Doctors Parking

I’m old enough to remember when physicians in general–and surgeons in particular–were held in high regard.  I mean, we used to have our own parking spaces and free coffee in the doctor’s lounge.  I remember when I was a resident in surgical training being taken to lunch between cases by my surgical attending at the hospital’s designated doctor’s only lunchroom, served a steak and fries by a waiter, then encouraged to finish my drink before running back to the OR to get the next patient ready for surgery.  And this was an inner city, midwest academic hospital! Table cloths and linen napkins!  I’m not making this up–it was the eighties.  Now that I’m an attending surgeon myself, I usually find myself wolfing down an Odwalla bar with cold coffee between cases. So I’m sensitive to the situation when one of my surgical colleagues is bent over the hood of a car, in handcuffs, with several guns pointed at him. How did we get to this?

MB2

Because, I hear you saying, you guys act like greedy, pompous dicks.  And while you are right (see “Mommas, Don’t Let Your Babies Grow Up to be Surgeons” for a start), that’s not the exact explanation.  Doctors used to run the hospital–literally and figuratively. In the twentieth century, successful hospital administrators were either grey-haired physicians who realized that the most important thing a hospital did was take care of patients, or no-nonsense nuns with MBA degrees who wouldn’t let anybody die in their facility, goddam it.  By the turn of the century, however, hospitals became “Medical Centers of Excellence” with “Program Initiatives” and extensive real estate investments, even the occasional shopping mall amidst the medical campus.  The CEO had bigger concerns than relieving suffering and curing disease, he had a big bottom line and a board to answer to.  That patient care stuff was delegated to a third-tier hospital administrator who could be found cowering in a windowless office, apologizing to the Chief of Cardiac Surgery for not getting his shiny new hospital wing finished on time, begging the surgeon not to make good on his threat to bankrupt the hospital by taking his skills across town.  Now the third-tier hospital administrators take home million dollar salaries as they lay off all the experienced nurses in that same, now careworn cardiac wing, because of the need to “trim the service line overhead.”  The center of power has shifted, you see.  Today, the Chief of Cardiac Surgery finds that his ID badge doesn’t even open the doors to the administrative wing.  And that’s where the nice cafeteria is.

Not so many years ago, I used to make a habit of leaving the hospital on my way home by walking out through the Emergency Room.  You learn after a decade of being the Chief of Trauma Surgery to look for trouble on the way out, because otherwise you had a pretty fair chance of getting called back in half an hour.  So on the way out I’d walk through the resuscitation bays and exit through the ambulance dock.  On one occasion, I was walking out this way when I noticed that a number of hospital security personnel were surrounding an individual, guns drawn.  The university had only recently granted our security personnel permission to carry weapons, and it wasn’t unusal at this time to see them working through the particulars of just when to employ their new, shiny Glocks.  It was dangerous to drop a candy wrapper in the lobby or complain too vocally about the lack of parking spaces.  So on seeing this little armed tableau, I just kept walking, somewhat ignoring the guy bent over the hood of his car, screaming obscenities.  I stopped, however, when I recognized the man’s voice.  That, I recall thinking, sounds like my colleague Mark.  Mark was a busy and talented surgeon who operated at several hospitals in the area.  I looked over.  Damn, I thought to myself, that looks like Mark, too.  I walked over to see a man struggling and cursing as he was bent double over the hood of a black Mercedes, being handcuffed by hospital security.  It was Mark.

“Mark,” I said, “what’s up, buddy?”  I noticed at this point that the big black Mercedes, Mark’s car, was parked on the helipad.

“Please stand back,” one of the security guys with his gun drawn admonished me.  “This is a dangerous situation.  I have to ask you to please step back, sir.”

“Geller, is that you?” Mark asked, his face being pressed into the hood of his car.

“Yeah, Mark, it’s me.”

The security guard waved his gun.  “Step back, sir.  Last warning.”  I’m not sure what he meant by that, so I stepped back.  He had the air of being the man in charge.

“Tell these assholes who I am, Evan!” Mark yelled.

“Do you know this man?” security guy asked.

“Maybe.  What’s going on, officer?”  They love to be called officer, because none of the security guys are real cops, you see.  They really, really, wanted to be real cops.  The guns helped.  New cars with the flashing lights also helped.

“Is he a doctor?”

“Might be a doctor,” I said.  “Why, what’d he do?”

“He tried to kill one of our officers,” the security guy explained.

“I just needed to park, so I could do a case!” Mark yelled over.

As I was later able to put together, it turns out that Mark was called to take care of a young patient with appendicitis.  When he got to the hospital, however, he couldn’t find a parking space in the ER lot or the designated doctor’s lot.  Being Mark, he elected not to pay to park in the visitor’s parking structure, deciding instead to park his black Mercedes 500 on the helipad.  This, it turned out, had made it rather difficult to land the helicopter with incoming trauma patients, so security had been called.  Mark finished his case and came out to see his car about to be towed so, being Mark, he got in his car. Being Mark, he assumed that this would resolve the problem.  ER security guy stepped in front of his car.  It seems that security guy, gun drawn, had decided that the goal was not so much to clear the helipad for the transportation of incoming trauma victims, as it was to make Mark pay for his effrontery by having his rich doctor car impounded.  At this point, Mark decided the wisest course of action was to drive away and hope everyone would just forget the whole silly episode, but unfortunately this involved nudging the officer gently with his large, black Mercedes.  Which quickly escalated to a lot more security guys with guns drawn deciding to arrest Mark’s rich doctor ass.

Once I understood exactly what happened, I had to explain to the security guy that no, I don’t think I know the guy after all.  Looked familar, but not the guy I thought he was.

And that’s kind of why things have changed for us doctors.

