Friday, December 24, 2010

The Visitor

This is a strange place, I thought, as I stared into the darkness of my solitary room. I’m not sure this is the place for me. I opened the curtains and stared into the darkness outside and then went back to the bed. There was nothing in the room except the bed, a large TV that didn’t’ work and two books in the drawer next to the bed. The first was a fat and flimsy phone book. I thumbed through its pages, but the lists of names and places seemed like a foreign language and had no meaning. I looked at the other, with its black cover and its simple title, “Holy Bible”. Inside was a stamp, “The Gideons International”.

I opened it up to the first page “In the beginning, God…Let there be light”. I stopped at this point and went to the window and opened the curtain. Rays of light pierced the black horizon and I saw the outline of a large tree which became sharper and filled with color as the light rose in the east. This God must be wonderful to create such a world. I closed the book and left my room and went outside into this new world.

I felt a cool nip from a brisk wind as I stared at the tree that I’d seen outside my window. Its leaves were a bright gold and, as the wind blew, I saw several of them carried on the breeze. They settled on the ground with silent resolution as I walked on, following the last leaf to its resting place far away from the mother tree. As I walked I saw many buildings and vehicles and the air became filled with a foul smell as I walked past a large black building that was sending its smoke high into the morning sky. I guess this world is not as wonderful as I thought. And I went back to my room.

I sat on the bed and read more of the book.

“Now the serpent was more crafty than any other beast of the field that the Lord God had made”.

And I read how the beautiful Garden was spoiled and I cried. This
God must have given something more. He wouldn’t allow his creation to exist with
such despair. And I read on. So many of the people were cruel and hateful, but a few remained true to God. And then I read the answer:

“I am the Lord your God, who brought you out of the land of Egypt, out of the house of slavery.
You shall have no other gods before me…”

I read those commandments over and over. These are words that will cause the ruin of Satan and surely will allow the world to return to its original beauty. And so I went out again, filled with hope that the laws of God were all that the people of the world needed.

I walked for a while. I saw the people milling about, some smiling, some hand in hand and I was filled with joy. God’s commandments were all the world needed. But, as I walked along I glanced down a side street and saw a man strike a woman. She fell to the ground and he ran off with the bag she had been carrying. But the laws; what about the laws? I walked on. I saw a group of men and women beating an old man, laughing as they kicked him in the side. I ran to help the old man as the vicious mob left him lying on the ground. I stooped down and held his bloody face, but there was no life in him as I gently laid his head on the ground. God’s laws mean nothing to these people. And I went back to my room.

These people have forgotten what’s in this book. Surely they all must have read it. I read on and on.

“For everything there is a season, and a time for every matter under heaven.
A time to be born, and a time to die…
A time to love, and a time to hate…
A time for war, and a time for peace”

Maybe it’s not the time for God? I’ll venture out into the world again. And so I went out, again. The sun was high in the sky and people milled about as before. I passed a building filled with people, laughing, singing, a place of celebration. I went inside. There were men and women mingling about, all of them smiling and laughing. I stood at a long wooden counter and a man asked me if I wanted anything. I looked at him and smiled, but I didn’t say a word and he went away. I looked up at the large TV “…war in the Middle East seems to be escalating as Israel and Lebanon traded bombs earlier today…” I picked up the newspaper that was on the counter “…terrorist attacks in Europe have raised the alert level to red…” A time for war, but is there a time for peace? I left that place and went back to my room. The crispness of autumn had given away to the frigid snow of winter.

I continued to read.

“For unto you is born this day in the city of David a Savior, who is Christ the Lord. And this will be a sign for you: you will find a baby wrapped in swaddling cloths and lying in a manger…

‘Glory to God in the highest,
And on earth peace among those with whom he is pleased!’…

…he was called Jesus…”

And I read on. Surely this Jesus is the answer. His words bring strength and meaning to God’s laws. And so I went back into the world. Outside the ground was white with snow and bright colored lights were everywhere. The world is celebrating the news, a giant, joyful gala for Jesus. The people must be very happy that God has remained faithful to them.even when they are bad.

