You, Too Can Be a Writer!

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~first posted 21 Dec 12

I’m sorry, but I am of the opinion that writing is not all that difficult. I know, that sounds wrong. We are all avid readers, we live in awe of the great books we have read over the years. As individuals and as a society, we pay great respect to our authors. They are constantly on Fresh Air, The Colbert Report, The Daily Show, Sixty Minutes–hell, they’re everywhere. It’s like they’re superstars, even though most are not all that photogenic and many mumble a lot. But we love them, one and all.IMG_0641

We love them, even though what they do isn’t all that difficult. I presume that they are caught up in the whole cult of the mysterious, creative artist thing we have in this country (though not to the degree they have it in France, say, or Sedona). I can assure you, however, that what you do for a living every day is much more difficult, and I say that without being completely certain what it is that you do. It’s easier, believe me. I bet that at your job, you don’t get to show up whenever you like, take a nap whenever you like (writers call this story development), grab a snack whenever you like. You probably can’t perform your job half-drunk or recovering from a bender (admittedly, I’m making some assumptions here; like you’re not a NY State Supreme Court justice). But the writing part, I hear you protesting, the writing is hard. Actually, it isn’t. If the writer can’t think of the right word, they have all kinds of reference books he can consult to help find it. If you write something really awful, they let you go back and rewrite it as many times as you need to–kind of like going to Yale. Hell, you don’t even have to be a really good speller–chances are they’re going to hire somebody to fix all that stuff anyway. I have to tell you, writing really isn’t all that hard. Certainly a lot easier than trying to get a half-trained surgical resident through the removal of a tumor from some patient’s liver without cutting open something that’ll make a big mess. I know, I’ve done both and believe me, the surgery thing is way harder. And you have to stand through the whole thing.

No, the writing thing is pretty easy. Even the hardest part–the part where you come up with the idea–is pretty straightforward. You’ve done it, I’m sure. You’ve had great ideas for a novel. You’re living with a schnook that’s more of a character than you find in most novels. You may have even lived through one or two things that would make a great story. You’ve told people about it, but mostly while you were pretty drunk at a bar that was so loud that she wasn’t really listening but just nodding and smiling to be nice. You could write a book.

But you haven’t. You should you know. It’s not that hard.

Evidently, My ICU Has A Helluva Skylight

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True Stories From The Front Lines Of Medicine

Patients die.  It is a sad fact of life for all physicians, but particularly acute for us surgeons.  When I operate on an individual, they have entrusted me with an incredibly personal, invasive, singular interaction; an interaction that is intense and unique. Like up to my elbows in their innards kind of intense and unique.  As such, whenever one of my patients dies, it is a personal loss for me, a loss that one never really gets over.  As I sit here, I can see the faces and hear the voices of literally scores of individuals, young and old, men and women, with whom I have sat, and held their hands, promised them that I’d do my very best for them, and watched as they died, despite my efforts and promises to the contrary.  And then went to tell their husband, or wife, or father, or mother, or child that their loved one was dead, and I was sorry.  It happens.  For some reason that I’ve never figured out, though, only the nice patients die.  The really irritating, obnoxious ones never die.  Ever.  There’s a lesson in there somewhere, but one you probably shouldn’t share with your children.Minolta DSC

About six years into my practice as a busy academic general surgeon, I saw an elegant, elderly gentleman in my office in consult, Mr. Smith.  He was 81 years old and sharp as a tack, well spoken and funny.   A recent colonoscopy performed to evaluate anemia had discovered a bulky cancer in his colon, just above the rectum.  He was referred to me for surgery.  I sat with him and explained the situation, the nature of the surgery that I recommended, the four or five days he’d probably need to spend in the hospital afterwards, the nature of his anticipated recovery.  He was accompanied by his two adult children, who seemed more concerned and put off than their father; each of which asked appropriate and intelligent questions.  I assured one and all that, despite the diagnosis and the gentleman’s age, I thought he should do well and had an excellent chance of being cured from his disease.  We scheduled the operation.

The operation, like most, went very well.  The tumor was indeed large but without invasion into adjoining organs or obvious metastasis.  I successfully maneuvered the senior resident scrubbed with me away from cutting the ureters during the dissection.  Blood loss was minimal, the tumor removed smoothly, the bowel’s continuity restored.  The anesthesiologist was impressed with the old man’s resilience and heart, having turned not a hair throughout the procedure.  As was common practice, however, I directed the residents to admit the gentleman postoperatively to the Surgical ICU, just to be on the safe side and monitor him closely.  You learn quickly that the frail and elderly patients do very well if treated well, but they don’t take a joke very well.  One complication, the kind that more robust patients will tolerate and overcome, will often lead to this type of patient leaving the hospital by way of the loading dock.  So, the SICU for a day or two, just in case.

That operation had been my first of the day.  I completed my list of surgery and donned a white coat over my scrubs to make evening rounds.  I had already rounded early in the morning with the residents on all the inpatients on my service, so evening rounds were limited to those I had operated on earlier or that I felt would benefit from a second look before I went home for the evening.  My last stop this evening was to the SICU to visit my nice, elderly patient from whom I had resected the colon tumor that morning.  I entered his room to find the gentleman hooked up to all the usual devices, the monitors beeping happily.  The patient was lying in the bed and appeared perfectly comfortable, his eyes open and staring at the ceiling.  I smiled and greeted him by name, but he ignored me.  I didn’t recall him being hard of hearing, but there was a lot of noise and distraction from all the machinery in the room, so I wasn’t surprised by this.  I spoke more loudly, asking him how he was feeling and assuring him that the surgery had gone just as planned, that the tumor had been removed completely and without difficulty.  He ignored me the whole time, continuing to stare at the ceiling.  I grew quite concerned and finally shook him gently by the shoulder and called his name again more insistently until, finally, he took his eyes off the ceiling and looked at me.  He smiled, recognizing me and acted like I had just arrived.  I repeated that the surgery had gone well.  He just nodded and went back to looking at the ceiling.  This was starting to piss me off.  I mean, come on, just a quick “Thanks, doc,” would do.  A little acknowledgement of an effort well done, another life saved–though, of course, it’s just my job, you know, just what I humbly do each and every day.