 

Mammographic Misery and the Plight of the Perpetual Patient

Mammograms save lives.  Despite several controversial studies over the last couple of years, there is no question in my mind or that of most other health care professionals that annual screening mammography for women over age forty has completely revolutionized the treatment of breast cancer.  Those studies can’t claim that people regularly receiving mammograms don’t have better rates of survival or cure from their disease–they claim, with mixed success, that providing a large population of women with mammographic screening is not cost effective.  What price a life, you ask?download

When I began performing surgery for patients with breast cancer in 1982, the typical patient presented with a mass she had felt herself.  By the time she came to me for surgery, her cancer was often in a relatively advanced stage.  Surgery involved complete mastectomy, usually with the removal of large numbers of her underarm lymph nodes, too often leading to disability and disfigurement.  This was followed by chemotherapy and radiation therapy. Worst of all, survival rates in this group of patients rarely reached 80% for the five years following surgery.

Fast-forward to my current practice.  Over 90% of women referred to me for surgical treatment of newly discovered breast cancer are now presenting with a lesion found on their annual screening mammogram.  Almost all of these lesions are about the size of a pea or smaller, having been discovered years before they grew to a size that could be felt on examination.  These early cancers have not spread to the patient’s lymph nodes or anywhere else in her body. There is no need for mastectomy to achieve a complete cure from this early stage of cancer.  Indeed, I can reassure patients that equivalent cure rates for such small cancers can be achieved by a small lumpectomy and a sampling of one or two lymph nodes, a procedure that takes less than an hour.  The patient is home later that morning and experiences minimal discomfort.  Newer forms of radiation therapy permitted by such early diagnosis expose only the localized tissue and can be achieved in five days, rather  than the whole breast radiation therapy over 4 to 6 weeks required in the past.  Most significant of all, this minimal therapy now provides cure rates well over 90% in these early stage patients.

All of this revolutionary success in the treatment of breast cancer has been made possible by earlier diagnosis due to routine screening mammography.  So don’t buy the hype–there is no controversy amongst practitioners over mammography:   A mammogram once a year can save your life.

But that’s not what this post is about.

Let’s talk about what happens after:  After that excruciating moment when I tell you that the biopsy showed cancer.  After the discussion of what we need to do, how soon we can do it (“Sorry, not yesterday”), what happens after the surgery.  Surgery for the treatment of breast cancer is safe, straight-forward, and relatively painless.  To be honest, surgery for breast cancer is the easiest operation I do.  Patients usually are surprised by their rapid recovery.  They come back to my office a couple of weeks after surgery feeling great.  Over the next several months, I see the patient as she completes her recovery and any additional therapy that’s recommended, usually a short course of radiation therapy and a daily estrogen-blocking pill.  By six months after her diagnosis, she’s feeling great and has her life back.   And then reality sets in:

The reality being that you are not really convinced you’re cured of cancer until the moment you die of something else.

We’ve moved from a paradigm of the valiant patient bravely battling her cancer to the successful breast cancer survivor–who now must live forever with her diagnosis.  It’s not a battle with cancer.  Battles are fought and won, and then we can move on. You don’t just fight cancer–you survive cancer, and then you live with having had cancer. This is a burden that few who have not experienced the diagnosis, or lived with someone who has survived cancer, can appreciate.  It doesn’t matter how great you feel, or how many times the doctors say that you’re doing great, or how great your spouse or friends say you look–you worry.  You worry every day.  Because you remember feeling pretty darn great just before the doctor told you that you had cancer.

Of course, we all worry about getting some disease or another.  We worry about that dark mole on our arm that might be a little bigger, particularly after we hear of a young friend recently diagnosed with melanoma.  We worry about heart attacks, because we get chest pain every time we eat Taco Bell or palpitations at the gym.  It’s not the same. It’s not the same because you’ve never been told by the doctor that the biopsy is positive, that your worst fear when you walked into the office was true.  You’ve heard of Post-Traumatic Stress Disorder?  This is Post-The Test Was Bad And You’re Totally Screwed But Now You’re Finally Better Stress Disorder.  And it’s every bit as bad. Maybe you didn’t experience faceless bad guys shooting bullets at you in Iraq, but you experienced some pretty heartless machines shooting xrays at you every day for a couple of months, or smiling nurses apologizing as they stabbed the needle in your vein for the third or fourth time, or watched the strange colored fluid dripping into your body knowing that in 24 hours you’d be doubled over the toilet vomiting because that’s just how this stuff works.  Cancer sucks, and it doesn’t stop sucking just because everyone tells you that you’re cured.

Sure, they say you’re cured.  But you don’t really believe it.  You don’t believe it because we keep sending you for more tests and more mammograms and more CAT scans and more PET scans.  If there were a PUPPY scan or a CUTE FUZZY BEAR scan, we’d send you for that, too.  If I’m cured, you keep wondering, why do we keep looking for it?  And every time you have to go for the test, it’s an opportunity to relive that special feeling you had that time when the test came back bad.  You relive that feeling for the week before you take the test, while you’re in the machine trying to breathe during the test, and for every single second until the doctor calls to tell you that it’s okay. This time, you think.  It’s okay this time.  The elephant steps off your chest–but he doesn’t leave the room, he just steps behind you for awhile.  Until the doctor says that it’s time to do another test.  And there is always another test.  If I’m cured, you think, why do we have to keep looking?

So here we are:  Surviving today.  The test was good.  Enjoy it.  You can run faster than any old elephant.

 

 

 

Magnificently Overrated: Whale Watching

My wife and I spent the day “whale watching” last weekend.  She had been anxious to pursue the great, wild whale ever since our last outing two years ago.  During that previous high seas adventure, we failed to spot the elusive, majestic whale.  This despite many, many hours tossing about the Atlantic Ocean, accompanied by seasick shipmates and an entourage of dolphins that made fun of us for even caring about whales.  No whales that day, alas.whale

On this sunny Sunday, however, we were successful.  We spotted a dozen whales!  Which was surprisingly similar to not seeing any whales at all the last time, just with more whales.

It became all too evident as we bobbed about the wide Atlantic Ocean, chasing from one sighting to another for hours, that these are not professional whales.  These guys are the ones that just happen to be lying about when the boat pulls up.  It’s as if you took your friends visiting from the Midwest into the city by driving for hours in hot, rush-hour traffic in your car with no air conditioning and four broken windows, but when you finally got into the city you decided not to take them to see Les Miserable or The Book of Mormon like you promised, but instead took them to a karaoke bar that was popular with taxi drivers recently emigrated from Eastern Europe.  Lack of stage presence is being kind.  Forget jumping over the boat in an arcing trail of crystalline spray.  No tail pirouettes or lunging jetes, either.  Those are the actions of the elite, highly-talented whales, it seems.  These guys were more circumspect.  More “log-like.”