I heard all types of song, about the joy of Christmas and people wishing each other Happy Holidays and exchanging gifts. But, the songs carried a different massage. The music sounded joyful, but the words were empty. I heard about Santa Claus and reindeer and snow and trees and poor Grandma was run over by a reindeer and there was something about a “Grinch”. But nary word about God or Jesus. I guess was wrong to think that a holiday called Christmas would be about Jesus Christ. There must be some other Christ that is being celebrated.

In despair I went back to my room. I read more of the book.

“So they took Jesus and he went out, bearing his own cross, to the place called The Place of a Skull, which in Aramaic is called Golgotha. There they crucified Him…

…it is finished, and he bowed his head and gave up his spirit.

…go to my brothers and say to them, ‘I am ascending to my Father and your Father, to my God and your God’. Mary Magdalene went and announced to the disciples, ‘I have seen the Lord…’.”

And I read on and then I knew. God never gave up on his creation. His love is so great that He gave all that he could so that mankind would be free. Even though the world wallows in sin, God’s grace overcomes the evil and his love shines through. And, finally, I understood and I went back into the world. I still saw the wickedness and corruption, but I also saw hope and truth; truth that needs to be shared with all the world.

MERRY CHRISTMAS!!

Sunday, December 12, 2010

At Night

“I only need the pain med at night”; “I just take one a day, at night when I’m trying to sleep”; “I need something to help me at night”; I hear words like these over and over from patients. Something happens at night, lying in the dark waiting for the escape of sleep to overtake us. The pain of recent surgery often intrudes and seems more intense at these moments. The distractions of the daytime; other people, the humdrum light and noise of the daytime are gone and all the pain that has been buried during waking hours rises to the surface.

Our brain is amazing, the way it filters out wave after wave of unwanted stimuli, selecting only what’s important to capture our attention. But all this stimulation fades away in the night and we are left with only ourselves, our thoughts, dreams and pains. My patients fill out a history questionnaire as part of their initial evaluation; one of the symptoms they can check is difficulty sleeping. I think almost half my patients check this box.

Little children cry out in fear and their parents rush to comfort them; the darkness and solitude are fertile ground for the young imagination, calling up horrible monsters that prey on the innocent, but are frightened away by even the tiniest bit of light and a few sharp words from a loving parent.

The monsters of childhood give way to the demons of our later years. The worries of these supposedly enlightened progressive times creep out during the dark hours, robbing us of the tranquility that sleep promises. Perhaps the monsters are real; a prodigal child, a wayward spouse, financial burdens or disappointment over perceived failure, concerns that well up into our consciousness at a time when we yearn for the serenity and peace of sleep.

Charlie Brown of “Peanuts” fame would lie awake at night and ask questions out loud addressed to no one in particular or, perhaps, to God. The answers were never particularly comforting:

“Sometimes I lie awake at night and ask ‘where did I go wrong?’ And a voice answers ‘This is going to take more than one night.”-Charlie Brown in ‘Peanuts’

“Sometimes I lie awake at night and ask ‘Why me?’ And a voice answers, ‘Nothing personal, your number just came up’-Charlie Brown in ‘Peanuts’

Is God so arbitrary? I doubt it.

But, the night isn’t always bad. Triumphs and successes of the day bring a sense of joy and excitement that can keep us from the peace of sleep. It is far more likely that elation leads to celebration and sleep is banished for a while; our day to day struggles pushed back into the recesses of our brain, quietly waiting for the moment to emerge and send our joyful feelings crashing into the abyss.