“Mr. Smith, are you okay?” I finally asked, irritated.  “Yeah, fine, doc,” he says, still not taking his eyes off the ceiling.  “What are you looking at?” I finally ask, looking up and not seeing anything more interesting than faded ceiling tiles.

“Heaven,” he says, smiling.

“I’m sorry?  What was that?”

“Heaven.  See?” he says, pointing up.  “I see heaven.  And angels.”  He’s smiling, goes back to ignoring me.

“Stacy!” I yell out the door.  Mr. Smith’s ICU nurse, Stacy, comes running in.

“Something wrong, Dr. Geller?”  She can see I’m upset.

“What did you give this guy?”

“Nothing, Dr. Geller.  I was just in a few minutes before you, asked if he wanted something for pain.  He said he was good, I didn’t give him anything.”

“You gave him Demerol, didn’t you, Stacy?”  Demerol was notorious for giving elderly patients hallucinations.

“No, I didn’t, Dr. G.  Why, what’s wrong?”

“Mr. Smith is looking at heaven up there,” I say, pointing.  “And angels.”

“Oh.”

“Yeah.  Oh.  Maybe you can check to see what they gave him down in Recovery, before he came up.”

“That was before noon, Dr. G.  Don’t think they gave him Demerol.  I’ll check, though.  Anything else?”

“Yeah.  Everything. Get everything, stat.”

“Huh?”

“Stat, Stacy.  EKG, blood gas, complete metabolic panel, CBC, chest x-ray.  Now.  And get the ICU resident, tell him I need him in here, please.”  I start to examine Mr. Smith while he continues to smile beatifically at the ceiling.  ICU resident arrives, asks what’s up.  I explain that Mr. Smith here is seeing angels, which I believe is not a good sign.  I would like him to pay particular attention to my patient tonight.  Please.  No problem, he says, in that special resident’s tone of voice that implies that I’m an idiot.  Which I don’t mind, as long as he watches my patient.

Of course, Mr. Smith’s exam is completely normal.  His vitals are perfect.  His abdomen is soft, his incision clean and intact.  Every test comes back perfectly normal.  Mr. Smith is still smiling at the ceiling as I throw up my hands and head home.  He doesn’t say good night.

I’m awakened by my beeper at 3 AM flashing the STAT PAGE signal.  I don’t even look at the number, I know it’s going to be the ICU.  I pull on my clothes and drive like a crazy person to the hospital.  Judgmental ICU resident and Stacy are busy coding Mr. Smith.  Billy, the former college football star turned ICU nurse, is doing the chest compressions.  Who’s the idiot now, huh?  “What happened?” I ask, examining Mr. Smith’s belly.  Which is still perfectly soft.  His incision still looks great.  Only problem is the guy has no heartbeat.

“No idea,” overconfident resident and Stacy say in unison.  “He was fine ten minutes ago.  No problem.”

“Hold compressions,” I say to Billy, watching the monitor. Nothing.  “Call it.  What time?”  I hadn’t put on my watch.  [Brief Aside:  If you have been following this blog, you have probably already figured out that you really do not want me running your code.  Really.]   I leave to wash my hands and call Mr. Smith’s children.  The daughter thanks me (next of kin always thank you when you tell them their loved one just died) and says she and her brother will see me in the morning.  I feel like crap and go home to go through my usual postmortem ritual at 4 am of sitting at the the kitchen table, eating lots of cookies and milk as I try to figure out just how I screwed up this time.

The next morning I sit down in the conference room with Mr. Smith’s children.  I feel awful.  “I’m so sorry about your Dad,” I begin, but they cut me off.

“Please, Dr. Geller, don’t be upset.  Dad was fine with it.”

“I’m sorry?  Fine with what?”

“Dad told us he wouldn’t be coming home.  He made all the arrangements.”  I’m just staring at them, trying to get my mouth closed again.  “Really, Dr. Geller.  Please don’t be upset.  We really appreciate everything you did–”

“Killing off your Dad, you mean?”

“No, not at all.  Dad really liked you and I know he’d tell you that he really appreciates everything–”

“If he were still alive, you mean?”

They nod.  “Exactly.  We’re good here, Dr. Geller.  Really.”

Just wish I was.

Mommas, Don’t Let Your Babies Grow Up To Be Surgeons

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There is a reason surgeons are generally disliked by other physicians.  And a lot of other people, too.  A fair percentage of us are assholes.  While disagreeable surgeons may be easily found in every field of surgery, it is universally agreed that the biggest assholes are thoracic surgeons.  There are many reasons for this, generally relating to the type of person attracted to a program that requires every-other night call for upwards of seven years.  There are other reasons, too.IMG_0122

As a senior medical student, I considered myself hot shit.  I was smart and extremely hard working–in other words, I had no girlfriend.  As a hotshit senior medical student at an institution that considered itself to be the world’s best medical school, and destined in my mind to be a famous surgeon, I felt compelled to do an elective rotation on the thoracic surgery service at the University Medical Center.  The audacity of such a move cannot be overstated.  This was undoubtedly the most demanding rotation a student could elect.  Actually, the term most often used by my predecessors was “abusive.”  My two housemates, at the time, were both performing elective radiology rotations in Hawaii.  They came back tan and able to surf.  Also, with a condition that required antibiotics and, for one of them, eventually required clandestine child support.  I never left the hospital.