The cruise was  narrated by a marine biologist with bubbling enthusiasm for all things whale.  This loud, incessant narration was piped over a battery of tinny, scratchy speakers set next to all available seating areas.  Some adjectives used by the marine biologist to describe the whales:  majestic, enormous, magnificent, playful, friendly, endangered.  Adjectives that crossed my mind as I stared at the same whales the biologist was pointing at:  grey, might-be-dead, abandoned-car-ish, and, again, grey.  Dr. Marine Biologist had names for all the regular whales, cute names like Susie and Eddie.  On this exciting cruise, however, two new whale friends were found and needed names, which the good doctor solicited from our ranks.  Sadly, he did not select my recommendations of “Roadkill” and “Old Rubber Boot,” preferring the much less apt “Pete” and “Pauline.”  He also did not invite me to become a volunteer marine biologist, though he seemed to encourage pretty much everyone else on board to do so.

The pedestrian whales such as we encountered were fairly limited in their entertainment skills.  The occasional sneeze, dramatized by the appearance of sneeze vapor wafting across the boat.  Sometimes, they slowly sink.  Every one of them totally ignored the  potato chips I threw their way.  Pretty aloof, actually.  A glaring lack of people skills.  Majestic?  Is a half-submerged Volkswagen beetle majestic?  Then, no.

Next week:  We go to a Mets game.  Woo-hoo!

DRONES ATTACK IN CENTRAL PARK!

We have seen the future:

A1a-1SQ-Quadcopter

Drones Mug Tourists in NYC

“My buddy and I were walking across the park, you know, and two of those drone copter things just came down right in front of us while we’re walking.  You know, those quad-copter things you see on Youtube.  So, we’re just walking but these two copter things keep buzzing right in front of us, so Steve kinda swats at one but it just dances away and gets right back up in our face and says, ‘Hey, asshole, don’t do that.’  Yeah, it called Steve an asshole, which we thought was pretty funny until the things stop right in front of our face and it says, ‘Give over your money and wallets.’  We didn’t even know what it was talking about, but every time we try to get away the things get in our face, you know?  Steve told the thing to fuck off, we’re not giving you anything and then, bam, the copter in front of Steve hits him square in the chest with a TASER!  Yeah, fuckin’ crazy, right?  Steve goes down and is screaming and the drone thing in front of me says I should take his wallet and his money and his phone and put it in the basket thing hanging under the copter that just TASER’d him.  I mean, the things menacing, you know what I mean?  So I did it.  Then I had to give it my phone and shit, too, and then they both just zoomed up over the trees and were gone, man.  Crazy, right?  That’s what the cops said.  They thought we were high.”

Blog Tour: Therin Knite’s Othella

It is a pleasure to host the blog tour of Therin Knite as she promotes her new novel, Othella.
Othella
Book Description:
Georgette:  Pulitzer Prize-winning journalist Georgette McClain can’t resist a juicy tip. So when a rumored crazy ex-CEO gifts her evidence of a vast conspiracy involving the world’s premier scientific community, Arcadian Heights, she sets her sights on the story of a lifetime. And all she has to do to grab it by the reins is sneak into the most secure facility in the world—and expose it for the slaughter house it is.
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Marco:  Tech company CEO Marco Salt has it all. Fame. Fortune. Family. But not long after Marco’s beloved genius daughter is invited to join Arcadian Heights, a rogue agent reveals to him the horrifying truth about the revered scientific community. Forced to flee for his life, Marco finds himself on the run with a deadly secret in his grasp and a single goal in mind: destroy Arcadian Heights.
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Quentin:  Quentin Belmont has been the Arcadian Heights spokesman for the better part of two decades, and his singular motivation is to keep the community safe at all costs. So when an internal incursion leaks vital information to an outside party, Quentin preps a “cleanup” without a second thought. But what at first appears to be a simple task turns out to be anything but, and Quentin comes face to face with the unthinkable—a threat that could annihilate the community.

About the author, Therin Knite:

Therin Knite is a 22-year-old recent college graduate who occasionally writes speculative fiction and has the odd delusion of literary stardom. Knite lives in a humble little place known as the Middle of Nowhere, VA, where she spends most of her days reading books and writing what may possibly qualify as books.

Knite is a graduate of the College of William and Mary and holds a BBA in Finance and English. In August 2014, Knite will begin work as an underwriting analyst at a large insurance company, where she intends to stay for the foreseeable future.

Knite, who’s been writing seriously for seven years, is an avid book reviewer, blogger, and the sort of person who spends far too much time imagining epic sci-fi battles in her head. Knite intends to publish 3 to 4 novels per year, ever year, until she runs out of ideas…which is highly unlikely, so she’ll probably be writing forever.

Finally, Therin Knite has a simple writing philosphy you may want to know before you pick up one of her books:

“50% Dark, 50% Snark”

Purchase the paperback:  http://www.amazon.com/Othella-Arcadian-Heights-Therin-Knite/dp/1499551258/

Purchase the kindle version:  http://www.amazon.com/Othella-Arcadian-Heights-Book-1-ebook/dp/B00L7DCTA8/

Website: http://www.therinknite.com/

Blog: http://knitewrites.com/
Twitter: https://twitter.com/TherinKnite
Goodreads: https://www.goodreads.com/author/show/7760963.Therin_Knite
Amazon Page: http://www.amazon.com/Therin-Knite/e/B00HRL0CXA/
Facebook: https://www.facebook.com/pages/Therin-Knite/663841677010575

I invite you to explore Therin’s excellent blog or try the sample of this new novel available on Amazon.

Best of luck to Therin on her new novel.

