–not!  I walk back to my original seat next to my wife and realize that my hands are shaking. I’ve done surgery for over thirty years, including a lot of pretty crazy trauma stuff, and I’m sure that this is the most shaken I’ve ever been after taking care of a patient. I was planning on discussing these feelings with my empathetic and supportive spouse, but I’m shushed by her so we can listen to the pilot announcing that, no, we won’t be taking off shortly to continue our voyage to JFK. Rather, he explains, this emergency diversion required by the doctor sitting in seat 6B has eliminated any chance of making it to JFK to be home with your loved ones or to make all those connections to lots of fun places because the doctor used up all the oxygen and the crew is traumatized and not allowed to continue so we’ll all be spending the rest of the night here in Denver International and we’ll try to get you seats on a plane in the morning to New York or somewhere, probably. Thanks for choosing Jet Blue!

At this point there is a general groan and many pointed stares pointed pointedly in my direction.

As we all gather up our carry-ons and make for the exit, I see Captain Pilot leaning against the doorway to the cockpit. I stop to chat. I introduce myself as the doctor who was on the other end of the intercom. “Oh,” he says without a smile. “That was you.” I agree that was indeed me. Just because I’m curious and still a bit pissed off, I reveal to Captain Pilot that I was surprised that there was such reluctance to land the plane even though it was my professional opinion that his patient was going to die otherwise.

Captain Pilot looks at me with a steely gaze and, in that Southern pilot drawl that they all have, says, “Doc, you got one life to worry about back there. I gotta worry about 186 lives. You do your job, I’ll do mine.”

I guess that’s pilot talk for “thanks for your help.”

 

 

From: Choosing a Specialty: A Letter to a Medical Student

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Society punishes those who improve it. Emerson observed this fact when he gave up a promising Christian ministry career to instead minister to all of mankind. Don’t expect awards and accolades from the psychiatric profession for bettering it. The awards go to those who maintain the status quo, not to those who change it. Freud never won a Nobel prize; they gave it to the fellow who introduced frontal lobotomy.

Nassir Ghaemi, MD, MPH

You Drive Like a Sodding Slugfuck

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This post was to be entitled, “You Drive Like a Dick,” but hey–it’s the holidays.  And in case you haven’t noticed, people drive even more dickishly (copyright, ERG) now than at other times of the year.  Hence, the new title.

Angry Cat Driver

In keeping with the holiday spirit, it is my considered opinion that people are now driving worse than ever.  Both of the regular followers of this blog know that I have a bit of a petulant streak when it comes to my fellow drivers, e.g.., “Overcourteous Assholes Like Me.”  Last year, I was irritated.  This year, I fear for my life.  This year, a new classless class of drivers has appeared, a class that adheres to the following three point credo:

I.  The rules of driving apply to you, not to me. 

II.  Get out of my way.  

III.  My car/truck is a two ton steel weapon on wheels which I am willing to use to injure, maim, or kill if you slow me down or generally do anything that pisses me off.

I refer to this new class of driver as “sodding slugfucks.”  But not to their face.  This is why I don’t refer to these people as “sodding slugfucks” to their face:  Detroit Driver Shot in Face in Road Rage Incident.  If you have ever been tempted to get out of your car to discuss driving etiquette with someone, this article will surely disabuse you of that silly notion.  Please don’t.

It has come to my attention that otherwise reasonable people can and do behave like sodding slugfucks when they drive.  I know this, because I live on an island.  When you live on an island, you occasionally find yourself in a situation of being assaulted by a sodding slugfuck while driving, only to subsequently realize that both of you are driving to the same destination.  On one occasion, that destination turned out to be our mutual place of employment.  We parked next to each other.  Somewhat awkward. On another occasion, the sodding slugfuck cut me off, tried to hit me, then screamed at me through my window before we both ended up in my neighborhood, only to realize that we live on the same block.  Even awkwarder.

With the foregoing in mind, perhaps it would be a holiday mitzvah to point out the type of activity that may lead to the realization that even you may be acting like a sodding slugfuck.  So you can stop.  As kind of a public service, I offer the following:

–Over the last six months, I have witnessed several guys who, in the middle of the day and at a busy intersection, decided that waiting for a traffic light to turn green was for losers, so they proceeded to just sprint across the intersection against the light. This causes every other driver to screech to a halt, wondering what the hell just happened and whether civilization as we know it has come to an end and nobody told us.  If you were one of these guys, and you didn’t jump the light because your wife was in active labor at a nearby hospital, then you, sir, are a sodding slugfuck.  Don’t do that anymore.

–I still pull over when I see an ambulance, lights flashing, come racing up behind me.  Call me old-fashioned, I know.  Other drivers may just drive faster to try to stay ahead of the ambulance, but last I checked that was kind of against the law.  What I’ve noticed now with frightening regularity, however, is that once the ambulance has passed, some sodding slugfuck (sometimes a whole string of sodding slugfucks) is chasing so closely behind the ambulance that I’m nearly killed when I try to pull back into my lane.  Unless you are related to the poor sap in the back of the ambulance, if you don’t let me back into my lane because you’re speeding behind the ambulance, you are a sodding slugfuck.  Or an ambulance-chasing lawyer, in which case you are also a sodding slugfuck.

–It appears that many drivers incur physical pain if they are required to use the brake while driving.  This must be some type of new epidemic, because I witness this ailment at least a half dozen times a day.  The symptoms are evident when a car slows to make a right hand turn and the car behind, instead of braking slightly to let the guy turn, swerves around him into the left turn lane.  Or in my recent experience, across the double yellow line to nearly hit me head-on, requiring me to veer off the road and almost hit a tree.  Main Street in my little hamlet is not the Nouvelle Chicane in Monaco, okay?  If you do this, please stop being a sogging slugfuck.   You’re going to kill someone.  Maybe me.

I could go on, but it’s the holidays.  I’ll save the rest for next year–like how your horn doesn’t make all the cars stuck in traffic ahead of you magically disappear.  Really.

Happy Holidays.  Don’t Drive Angry!