The thoracic surgery service was run by a young, brilliant, academically-trained surgeon.  For many, many reasons, too many to go into here, I regard him, to this day, to be the greatest asshole the surgical world has ever known.  I spent two months on his service, rarely leaving the hospital except to change clothes.  He never learned my name.  The tone of the service was evident almost immediately.  On my first day, I was told to scrub in on a complex operation being performed by Dr. Asshole.  This didn’t faze me, as I had already completed two lengthy surgical rotations and felt at home in the OR.  In addition, I had spent the vacation time prior to this rotation reading everything I could about thoracic surgery and Dr. Ahole’s publications–all of them.  I told you, I was hot shit–and had no girlfriend.  Anyway, I scrubbed in and introduced myself to silent nods all around.  Dr. Ahole seemed at ease, bantering with the Chief Thoracic Surgical Fellow as the operation proceeded smoothly.  I was familiar with the procedure from my readings and quite knowledgeable regarding the controversies surrounding it, as well as Dr. Ahole’s writings on the subject.  As the majority of the operation was accomplished and the chest was being closed, I gently but professionally asked Dr. Ahole a question; an insightful, sincere, and well-meaning question.  The question was greeted by complete, cold silence.  During this silence, Dr. Ahole stopped working, carefully put down his instruments, and looked me straight in the eyes.  “Who are you?” he finally asked.  I reintroduced myself, it having been a full forty minutes since I last told him who I was.  At this, he gently shook his head, picked up his instruments, and went back to helping close the chest.  During the subsequent eight weeks of working with him, he never said another word to me.  Great guy.

During this rotation I became good friends with the Chief Thoracic Surgical Fellow (CTSF), a very decent individual, married with two kids, who spent every single moment for two years in the hospital.  Every few days his wife brought his kids over so that they could all have dinner together and the children reminded that their mom really wasn’t a single parent, meeting lovingly in the hospital cafeteria.  She also brought him clean clothes for office hours and conferences–every other moment he was dressed in scrubs.  He was a great teacher and mentor.  About three or four weeks into the rotation, I was scrubbing with the CTSF, getting ready for a very interesting procedure.  It was one of Dr. Ahole’s specialties and he did a lot of them, patients coming from literally all over the world to have him perform the operation.  Usually, Dr. Ahole would appear about thirty or forty minutes into the operation, allowing time for the CTSF to get the patient positioned and the chest opened with the Senior Surgical Resident currently rotating on the service.  On this day, however, Dr. Ahole suddenly appeared and started scrubbing with us.  He was in an exceptionally good mood, joking with the residents (and, of course, completely ignoring me).  Just before we’re all ready to quit the sink and head for the OR, Dr. Ahole turns to the CTSF and asks, “So, Paul, how long?”

“I’m not betting,” Paul, the CTSF, replies.

“You have to bet, Paul,” Dr. Ahole responds.

“I don’t think it’s right, Dr. Asshole.  I can’t bet you.”

“If you don’t bet, Paul, you might as well scrub out because I’m gonna do the whole goddammed case with whoever this asshole is (nodding at me), then.  You won’t touch the knife.  So, how long?”

The CTSF shrugs, “Fine.  Thirty minutes.”

“Great, thirty minutes, twenty bucks.”  And Dr. Ahole sweeps into the Operating Room.

“What was that?” I ask the CTSF

“Shut up.”  He followed Dr. Ahole into the OR, and I followed him.

Dr. Ahole, as Chief of the Division of Thoracic Surgery and a very busy surgeon, had his own operating room with a dedicated team of nurses and technicians.  He had been at The World’s Best Medical Center for quite a while and his team was exceptional.  As a testament to their experience and competence, whole procedures would often be accomplished without the surgeon ever asking for an instrument.  He would put out his hand and Stella, the scrub nurse, invariably slapped the exact right instrument into his palm without the great man’s eyes ever leaving the operating field.  In two months, I never saw her give him anything except the exact right instrument without so much as a fraction of a second’s hesitation.  Stella was a middle aged African-American woman, tall and soft spoken, who scrubbed on all of Dr. Asshole’s procedures.  The two circulating nurses on the team were just as dedicated and competent.  Every operation was like a beautifully choreographed ballet.  And there was never any doubt in the room about who was the principal dancer, maestro, and sovereign authority.

On this day, however, it was immediately apparent that something was up.  As Dr. Ahole dried his hands, he asked Stella how she was doing, and made small talk about her family.  “Just fine, Dr. Asshole, thanks for asking,” Stella replied, smiling.  I’d never seen him so personable.  Maybe my impression of him as the world’s biggest prick wasn’t completely accurate, I remember thinking.  “Everybody all set?” Dr. Asshole asked jauntily.  Everybody enthused their affirmatives, and the CTSF made the incision.

The operation was going great,  Dr. Asshole was letting the CTSF do most of the work and Paul was an extraordinarily skilled operator. Dr. Asshole was actually complimenting him on his technique.  About twenty minutes into the operation, Dr. Asshole, in a completely nonchalant tone and without looking up, asks Stella for a curved Satinsky clamp.  Immediately, Stella shot a glance at the circulating nurse.  The circulating nurse bolted for the door.  Dr. Asshole still had his hand out.

“Dr. Asshole, that clamp is not on my field.  I’ll have it for you in sixty seconds,” Stella stated calmly, though I could tell she had blanched above her mask.  “Is there another clamp that will suffice?”

Dr. Asshole stood up straight and looked aghast.  “You don’t have the Satinsky?” he asked, incredulous.

“Dr. Asshole, we’ve done this operation together over one hundred times.  You have never asked for the Satinsky before.  That clamp is not on the tray.  I’ll have it for you in  thirty seconds,” she responded smoothly.  She was right, of course.  I had, myself, scrubbed with him twice earlier in the week on the exact same procedure and he hadn’t asked for the clamp in question. I had no idea what was going on.

“My God, woman!” Dr. Asshole suddenly shouted.  “How the Hell am I supposed to do this operation without a goddammed clamp? Huh?”

“Is there another clamp I can give you, Dr. Asshole?”

Dr. Asshole reached over onto her tray of instruments, something that I’d never seen any surgeon do before.  The scrub nurse’s Mayo stand was her territory and sacrosanct.  It was almost as if Stella had reached over into the wound to pinch the heart.