Anniversary of a Tragedy

In memory of those lost one year ago today, I reprise my earlier post:

Superman is a Myth

It was a classic Superman moment. A train of seventy-two railroad cars filled with highly flammable liquid was poised precariously on a hill above a sleepy town filled with innocent Canadians. It was dark. There was no driver or attendant to witness that the airbrakes preventing the train from slipping are slowly draining pressure. The train begins to slowly roll downhill, picking up momentum as it ponderously but inevitably begins to roll faster and faster towards the center of town, disaster looming–but wait! Here he comes, streaking out of sky! A red and blue caped blur, a powerful hand braced against the lead locomotive, a grimace and then, with a squeal–all is saved, disaster averted.Minolta DSC

Only it didn’t happen. No Superman. Instead, disaster, death, and destruction. Innocent lives lost. The classic Superman moment, one I had witnessed in comics and onscreen since my wide-eyed youth, went horribly wrong. No Superman.Minolta DSC

At first, I hoped and believed that Superman could not save the day because he was otherwise occupied achieving even greater goodliness, saving even larger populations of threatened innocents. But I checked–it seems that North Korea had not simultaneously launched a nuclear tipped missile aimed at a New York museum at the exact moment that Lois Lane was visiting with her little nephew’s fourth grade class. The only other possible explanation, that Lex Luthor had Superman incapacitated under a geodesic dome made of Kryptonite, was also disproved by a quick Google search. No Superman.

How could it be that Evil had triumphed? How could the sinister forces of darkness and malevolence succeed, unchecked by our heroes? Such a situation is contrary to the workings of a moral universe, would require the balance beam of justice to be bent beyond all reasonable fairness. Not possible; the Fates are not so cruel.

But, hold on a second. Deep investigation reveals no Fates, cruel or otherwise, in the immediate vicinity at the time of the accident. Reviews of salient radar logs show a sky clear of evil, flying monkeys. Overhead satellite imaging clearly indicates that a demonic miasma did not dissolve the critical feedlines to the airbrakes. Not at all. No Evil, either, it seems.

No, upon further investigation it appears that a well-meaning crew of volunteer firemen, responding to a fire on the train, skillfully extinguished the blaze. They did their best, including following the protocol which required them to shut down the engine to the burning train. The engine that provided the pressure necessary to maintain the airbrakes. And then they went home.

No evil. Not even an absence of good intent. But no Superman.

It makes me sad.

My heartfelt sympathy to the families of the victims of the Canadian railway tragedy.

Requiem en pace

The Alternate Reality We Live In

In light of this past week’s incomprehensible ruling by the Supreme Court of the United States, and since I am still intellectually stuttering in my attempts at a reasoned response, I instead present a very old essay that pays tribute to another of our Supreme Court’s auspicious decisions.  Hindsight is easy, I know, so please take this with the sense of irony with which it was conceived.  Have a happy and safe Fourth of July holiday.

BROUGHT TO YOU BY THE THOSE FINE FOLKS AT  THE SUPREME COURT OF THE UNITED STATES OF AMERICA

REALITY  (JANUARY 22, 2001):

“Gee, Dick, is this the first damn meeting in this office?  The tags are still on the chairs.”

“You know, Bill, now that you mention it, I think it is.”

“Well, Dick, I want to just say how great it is to finally have a couple of real Americans running this country.  And Texans, to boot!”

“Not just Texans, Bobby, Texas oil men!”

“Gentlemen, thank you.  And I know you know how much me and George deeply appreciate all you’ve done to make this a reality.  Now you know why you’re all here–our country needs an energy policy, and we’re here to write it.  This is our first and highest priority.”

“We appreciate the opportunity to participate at such an early stage.”

“Hey, Dick.  Since we’re talking about oil–you and George ever notice how Iraq is just about the same size as Texas?”

“Yeah–we could call it East Texas, Dick!  Way East Texas–I think Jeb’s gonna need a new state to run soon.  Term limits, you know.”

“Whoa, whoa.  This would be a prudent time to point out that this meeting is being transcribed and will be subject to discovery under the rules of the Freedom of Information Act.”

“Yeah, Dick.  Like you’d let that happen in this century…”

ALTERNATE REALITY (January 22, 2001):IMG_1114

“Mr. President, I appreciate you seeing me so early on in your Presidency.  I know you’re very busy.”

“I certainly am, Mr. Pickens. My staff tells me you’ve been calling nonstop since I finished my acceptance speech. You’re my token meeting with Big Oil.  Talk fast.”

“Yes, thank you Mr. President.  Please call me Boone.  Mr. President, our country’s highest priority is a new energy policy.  I believe our very survival as a nation will depend on what we do in the next decade.”

“I couldn’t agree more, Boone.  I said as much at my inauguration.  But drilling for more oil all over ANWAR is not the approach this administration is going to take.”

“I’m not here to talk about oil, Mr. President.  I’m here to talk about natural gas.”

“Gas?  I was hoping for something a little more imaginative from you, Boone.  Nothing renewable about gas. At least pretend you listened to my speech.”

“Mr. President, the technology does not yet exist to obtain any meaningful relief from our nation’s energy crisis from renewable resources.  That’s just reality, Mr. President.  What we do have, sir, is a breakthrough in our ability to tap our nation’s reserves of natural gas.  I believe that my plan will make our country independent of foreign sources of oil by 2020.”

“You have a plan?  Do your buddies in Texas know about this plan?”

“Mr. President, I think it would be best not to involve too many oil execs during these early critical months.”

“Hell, couldn’t agree with you more.  Let’s ask the Secretary of Energy to come in and listen to your plan.  I think we can find some extra time in the schedule–I only pencilled you in for five minutes.  Not wind power, huh?”

“Not in our lifetime, Mr. President.”

~~~~~

REALITY (September 12, 2001 AM)

“Bill, you’re my goddamn head of CIA.  How in God’s name could you let this happen?

“I’m sorry, sir.  We screwed up.  We had these guys on the radar.  FBI, too.  We didn’t know they were this close.”

“Close?  There’s a goddam smoking hole in the ground where the Trade Center used to be!  Over three thousand people dead, probably more by the time this is over.  On my watch!”

“Yes, Mr. President.  Let me just say that the CIA feels devastated by this.  I’ve got senior analysts in tears at their desks.  But we are all over this.  Nobody has gone home since this happened. We’re working our assets and configuring our response–”

“That’s just bull and you know it.  After the fact.  Hell, they should be in tears.  They failed.  They let down America.”

“Mr. President, it’s not that simple.  But if that’s how you feel, sir, you will have my resignation on your desk in the next hour.”

“It is that simple and that is how I feel.  But Dick and Karl and I have been talking and now isn’t the time to change horses.  No resignations, not right now–that would just send the message that we screwed up.  No–you stay.  But, Bill, I want a good old-fashioned house cleaning.  I want everybody who failed our country out!”

“Mr. President, it’s not like that.  These people are professionals, they are the best in the world.  I stand by my–”

“House cleaning!  Or I’ll put somebody over CIA who’ll do it.  And Bill–”

“Yes, Mr. President?”

“Don’t go signing any long-term leases in this town, you hear me?”

ALTERNATE REALITY (September 12, 2001 AM)

“What happened, Bill?  We’ve been talking about this coming for over a year.”

“Yes, Mr. President.  We knew.  We knew these guys–we just didn’t know enough.  And CIA didn’t know they were in country.”

“What are you saying?”

“FBI knew they were in the country.  But they didn’t know who they were.  We blew it–we all blew it.  Three thousand dead.  My God.”

“Mueller told me the same thing just now.  My God.”

“It’s not the people, Mr. President.  We’ve got the best.  Mueller’s got the best.  It’s the system–the system failed.  It’s gotta be fixed.”

“Can you do it?”

“I’m not your man–you need a systems guy.  Somebody younger–I’ve got a couple of names.”

“Thank you for not making me  say it.  Mueller’s getting me his letter in the morning.”

“You’ll have mine in the morning as well.  I’m sorry, Mr. President.  We let down the country.”

“I know it wasn’t your fault, Bill.”

“Three thousand people dead–you tell me whose fault it is, Mr. President.”

~~~~~

REALITY (September 12, 2001 PM)

“Gentlemen, America has been attacked.  I know it’s soon, but I want to go around this table and have your thoughts.  Please speak freely.”

“Mr. President, as you say, America has been attacked.  This is our generation’s Pearl Harbor.  We are at war.  We must respond.”

“That’s easy to say.  But at war with who?  How do we respond?  Dick?”

“SecDef is right, Mr. President.  We’ve pussyfooted around this too long and this is the result.  Clinton wouldn’t do it, last time around.  Hell, the last guys who tried to knock down the Trade Towers are eating three squares in San Quentin.  This changes the game.  We take it to the next level–no more police actions, no more trials.  They wanted a war–let’s give it to them.”

“You mean bomb those bases you showed me pictures of?”

“No, Mr. President.  That’s not enough.   That’s what the last administration did. This is a game changer.”

“Yeah–a game changer.  I get that.”

“Mr. President, we need a new policy on terrorism.  The Bush policy–we bring the full force of the world’s most powerful military to bear on any country contributing to terrorism.”

“Dick, that’s half the countries in the Middle East.”

“We know where these guys came from–we hold the state responsible for the actions of its citizens.  Providing safe harbors, that sort of thing.  And we don’t stop there–we take the offensive.  We go after them before they do this again.”

“The Bush policy?”

“Yes, Mr. President.  Pre-emption.  Offense, not defense.”

“There’s still the problem of which state to hold responsible–hell, you told me half these guys were from Saudi Arabia.  You’re not saying we bomb Riyadh, are you?”

“No, Mr. President, not at all.  But there are targets worth considering.  I’d like you listen to Mr. Wolfowitz, from the Pentagon.  I asked him to prepare a short presentation.”

“Thank you, Mr. Vice President.  Mr. President, gentlemen.  While the events we are discussing this morning are truly tragic, I believe we are now presented with the opportunity to directly confront the greatest danger currently facing our country–I am referring to Saddam Hussein and Iraq.  Could I have the lights down, please?”

“Did he say Iraq?”

ALTERNATE REALITY (September 12, 2001 PM)

“Mr. President, the people of the United States demand a response.”

“I know that, Mike.  But I’m the President and I’ll tell you something–this is not Pearl Harbor.  We are not going to treat these guys like the Imperial Empire of Japan.  This was horrible, I know.  But we’re not the first country to be attacked.  I’m going to weigh our options.”

“We have very few options, Mr. President.  I believe it is imperative that we immediately respond with overwhelming force.”

“Where?  Against whom do we respond with overwhelming force?”

“To start, Afghanistan.  We know Bin Laden was behind this.  We know he’s there.”

“So we bomb the whole country?”

“Not just bomb, Mr. President.  It will take a major land force to take out Al Queda.  Not to mention toppling their government–the Taliban have been supporting them all along.”

“Invade Afghanistan?  Are you nuts?  My Secretary of Defense is recommending I recreate the biggest military fiasco of the twentieth century?”

“No sir, I’m just saying…”

“Is that what you’re saying, Joint Chief?”

“Absolutely not, Mr. President.”

“Well, maybe you could share your thoughts, then.”

“As the Secretary said, we know who’s behind this, Mr. President.  We know where they live.  Al Queda isn’t an army–it won’t take an army to take them out.  We know how to do this.  I need additional assets, additional funding–and time.  We’ll take them out, completely and permanently.  But there won’t be any headlines.  It’ll take six months, maybe a year.”

“A year?  The American people won’t wait a year for revenge for yesterday.”

“Revenge, Mr. President?  Revenge I can do in six weeks–very loud, lots of explosions.  It’ll look great on the evening news–shock and awe, the whole works.  But if you want us to really take care of this–six months, at least.  A doubling of funds for special forces.  Creation of a new special forces command, complete international integration–the Israelis, the Brits, the French, the Saudis.  And no headlines–completely dark.”

“Can we sell this, Mike?”