“Just give me a fucking clamp,” he growled.  As he grabbed a clamp off of the tray in front of Stella, he knocked about twenty carefully arranged instruments crashing to the floor.  Stella’s eyes were wide above her mask, but she said nothing.  Dr. Asshole began to roughly dissect in the patient’s chest cavity with a long right angle clamp he had grabbed from her tray.  At  this moment, the OR door burst open and the circulating nurse skittered in, breathless.  She smoothly delivered the Satinsky clamp onto Stella’s back table with the practiced motion of a professional baseball pitcher.  Stella smoothly proffered the clamp.  “I have the Satinsky, Dr. Asshole,” she said flatly.

But at this point Dr. Asshole was loudly cursing into the wound as he roughly dissected in the chest.  Dark blood began to well out of the chest cavity.  Paul had become a statue.  He looked like he was in pain.

“Look at this, Stella,” Dr. Asshole nearly screamed.  “Now he’s bleeding, he’s goddammed bleeding because you don’t have the tools I need to do this operation.  This guy’s gonna bleed out because you didn’t think to have the tools I need.”

“I have the clamp now, Dr. Asshole,” Stella repeated.

“Too late, goddammit,” Dr. A snarled.  He grabbed the clamp from her and hurled it across the room, just missing the circulating nurse.  It clanged off the wall behind her.

Stella looked stricken.  There was a brief moment of silence as we all looked at the merlot colored blood welling up from the chest cavity.  Suddenly, Stella burst into tears.  She muttered something apologetic about having to step out for a moment.  She ran from the room, pulling off her gown and gloves.

The operating room was stone silent.  Dr. Asshole looked at the clock, then at Paul standing on the other side of the OR table.

“Twenty-four minutes.  You owe me twenty bucks, buddy.”

Eventual Rejection

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I’ll be the first to admit that I take rejection badly.  This trait is fine for a surgeon (general anesthesia is a great way to avoid rejection), but is a problem for any new, aspiring, delusional writer, such as myself.  So, today I received the following terse, fairly standard email of rejection:

Thank you for your interest; unfortunately this falls outside of my area of expertise. I wish you all the best finding the right agent and publisher for your work

.-Chris P*__________

I should note that this reply arrived exactly one year after my query submission.Minolta DSC

So, I replied thusly:

Dear Chris:

Thank you for the courtesy of your reply to my query from one year ago.  Congratulations on your recovery from the deep coma that prevented you from replying in a more timely, professional manner. During your  absence, and due to a lack of any evidence during the past year that you or your company actually functions as a literary agency, I and my friends at the DEA have been forced to conclude that the financial transactions masquerading as the activities of a valid agent actually represent a probable money laundering enterprise for a Colombian drug cartel.  You may anticipate further inquiries in this matter.

Again, thank you for taking such a lengthy and appreciative interest in my work.  I’m sorry that I have been forced, in your absence, to pursue another path.  I wish you luck in your future endeavors as a “literary agent.”

Sincerely,

Evan Geller

Which, of course, is yet another reason that I’m not “traditionally published.”

“Discoverability”: An Indie Author’s Publishing Parable

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~first posted 23 Feb 13

[In the manner of those times when you showed up to the lecture that everyone else had cut, and the prof spent the whole class complaining to you about the poor attendance and then was so ticked off he refused to give the lecture…]

You’re not reading this, because you don’t know who I am. You’ve never heard of me, or this blog. Yet here I stand, knee-deep in snow in the Amazonian wildlands, the wind howling about me, as I toil at chopping down this huge tree, a mighty oak of a tree; a damn fine tree, if I do say so myself. And then, finally, suddenly, the tree falls…

…without a sound.IMG_1110

The tree lies there, silent and still, as I stand above it, victorious and proud, sweating, with heavy axe shouldered, my boot atop its fallen trunk. Breathing heavily–falling trees alone in the woods is hard, under appreciated work–I take stock of the magnificence of the work I’ve just accomplished, somewhat chagrined that there isn’t a crowd of appreciative well-wishers gathering about to clap and congratulate me on having accomplished the dropping of such a big and important tree. Why is that, I wonder.

So I wait for a bit; but no, it seems that no one is coming. Or noticed. In the distance, I can see quite a few people milling about other, lesser fallen trees. I really don’t get it, those are like saplings compared to this sucker here. Those folks don’t even seem to know what they’re missing, as if they really don’t know much about trees at all…

“Excuse me,” I hear a small, plaintive voice say. I reluctantly tear my gaze from the other, more appreciated trees, and look down to see a very cute little bunny caught by a branch of my fallen tree. “Excuse me,” he repeats politely, “but I seem to be caught here by your fallen tree. I’m sorry to be a bother, but I never even heard the thing falling, otherwise I certainly would have avoided your tree altogether. Might I trouble you for a little help?’

He is so cute and well spoken! “What is your name, little bunny?” I ask, kneeling next to him. I scratch his head between his pink bunny ears, but he doesn’t seem to appreciate this much.

“Is that important?” he asks, a bit annoyed after the head scratching episode. “I mean, just to move the tree a couple of inches and let me on my way? Are we to exchange insurance information as well? Can I expect a card on Easter?”

“Well, I was just trying to be nice, is all.” He is so fluffy, I’m sorry my tree has trapped his paw. I feel bad.

“Nice? Nice would be watching out not to drop a tree on any innocent soul that happens to be passing by. Or at least calling out something before doing so; saying, oh, I don’t know, something like ‘Tim-ber’ or ‘yet another self-important freelancer tediously dropping a tree randomly in your vicinity.’ Something like that would be nice.” I look wounded. “Reed. The name’s Reed.”

“Reed? Reed Rabbit? Is your middle initial ‘R’?”

“No. And my last name isn’t Rabbit, either, it will shock you to learn, I’m sure. As I myself would be, if your last name isn’t ‘Pathetic Dumbshit.’ ”

“Oh. Sorry. Listen, since you’re here anyway, would you like to discuss the critical importance of my tree? Or why this is the most significant tree felled in our lifetime?”

“No.” I see the fluffy bunny struggling to free himself.

“Well, if I free you, can I at least ask you to nibble a bit of the bark here? You know, just take a little bit to get the taste of how marvelous this tree is? Since you’re here already? Just a taste?”

“I think not.” Reed struggles mightily at the entrapped paw, somewhat panicked now. He looks up at me, obviously concerned that I’ve made no move to release him. “Listen,” he says with a slight twang of desperation, “how about you release me and I’ll mention to everyone I meet here in Amazonia just how decent a chap you are? How about that?”

“Oh, so you will try my tree then?”

“No.”

“But then how–”

“Does that really matter? I’ll be on my way, you’ll be happy here with your twisted little bramble bush. I mean, look at this. It looks like a prop from ‘The Charlie Brown Christmas Special.’ Just lift the thing for a second. It’s the decent thing to do.”

I realize that the fluffy little fellow is right, though he seems a rather heartless little bunny. I stoop to lift the tree. “Maybe you could stop by my house here in the woods sometime, try my blog soup.”

“To be honest, I’d rather gnaw off my own paw.”

Lub Dub

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During my Chief Residency (fifth and last) year of surgical training, I was working at the large academic hospital for a three month rotation.  During this rotation, I was in charge of a general surgery service with an emphasis on oncology surgery.  This was a plum rotation for the chief, for we got to perform large operations just about all day, every day.Minolta DSC

While finishing a particularly satisfying distal pancreatectomy with my attending, my junior resident came into the OR, excused himself for interrupting, and told me that he had received a request for a consultation in the Medical ICU to “rule out acute abdomen.”  This phrase, when voiced by any member of the Medical ICU resident staff, uniformly portended disaster.  I instructed him to find the third year resident on our team and for them to go check things out.  I went back to closing with the help of the intern while my attending broke scrub to do whatever attendings did between cases.  Once closed, I left instructions for the intern to write postop orders and, donning white lab coat, took the elevator up to the MICU to check out the consult.

My residents were at the bedside of the patient in question and explained that, as expected, the gentleman was an elderly, sick-as-shit individual,  currently hanging onto the merest shade of life with the help of infusions of every medication the medical intensivists had available.  It was also obvious, from a cursory review of the patient’s medical record, that he had begun the process of dying almost ten days earlier due to impaired blood flow to his bowel.  Though that diagnostic possibility had eluded the medical intensivists, today the rather clear-cut evidence of full blown gangrene of the bowel had pushed them to think fondly of their surgical colleagues for assistance.  Almost any internist will call a surgical consult when the patient is screaming at the top of his lungs about how much his belly hurts.  Of course, the initial reaction to this event had been for the internists to promptly sedate, paralyze, and intubate the individual, six days ago.  Connecting the patient to a ventilator always makes the screaming stop.  Now that the patient had deteriorated to the point of imminent demise, and it was impossible to examine the patient or take a medical history, they had called the consult.

Though unable to perform at this point a meaningful bedside exam, my residents had reviewed the laboratory tests of the past several days, about eighty of which clearly indicated progressive gangrene of the bowel.  They had also reviewed the three CT scans which had been obtained during the past eight days, each documenting the clear progression of gangrenous changes of the bowel.  They also reviewed the medical student’s ICU admission note, cosigned but undoubtedly unread, that listed as number 14 on the differential diagnosis list “Ischemic gangrene of the bowel.”   My third year resident had circled that, written “You think?” next to it with a smiley face.  I instructed my team to get a consent for surgery from some family member and have him down in the OR after my next case.  I told them that if they didn’t screw this up, I’d staff the two of them on it and let my fellow Chief do the last case in my room  He’d be thrilled and they were thrilled at the prospect of doing a real operation.

Two hours later, I was finishing my next case when the intern came in to tell me the consult patient was in OR 7, being prepped by anesthesia.  I said great, good work, I’ll be right over.

I came into the OR just behind an EKG machine being wheeled in by the circulating nurse.  Mr. Really Sick MICU guy is on the OR table with an anesthesia attending and two anesthesia residents buzzing around him.  There’s a nurse anesthetist who looks about sixteen years old sitting at the head, working the controls.  I stand in the door as I watch one of the residents start to hook up the new EKG machine, a most unusual thing to do.

“What’s up?” I ask innocently, to no one in particular.

“EKG’s screwed up,” Anesthesia Resident Number One replies.

“Unusual,” I comment sagely.

“Happens,” he replies, supersagely.

“Is his pressure okay?” I ask.

“Can’t get a pressure off the cuff, too edematous,” Anesthesia Resident Number Two informs me.

“Hmmm,” I reply.  ‘How about the a-line?” I inquire, pointing at the monitor.

“Waveform’s damped, haven’t been able to flush it.  Probably kinked,” Number One again.

“Hmmmmm,” I reply.  I approach the patient and can’t help but notice that the second EKG tracing is not very impressive either.  I gently palpate the patient’s groin for a pulse.  Nothing.

“Excuse me,” I say to the nurse anesthetist, who is listening to the patient through an esophageal stethoscope.  She looks up and pulls the earpiece out to listen to me.  “Excuse me, but do you hear lub, dub?”

“What?” she asks smiling, pleasantly confused by my question.

“Do you hear lub dub, lub dub?  You know, like a heartbeat?”

“Actually, no,” she responds rather sheepishly, “Good breath sounds, though”–more brightly.

“Okay,” I announce loudly, making a show of looking at my watch, “I’m pronouncing at 3:42.  He’s dead.”  All motion stops.  Awkward silence.  Anesthesia attending sputters to life–“What are you talking about?”

“He’s dead,” I deadpan.

“What do you mean?”

“I mean that you have been giving anesthesia to a dead person for–how long have you been in the room?” to the circulating nurse.

“Twenty minutes or so,” she answers.

“Twenty minutes or so,” I conclude.  I smile.  I really shouldn’t have smiled.