“Your’re the president, Mr. President.  You tell me.”

~~~~~

REALITY (August 25, 2005)

“Mr. President, I’m sorry, I know you’re very busy.”

“Not at all.  Just getting ready to head to the ranch for a couple weeks of R and R, you know.  Gawd, I hate this town in the summer.  Feels like we’re living in a swamp.”

“Yes it does, Mr. President.  I wanted to just quickly mention one thing.  I’ve got a guy over at the National Weather Center who’s called about a hundred times about this hurricane in the gulf.  He’s bending everybody’s ear about a real disaster scenario.”

“Really?  Did you know about this, Karl?  Does this mean the weather’s gonna suck down in Texas?”

“Yes, Mr. President, I heard about it.  He’s called about every department in the government.  He thinks New Orleans could be hit hard.  It’s just one possibility–he’s a weatherman.  Twenty percent probability sort of thing.

“What do you think, Karl?  Get a task force together like we did in Texas?  Let’s get FEMA on it–who is FEMA, anyway, Karl?

“Michael Brown, Mr. President.”

“You’re kidding!  Brownie?  That Michael Brown?  Couldn’t find his office for the first six weeks when he was head of the racing commission?  Head of FEMA?  You have got to be kidding.”

“No Mr. President.”

“Karl, this is bad.  You’ve got to get Brownie some help.  Hell, he probably couldn’t find New Orleans on a map.  Put together an emergency task force, mobilize the Guard.  Let’s get on this!”

“Of course, Mr. President.  But could we discuss some of the other aspects of this, Mr. President?”

“Other aspects?  Karl, it’s a hurricane.  We’ve seen our share while I was governor.  We know how to do this.”

“This isn’t Austin, Mr. President.  There are bigger ramifications to how we handle this.  A big difference between state and federal authority.  This is a problem to be handled at the state level.  If we go charging up at the federal level, what kind of message does that send?

“Your losing me, Karl.  The man said this could be really bad for New Orleans.  What if they can’t handle this at their level?”

“Of course, Mr. President.  But we’re talking only possibilities.  Nothing’s definite.  Do we want to send a message that the federal government is willing to charge in, take care of all your problems?  That’s not us, Mr. President.  Remember, smaller government.  Compassionate conservatism.  Responsibility to the states.   Let’s see how this plays out.  If things look bad, we can always have Brownie come to the rescue.”

“Gee, Karl, you’re always seeing the political side.  It’s just a hurricane, for crissakes.”

“That’s what you pay me for, Mr. President.”

ALTERNATE REALITY (August 25, 2005)

“Mr. President, one more thing.”

“If I had a buck for every time somebody said that…”

“Yes, Mr. President.  It seems the Chief Meteorologist at the National Weather Service is having a conniption over this storm in the Gulf.  He’s called everybody with a phone, telling  a doom and gloom scenario about New Orleans.”

“When?  I haven’t heard about this.  What’s he saying?

“Evidently, this guy’s an authority on New Orleans.  He says there’s about a twenty percent chance that this is the big one–broken levees, massive flooding, hundreds of thousands homeless.”

“Holy cow!  When?  How come I’m just hearing about this now?”

“It’s not definite, Mr. President, just a possibility.  Nobody really thinks it’s gonna happen.”

“You don’t think so?  This is just the kind of thing I’ve been talking about for twenty years, dammit.  This is global warming taking a swing at us.”

“I’m sorry, sir, you’re losing me.  Global what?”

“Are you kidding me?  You’re my Chief of Staff?  What are you doing about this?”

“Well, nothing yet, sir.  I wanted to get your take on how you’d like to proceed.  As I see it, there are two approaches.  Traditionally, this sort of thing falls to the states.  We could let them handle it.”

“Have you ever been to Louisiana, Elliot?”

“Uh, no sir.”

“What’s your other approach?”

“Well, just the opposite, I guess.  Full court press.  Activate FEMA, call out the Guard.  Though, of course, we’d have to do that in cooperation with the governor and all.  Don’t want to offend–”

“Offend?  Don’t you think the sight of a few hundred bloated bodies floating in the bayou on the six o’clock news might offend?  Listen, Elliot.  This is what you’re going to do–who’s at FEMA, anyway?”

“Actually, I don’t know, sir.”

“Oh for crissakes!  Remind me to look for a new Chief of Staff.  Find FEMA and light a fire under his ass.  I want bigger than full court press–you put together a damn federal emergency task force.  I’m talking the army, not just the reserves.  Put somebody you know in charge–don’t screw this up.  Get a general, somebody in uniform.  I want helicopters and those big Starlifters we use when there’s a disaster in Somalia or whatever.  If we can send them to India every time there’s a goddam monsoon, we can sure as shit send them to Louisiana.  Use less gas, too.  And I want press notified–get them on this hard.”

“But, Mr. President–he’s a weatherman.  What if he’s wrong?”

“Then we’ll call it a damn training exercise for when the big one really does come.  You’re kidding about not knowing about global warming, right?  And Elliot–”

“Yes, Mr. President?”

“If this guy’s right, I’m gonna give him a medal in the Rose Garden.”

END

Anesthesia is Hard-3

The Subtle Science of Sedation

As a general sugeon trained in a specific era and at a particular type of academic institution, I was taught that I should be able to do everybody’s job in the hospital just a little better than the folks whose job it was to do just that thing full time and to the exclusion of everything else after spending many years learning to do just that stuff.  It was believed that in this manner, we could protect our vulnerable, recovering patients from all the other doctors and health care professionals who didn’t care as much about the patient as we did.  With the foregoing mindset, I launched upon a two month rotation on the anesthesia service of a very large, very academic medical center.  One can easily foresee that this was not to go very well.  Not well at all.  Anesthesia practice is predicated on a team approach, an “all-for-one,” “we’re all in this together for the good of the patient,” approach. If an anesthesiolgist (or anesthetist) is having difficulty with an intubation or the patient takes a sudden turn, he or she is trained to immediately seek the assistance of a colleague.  Ego is put aside for the good of the patient.   I was trained to take a different approach.Top Gun

For reasons that still elude me to this day, during this anesthesia rotation I was permitted to manage patients with an extraordinary degree of independence.  This may have something to do with the fact that I had no official supervisor.  I fell through the cracks, in a way, and the result was that I managed the anesthetic of quite a number of patients with a degree of independence not even given to anesthesia residents until their last year of training.  The physicians directing me thought that everything would be okay if they just assigned me the simplest, most straight-forward cases.  Interesting point, though, is that there is no such thing as an easy case for the truly incompetent.

Many cases come to mind.  It should be noted that I did this anesthesia rotation during a time period and in an institution that held the technique of regional anesthesia in very high regard.  That is, every case was approached with the attitude of “Why not use a spinal?”  So I did a lot of spinal anesthesia.  I got, I thought, very good at spinal anesthesia.  I could place a spinal in a couple of minutes on patients of every age and body type.  I was instructed in various approaches and was fairly skilled at several of them.  Wherein lies the problem.  The technique of anesthesia is not difficult to master, it is the practice.  As a surgeon in training, learning technique was what I did.  I didn’t have a clue about anesthesia practice, however.

On one Monday morning, I was assigned to provide anesthesia to a patient undergoing an open knee procedure to be performed by the Chairman of Orthopedics.  It should be noted that the Chairman of Orthopedic Surgery was equivalent to Tutenkamen of ancient Egypt.  He was easily the institutional equivalent of The Chaiman of Thoracic Surgery (see “Mommas, Don’t Let Your Babies Grow Up to be Surgeons”), but more powerful.  Therefore, this assignment surprised me.  I had been on the anesthesia service for several weeks and was looking good. (Definition of looking good:  Nobody knew who I was.  That is, I hadn’t been noticed at all since I hadn’t killed anyone yet.  Close, but no permanent loss of life.)  Even so, this was a plum case, usually assigned to a senior anesthesia resident.  But the seniors were all away at conference and the administrative anesthesiologist had no idea who I was, he just knew that I wasn’t a junior anesthesia resident and assumed I, therefore, must be the guy.  I shrugged and trundled off to see the patient.  He turned out to be a twenty year old football player who had blown out his knee in practice.  Nice guy. Very large.  Muscular.   I introduced myself, did my preop assessment, and informed him that I’d be giving him a spinal anesthetic, of course, since I gave everybody a spinal anesthetic.  The patient was fine with this.

Placement of the spinal went great.  It always did, I was pretty good at it.  I got the patient comfortably positioned on the OR table and started in on my hypnotic “You are getting sleepy” dialogue with the young patient as I began to infuse a little hypnotic potion in his IV.  Again, this was the eighties, when about the only IV drug for this sort of thing was Valium, a drug which was notorious for its great variability in effect when given IV, particularly on young, anxious individuals.  Like football players undergoing sugery.  I checked the efficacy of my spinal anesthetic and was pleased to note that I had achieved a unilateral (one sided) block to a level of about the groin.  It was even on the side to be operated on.  Perfect.  I was proud of myself.  I had dosed the spinal for a duration of two hours, as the Chief Orthopedic resident doing the case with the Chairman of Orthopedic Surgery told me the case would take “about an hour, hour and a half, tops.”  I gave the patient a little more Valium in the IV and murmured sweet nothings in his ear.  He was asleep.  All good, I started my charting.

I turned away from my charting when the patient asked what was going on.  I was annoyed, as the patient had been nicely sedated and asleep.  Nothing should be going on.  I looked over the screen to see the Chief Ortho resident putting a pneumatic tourniquet high on the thigh of my patient.  “Hey,” I said.  “You’re operating on his knee.”  The ortho resident smiled at this information.  “Orthopods hate blood,” was his response.  This was a little problem.  A pneumatic tourniquet inflated to twice my patient’s blood pressure did not feel good.  While it was within the region of my block, it was much closer than I had anticipated.  I dialed the OR table to trendelenburg (head down) position, hoping that I could get the local anesthetic bathing the patient’s spinal cord to drift a little more upstream, giving him a higher level of numbness.  This only works for a few minutes after the spinal was placed, however, so I wasn’t feeling terribly confident at this point.  And I couldn’t recheck the level of anesthesia, because now the nurse was starting to prep the patient’s leg with antibacterial solution.  Just to be safe, I elected to give the patient more Valium.  And some intravenous morphine, too.  Just in case.  Back to charting as the patient began to snore.

The case began uneventfully.  The patient snored peacefully through the initial incision and exposure, my spinal having achieved a nice, dense block.  The chief ortho resident, like all chief ortho residents at institutions of great learning such as this one, was brilliant and highly skilled.  I watched over the sterile drapes as the chief resident put down his instruments and started to do nothing.

“I’m pretty sure you’re supposed to fix it, too.  That’s what it said on the consent, you know,” I said to the ortho chief.  Ortho chief smiled at me.  “Gotta wait for The Big Man.  That’s his job,” ortho chief replied.  I looked at my watch.  One hour into the case.  I looked at the upside down face of my linebacker patient.  He was smiling through a nice, drug-induced dream.  I shrugged and went back to charting.  Half an hour later, the Chairman of Orthopedic Surgery had still not arrived.  “Call him,”  I told the ortho chief resident.  “Yeah, right,” was his response.  “How long once he gets here?” I asked, looking at my watch.  ‘Hour and a half, tops, the guy had said. I began thinking that I might have to switch to a general anesthetic if this went on too long.  For that, I would have to call in my attending to let him know what I was doing.  That would be embarrassing.  I existed on the technique of staying inconspicuous.  If I called in my attending, I would have to explain that I had miscalculated the dose on the spinal.  Embarrassing.  “Once he gets here?  Not long,” ortho resident said.  He went back to doing nothing.  My patient chortled.