Anesthesia attending goes ballistic.  “Call a code!” he yells as he starts to pull all the covers off the patient.  “Start CPR!” to Residents One and Two.  All hell starts to break loose.  “Get a code cart in here!”  Multiple anesthesia attendings and residents begin to flood in through various doors.

“Hey, come on,” I beseech, fairly loudly over the din.  “He’s been dead for almost half an hour–you’re going to start coding him now?”  Awkward silence re-ensues.  “3:42.  Dead.  Elliot–” to my third year, “call the next of kin.  See if you can get an autopsy.”  And I’m outta there, stealing back my case from my fellow chief resident.

Surprisingly, it takes a full two days before I’m told the Chairman wants to see me.  “You wanted to see me, Dr. W*?”

“Yes, Evan.  How are you?  How’s your lovely wife, Sheri?

“Great, thanks.  How’s yours?

“Great, thank you for asking.”  I’m looking at a report on his desk.  Upside down I can make out (all capitals) LUB DUB. Underlined twice, with quotes.   “Say, Evan, just wanted to speak with you about a note I received from the Chairman of Anesthesia.  You might remember a case from a couple of days ago…”

Why Happy People Make the Best Editors (With Apologies to Erin Morgenstern)

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~first posted 3 Mar 13

Now before you start, I’m not talking about nonfiction editors, okay? And not copy editors, either. So don’t send all those nasty emails. (Who am I kidding, right? You and I are the only ones who read this blog. And you never write. Why don’t you write?) When it comes to copy editors, especially, go ahead and hire the skinniest, bony nosed bespectacled one-eyed fella you can find; he’ll do a great job moving those commas inside the quotations, every time. Not like he’s going out clubbing this coming Saturday night, anyway. No, I’m talking about the kind of person that you entrust with your story. When it comes to your real, live story editor, go happy or take that manuscript home. Avoid asceticism; err on the side of jovial gluttony. Ascetics are mean. You want the editor that hands back your manuscript with “Cherry Garcia” stains all over it, saying “That was great, I just made a few suggestions…”Minolta DSC

We all know the drill. Any author who desires “acceptance” must submit to professional editorial oversight. You must! Even if you’re self-published (which we all lovingly refer to now as “indie”). Especially if you’re self-published indie. If you can at least say, with a straight face, “I spent my hard earned money, which I will never in a thousand years recoup from the sale of this dog, to hire a professional editor and I incorporated all her suggestions in this fine, final product. It is the minimal price of admission, though it still just gets you staring at the door, being held back by the big bouncer of anonymity, but you’re so much closer to really getting in (sticking with the clubbing metaphor here). And if you’re lucky enough to actually be under contract, you will submit to editorial oversight/improvement/mercantile optimization/product placement; whatever is asked of you. It’s in the contract, brother. Right there, and there, and again here on page nine hundred twenty-two. So if you have to submit, let it be to a comfortably endowed, built for comfort/not speed, kind of editor. I, for one, quake at sharp tongued criticism of every adjective or descriptive nuance as “not moving the plot forward.” I like the fat, I love the fat. Even when said fat drags the plot a little backwards like a reluctant rump. I write like I cook–with lard, not dried out and burnt to a crisp. I don’t “kill my darlings,” I love my occasional authorial shining nuggets. Everyone says to get rid of the little parts you really love; but I won’t do it. It’s what makes the writing fun. I love the slight poetic excess, the unique turn of phrase, the ironic juxtaposition–even when something much pithier will do. I hate pithy. Except Hemingway. I’m not Hemingway, and, now that I mention it, either is anyone else. And Hemingway was a very sad man.

Of course, this attitude is one of the many reasons that you haven’t bought my book. A true story: I almost had a real live, professional agent, almost. Maybe. She is one of the best in the business, and I was in earnest discussion with her about my new book. She was interested. She was impressed that a good friend in the business that she respected had read my manuscript and strongly recommended that she consider taking me on. We enjoyed repartee, verbal and electronic. This until the fateful day when, in the course of discussing the work, I mentioned that it was 185,000 words. Anguished wailing ensued. The budding courtship was pinched off–unless and until I got a professional editor to excise at least 60k of dead stuff. But, I insisted, there is no dead stuff, it’s all great, all vital tissue. It is a great read, don’t you think? I ask her. She really can’t say, since she admits at this point that she hasn’t had the opportunity to read the thing, or even have her unpaid intern read the thing, and now that she realizes how long it is, she’s sending it back, because it’s soooo long. Wait, I protest, how can you say it’s too long if you haven’t even read it? Because, she says, I can’t sell it at that length.

And that, dear reader, is how it works. Almost-agent of mine wasn’t being mean, or unartistic, or unappreciative of my hard work–she was stating a fact of life in the literary industrial complex. Why should she take this on if I’m not willing to do the work to make it into something that she can actually sell for me/us? Answer: She shouldn’t. And she didn’t. I decided that I would prefer the book I love to sell in the dozens (how prophetic of me, eh?) than to retire on the fat movie royalties guaranteed if I’d only just play the game. But wait, you say,  professional editors make books better. Yes and no. Any professional editor with sense would improve my book, but anyone getting paid to cut 30% off is mangling my masterpiece. I won’t have it, not to my child, no way. I love my ‘non plot-driving scenes,’ my lacy descriptive prose, my ‘realistic-to-the-point-of excess-verbosity’ dialogue. I will not have it sliced off down to the sinew, even if done by a master surgeon. No doubt, I would be forced to give up the little literary techniques that I think I invented, that I love to employ. Like, when I use the exact same line of dialogue twice, spoken by different characters but with a completely different meaning, to draw a meaningful connection between remote areas of the book. Who else does that, I ask you? And other, equally cool stuff. It’s why I write stories, not technical manuals about how to tear down and rebuild your Ducati.