Chairman of Orthopedic Surgery swept into the room ten minutes later.  Finally, I thought.  I checked the patient.  He seemed comfortable, though his heart rate was up a bit.  More Valium.  A touch more narcotic.  I looked over the drapes.  Chairman of Orthopedic Surgery was still not scrubbed in.  “Where’d he go?” I asked.  Ortho resident shrugged.  Ten minutes later, Chairman of Orthopedic Surgery, gray haired and dashingly handsome, re-entered the OR, hands held up and dripping.  “Let’s get this man back on the field!” he boomed.  “Go Yellow!”  I rolled my eyes.  Finally, I murmured under my breath.

“It hurts,” my patient said.  I looked down.  His eyes were open.  “My leg hurts,” he said.  I looked over the screen.  Chairman of Orthopedic Surgery was finally thinking about maybe doing some surgery.  I looked at my watch.  Ninety minutes of tourniquet time.  Ouch.  “No problem,” I told the patient.  I infused narcotics. More Valium.  His eyes closed.  This was going to be close.  “Not long once he gets here,” the resident had said.  Just in case, I started drawing up drugs for a general anesthetic.  Just in case.

The patient murmured something unintelligible.  His heart rate was up.  His eyes were closed.  “What did you say?” I asked softly, mouth close to his ear.  “Fucking son-of-a-bitch,” he murmured softly.  Oh, that’s what you said. I gave more Valium.  I looked over the drape.  Chairman of Orthopedic Surgery was chatting up the scrub nurse as he slowly repaired linebacker ligaments.  I made a hurry-up gesture to ortho resident.  He smiled and shrugged sheepishly.

That’s it, I thought.  Embarrassing or not, I better call my attending and switch to general anesthesia.  It wasn’t my fault that the Chairman of Orthopedic Surgery was a molasses-slow, late-arriving horse’s ass.  We were over two hours on my spinal.  No way I had any anesthetic left at the level of the tourniquet.  We were on borrowed time.  I started to turn around to use the phone to call in my attending.

Now every anesthesiologist (and anesthetist, okay?) knows that there is a perfect plane of sedation that you don’t ever want your patient to achieve.  It is that level of sedation where the patient is confused and completely disinhibited, but not asleep.  If this were Top Gun, and I was a taller version of Tom Cruise, the Maverick of brash anesthesiologists in training, it is at this exact moment that the soundtrack switches to a very loud rendition of “Danger Zone.”  As I dialed the phone with my back to my patient, I heard the sound of Velcro arm restraints being ripped in two.  Then I heard my patient say, very loudly, “FUCKING SON OF A BITCH.”  I turned back to see my very large, linebacker patient sitting bolt upright on the OR table.  He had ripped down the drapes between us and the operating field.  The patient stared at his open knee.  He repeated “FUCKING SON OF A BITCH.”  The Chairman of Orthopedic Surgery, the ortho chief resident, the scrub nurse, and the medical student hoping to some day become an orthopedic surgeon, all stared back at the patient, incredulous.  In the words which would later be stolen by Goose in that classic movie, I said, “This is not good.”

I grabbed the full syringe of Surital that I had just drawn up in anticipation of having to induce general anesthesia.  A “stick” of Surital, a short-acting barbiturate, was our general anesthetic induction of choice in those days.  I rapidly pushed the whole stick into the patient’s IV.  He flopped back with a thud onto his pillow, deeply unconcious.  I readjusted the sterile drapes to once again separate my world from the sterile operating field.  I infused a muscle relaxant into the patient’s IV and proceeded to intubate the patient and connect him to the ventilator.  There was complete silence in the OR.

The Chairman of Orthopedic Surgery broke the silence.  “What the FUCK was that?” he asked.  I returned to charting my new anesthetic technique.  Not a good time to call my attending just yet.  “You there,” the Chairman of Orthopedic Surgery bellowed.  “Behind the drapes!”  I stood up.  “Yes, sir?”  “What the FUCK was that?” he repeated.  “What?”  I asked.  He looked at me, astonished.  “What?  What, what?  That!”  he said, pointing at me, then down at the patient.  “Not sure what you mean,” I said.  The Chairman of Orthopedic Surgery looked around at the others scrubbed at the OR table.  “Didn’t you guys see that?” he asked.  Ortho resident shrugged.  Med student nodded.  Scrub nurse chose to straighten the instruments on her back table.  This just made the Chairman of Orthopedic Surgery a bit more pissed off.  He strode over to the wall and mashed the bright red code blue button on the wall with his bloody, gloved hand.  No less than five attending anesthesiologists came crashing through the door.

“WHAT?”  “What’s going on?”  “What’s wrong?”  “Is it a code?”  “Aarhgh?”  They each said, surrounding me.  I shrugged and pointed to the Chairman of Orthopedic Surgery.  Two nurses rolled the code cart into the room.  More anesthesia attendings and residents entered.  Everyone looked around.  Everything looked okay.  The patient was asleep, under anesthesia.  The ventilator sighed assuringly.  The monitors beeped happily.  I reapplied the Velcro arm restraints and said nothing.  The anesthesia attendings turned to the Chairman of Orthopedic Surgery.  “What’s wrong?” the senior anesthesia attending, my attending, asked him.  The Chairman of Orthopedic Surgery stammered, “The patient, he was awake, he screamed at me, he called me a fucking son-of-a-bitch!”  The anesthesia attendings all turned to me.  “I had to switch to a general.  The tourniquet time is over two hours.”  I raised my eyebrows significantly and rolled my eyes toward the Chairman of Orthopedic Surgery.  “We had to wait over a half hour for What’s His Name, here.”  The Chairman of Orthopedic Surgery began to turn bright red.  “Do you know who I am?” he seethed at me.  I shrugged.  Went back to charting.  My attending stepped over and began to assess the patient.  Everyone else drifted out, shaking their heads.  The code cart was withdrawn.  My attending went over my anesthesia record, which was perfect, by he way.  I loved charting.  It made everything look so neat.

The Chairman of Orthopedic Surgery was still seething, arms crossed.  “Well?” he demanded of my attending.  My attending straightened up from the chart and looked at the Chairman of Orthopedic Surgery.  “You’re pretty long on the tourniquet, Bill.  Maybe you should try to finish up?” my attending said.

“That’s it?” the Chairman of Orthopedic Surgery asked.  “That’s all you’re going to say?”

“Yeah,” my attending said.  “And now I’m leaving.”  He turned to me before he left.  “Give me a call if you need a break, Geller.”  He winked at me.