A completely speculative example may be illustrative. I loved the book The Night Circus, by Erin Morgenstern. It was, in so many ways, fantastic. I must admit, however, that I read the final act with an aching heart. The depth of feeling in the writing seemed to grow shallower as I fought the crashing waves of the last third to the climatic shore of conclusion. Only my opinion, now, and please keep in mind that I truly love the book as a whole; it is one of my favorite books and I’ve been reading a good deal longer than Morgenstern has been alive, an amazing statistic. But I got the sense, and still have it on rereading, that somebody at Doubleday Publishing, Inc. lured her unsuspecting manuscript into one of their basement ‘repair’ chambers and, with Erin protesting loudly against her contractual restraints, the smoothly running but rather luxurious manuscript was put up on the rack and had a significant amount of ‘excessive oil’ and ‘overstuffed upholstery’ editorially removed. By professionals, of course, who hardly left a mark. But the result in the third and final act was a thinning of the magic that Morgenstern had deeply ladled into the previous two acts. (Note that I am employing ‘magic’ here to represent the magic of Erin’s writing, not her writing about magic, and that ‘thinning’ is here used in an alternate meaning that contrasts to the overweight metaphor that began this blog. Just riffing here, reader.)

I could well be wrong. I have never met Erin Morgenstern, heard her speak, or exchanged even the most cursory of missives. I’m sure she loves her editors and sends them quirky gifts at unexpected moments. It’s entirely possible that she may not have even had the most minute manicure of her glorious opus at their hands. This is complete speculative bullshit on my part, based upon what I think, having read her book and a bit of her other fine writing. She is an undeniable talent and, no doubt, will forever be a literary force to be reckoned with. I think, though, that she might have been editorially sandbagged on her first outing. No doubt, the movie rights will lead to a fantastically rich adaptation that will have painfully little in common with the best parts of her book, but hopefully will net her a huge amount on the back end for life. Congratulations and well deserved. For this next one, though Erin, get yourself a comfortably plump editor. You deserve it.

Inflammable Man

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During the first year of my surgical residency, we were required to rotate through the Burn Unit.  The Burn Unit was an isolated six bed ICU with a twenty bed stepdown ward.  The unit had living quarters, and the burn resident was required to basically live in-hospital for the entire two month rotation.  Depending upon how early in the year you drew the rotation, the resident knew something between nothing and very little.  Nonetheless, the burn resident was the sole physician in charge of caring for the sickest patients in the hospital.  Thankfully, there was an expert crew of Filipino nurses who really ran the show.  It was a good thing, because the only attending supervision consisted of one of the staff plastic surgeons, Eli G*, weekly sticking his head into the airlock doors and calling out, “Everything going okay?”  The resident, overwhelmed with critically ill, septic, and dying patients would run to the door, yelling that “No, no everything was not okay, we need some help here, need to discuss operating on a couple of patients, Dr. G* “–to which G* would invariably turn a deaf ear and call over his shoulder as he strode purposefully away about the resident doing a great job and that he should feel free to call him if he was having any problems or needed any help with surgery.Dog Doctor253

I did the Burn Unit early in my first year, before doing any significant critical care rotations where I could have been taught something by a supervising Chief resident.  So I was basically completely incompetent to run the Burn ICU.   We had some great critical care nurses, but I had the misfortune of having a continuously full unit, with a bunch of big time, sick-as-shit “crispies.”   The patients would constantly die, but were immediately replaced by someone even toastier and sicker.  Most were alcoholics or addicts, homeless individuals who had managed to set themselves on fire in various ways.  It was late autumn, when every homeless Detroiter fired up their makeshift Sterno furnace, which usually promptly blew up or lit their Muscatel soaked clothing on fire.

A couple of weeks into the rotation, I was taking care of a fellow who had suffered thirty percent body surface area (BSA) burns when he fell asleep smoking and lit his mattress on fire.  Now this guy was relatively young, in his early thirties and, though an alcoholic, relatively healthy.  So I was kind of hoping I could get this guy out of my unit alive.  I was batting about .150 at the time.  Most of the patients, the ones with eighty percent BSA  burns or older than seventy years old with any significant burn at all, we were just kind of going through the motions because we knew they weren’t going to survive.  This guy, though, he came in with a survivable burn and talking, initially doing pretty well.  As usual, though, after a few days he started to go into DT’s (delirium tremens).  He became delirious, then septic, and finally ended up intubated on a ventilator.  We had had to sedate him due to the DT’s, and as he started to improve I stopped his sedation, but he didn’t wake up.  I waited a couple of days and finally called in neurology for a consultation.  I was still new and hadn’t had rule number four of the surgical residency program beaten into me–never, ever call a consult. So neurology, of course, orders an EEG to see if he’s still in there or if my expert care has already made the guy a vegetable.  About nine in the morning, after my initial ICU rounds, the tech comes in to  give the guy his EEG.  I’m around the corner in the stepdown unit when Filipino head nurse yells she needs “Geller Doctor STAT!”  I come flying back into the ICU to see the guy’s nurse doing chest compressions and yelling “V-tack,V-tack!” over and over again.  The EEG tech, who had just finished gluing about fifty electrodes to this guy’s head, decides he’s going to go on break now, maybe come back later.  You know, if the guy’s still alive and all.

Rule number three of the surgical residency was never, ever call a code.  The reason  for rule number three was the same as the reason for rule number four–the result would be a lot of crazy, dumb as a rock, medical residents gathering around your patient and ordering a lot of useless tests and medications that would inevitably kill off your patient.  Unfortunately, I was equally ignorant of rule number three.  So, upon seeing the nurse doing compressions and confirming that, yes, indeed, that was a pretty funky looking rhythm on the monitor, I picked up the phone and called a code.  “Bad, bad move, Geller doctor,” commented the head nurse when I hung up.  And she was right. Head Filipino nurse always right.

As I mentioned, the entire Burn Unit was an isolation ward.  It was entered solely through a double airlock door with all personnel being required to don isolation gowns, masks, booties, and hats prior to entering.  As the twenty man code team started to arrive, the head nurse stood just inside the airlock and insisted that everyone dress before entering.  This slowed things down considerably, and generally pissed off the medical residents anxious to save a life.  Meanwhile, I was in the process of trying to code my patient.  This one was supposed to live.  Now, even I knew the treatment of sudden ventricular tachycardia.  It’s  the application of a 700 joule jolt of electricity to the man’s chest.  So while the nurse continued CPR, I charged up the defibrillator to full power.  It may be worth noting that I had never done this before.  Actually, I had pretended to do it once on a mannequin.  So I was ready.  The first members of the code team, dressed in disposable paper bunny suits, started to arrive at the bedside as I applied the defibrillator paddles.  To her credit, the nurse momentarily paused in her chest compressions and indicated that this might not be a great idea.  I remember being somewhat annoyed by her lack of enthusiasm.  I was very excited to be defibrillating my first patient.

At this point, I must digress a bit to explain that, in order to perform an EEG, numerous electrodes are applied to the patient’s head.  By applied, I mean that they are glued to the scalp with a highly flammable compound called collodion.  While I was not familiar with the exact nature of collodion, I did like its smell.  Somewhat alcoholic in nature.  It’s rare that its flammability is much of an issue.

It is not difficult to properly apply a defibrillator.  It simply involves applying a special conducting paste to the paddles and then firmly pressing the paddles onto the patient’s chest.  The location for applying the paddles is conveniently pictured on the device itself.  It is traditional to loudly call out “Clear” just before pushing the little red button to deliver the jolt.  This gives the nurse the opportunity to move away from the patient so she does not also experience the 700 joule shock.  While I’m sure it was not a conscious decision, I elected not to bother with the conducting paste.  Like I said, first time was a manequin, no problem.

I yelled “Clear” as the the nurse yelled something about paste.  There was a flash, immediately followed by a strong burning smell.  The smell originated from two sources.  Initially, it was from the electrical burn I had caused my patient by not applying the paste.  This did not trouble me greatly, as I was a specialist in treating burns.  In addition, I was very pleased to note on the patient’s monitor that my jolt had been effective in converting his heart rhythm back to normal.  However, the nurse at this point indicated that I should perhaps take note of the patient’s head, which was now engulfed in flames.  It seems that the improperly applied paddles had arced, causing the collodion to catch fire.  I believe that Jeri-Curl, an alcohol based hair product popular amongst my patients at the time, may also have contributed.  In any event, as additional members of the code team joined the bedside, we all watched incredulously as the fire rapidly spread to the patient’s pillow and bedsheets.  It then spread to the tubing carrying pure oxygen to the patient’s ventilator.  This melted and began to shoot fire, flamethrower fashion, about the room.

The senior medical resident, a usually reserved Indian gentleman in his thirties, was the first to give voice to our general concern.  “Everybody out,” he screamed in accented English, “It is going to blow!”  Now, at this moment about half of the code team had made it past the head nurse and the double automatic airlock doors, dressed in highly flammable paper bunny suits, paper booties, paper hats, and paper masks.   These individuals, sensing the significant possibility of becoming one of my patients, turned and ran.  The remaining half, however, still oblivious to events unfolding within, continued enthusiastically to join our lifesaving efforts at the bedside.  The problem with automatic double airlock doors is that they only swing one way and rather slowly, at that.  Panic rapidly ensued.

It was at this point that a nurse kindly pointed out that perhaps I should do something, doctor-fashion, to address the rapidly progressing cataclysm.  I agreed enthusiastically, but was sadly at a loss.  As usual, the head nurse had already sprung into action.   Though somewhat trampled by the stampeding physicians still recreating a Keystone Kops routine at the airlock, she rapidly moved to the oxygen cutoff valve on the wall, disarming the torchlike ventilator.  Prior to that moment, I was quite unaware that such a valve existed.  It was, in retrospect, spectacularly convenient to have such a device.  Having extinguished the oxygen hose, she proceeded to soak a blanket in the bedside sink and throw it over the patient and myself, extinguishing the flames.  The patient woke up, ripped the tube from his airway, and began screaming and cursing out everyone in the room.

The patient survived.  He was discharged from Our Medical Center six weeks later.  His discharge diagnosis was “Second and Third Degree Burns, 48% BSA”  Hardly anyone noticed that his admitting diagnosis was “Second and Third Degree Burns, 30% BSA”.

Rope

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“That’s a lot of rope.”

                                                       God Bless the Dead

                                                         Evan Geller

Setting

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~first posted 17 Nov 12

Most of the time I’m not entirely sure where I am. I mean, who really is, most of the time? It’s hard enough just to keep track of what I’m doing and why. Usually, even the why is pretty murky. But the where is just kind of taken for granted. I can’t tell you how many times I’ll pull into my driveway and look up in shock at my house, wondering how in hell I got here. And wondering if I stopped at any of the traffic lights between where I was and where I am now.

Is this a problem? Not really. How often does what I’m doing depend on where I’m doing it? Not very often. Oh, occasionally I’ll find myself at the top of a windswept mountain or completely lost in the woods, but not very often. Usually, my surroundings are pretty pedestrian. The house is unremarkable, unless I step barefoot in a puddle of dog vomit. Suddenly, my setting becomes important. My environment has just started to drive my action. Before I stepped in the dog vomit, I was planning on sitting down in front of Meet the Press with a cup of black coffee and a copy of the NY Times. Now, events are dictated differently. Shouldn’t have given Bob Barker all that left over pizza. Remorse. Concern. The pressure-packed search for a roll of paper towels.

Sorry, Dad. Bad anchovy.

Sorry, Dad. Bad anchovy.

Usually, though, you don’t want to know much about where I’m sitting. You want to know what I’m doing. Perhaps, you’re interested in how I’m feeling, or why I’m doing what I’m doing or why I”m feeling the way I’m feeling. Do you care about the color of the sunset outside my window? Does the hue of my Hawaiian shirt affect your understanding of my mood? I think not. And all the time I spend in deeply nuanced description of setting, ambiance, or weather; whether poetic or pedestrian, is time spent sifting through detritus in an effort to get back to what’s important.

Let me paint the walls if I wish. Most of the time, I’m not even sure there are walls. Roof stays up anyway.