The Bible speaks of rest as a reward, something given by God for work well done.
"Come to Me, all you who labor and are heavy laden, and I will give you rest. Take My yoke upon you and learn from Me, for I am gentle and lowly in heart, and you will find rest for your souls. For My yoke is easy and My burden is light." -Matthew 11:28-30

At the end of a long day or a long life God rewards us with His rest. Scripture presents rest as the ultimate gift from God. Over a six day period God created the universe and our world and on the seventh day He rested. Number four of the ten commandments is to remember the Sabbath day and keep it holy, which means set apart as something special, a time for rest.
So night is the time for rest, to be alone with God and with our thoughts; a time of reflection on the day’s events and a time to anticipate the days to come. So many times at night I think about the day that has just past, surgery’s that have been done, family concerns and any troubles. It’s a time to offer prayers of thanks and supplication. Personally, I think God listens best at such moments or, more likely, I can focus better at these times; the quiet darkness shielding my thoughts from unwanted intrusion.
And then there’s sleep. We drift away from consciousness, but remain alive. While we sleep amazing things happen. Although it has never been proven I think that sleep provides a time for repair: physical, mental and emotional. Body temperature falls, heart rate decreases, blood pressure decreases and vascular resistance falls. Our organs are bathed in blood that seems to circulate more slowly during sleep, allowing built up toxins to be released and disposed, focusing our immune system on potential invaders, repairing damages done and probably a multitude of other functions that remain a mystery.
Sleep is the time for dreams, our pent up thoughts and feelings released into a private theater that may be cryptic, vivid, heart-warming or terrifying. Sometimes in color, sometimes in black and white, Freud wrote a whole book on the interpretation of dreams. The Bible gave special credence to those that could interpret dreams and treated our dreams as messages from God. Daniel and Joseph were the premier dream interpreters of the Bible; they both suffered because of this skill, but were also rewarded. Most often our dreams leave us confused and often we forget them as soon as we awaken; leaving us with a vague recollection that something of importance may have transpired, but little more.
We may never remember a dream and remain oblivious to our environment, but we still yearn for sleep, for this time of physical, mental, emotional and spiritual repair. We cannot live without its benefits and yet it can prove to be so elusive. Lying awake, tossing and turning, counting sheep by the millions, downing pills and elixirs; searching for the elusive rest. Our world has become so complicated that moments to relax, do nothing and dream become fleeting until they seem lost forever.
Where can we find peace? As children the comforting word or touch of a parent was all that was needed. So, we come back to our parent, to God, our Heavenly Father. His word, His grace, His promise are all that we need to find rest. It is promised throughout the Bible and night is the time when we can feel His soothing touch and receive His peace.

Monday, November 29, 2010

Aliens Among Us

I just read an article which discussed how the teenage brain is wired differently than the brains of other normal people. Apparently, there was a study done that proved this difference; a fact that has been obvious to parents for ages, probably since the days of Cain and Abel.

That teenagers function on a different level when compared to younger children or adults is more than the result of “different wiring”. No, it is the consequence of a much more sinister plot; a plan that could eventually lead to the end of civilization as we know it. Recent observations out of Roswell, NM have clearly demonstrated that during a child’s thirteenth year aliens visit and our sweet innocent children are replaced.

Every parent has had the experience. That sweet child that loved to be with Mom and Dad, be it a simple walk or a game of catch, suddenly can’t be seen with parents. But it’s more than this. There is no question that teenagers are not human.

For example, years ago I had a simple surgery scheduled on a fifteen year old girl, excising a cyst from her scalp. It was too big to do under strictly local anesthesia in the office, so I scheduled the surgery to be done in the OR utilizing local anesthesia along with intravenous sedation. The procedure started uneventfully; the area on her scalp numbed adequately and her peaceful snores indicating an appropriate level of sedation.

As I made my incision she became agitated and started to scream that someone was trying to cut off her head. I have to comment at this point that local anesthesia will eliminate most sensation, but pressure feelings and awareness that something is being done still are maintained. As she became more agitated the anesthesiologist gave her more sedation, actually enough to stop a charging elephant. My patient tried to jump off the table.

Needless to say the surgery was stopped, she was given general anesthesia and we finished the procedure without incident. At that time I chalked it up to a single paradoxical reaction. But, about six months later I had another similar occurrence. A minor procedure on a sixteen year old boy, once again under local anesthesia with IV sedation yielded the exact same outcome. This time we were better prepared and as soon as it was apparent that the sedation was not effective, general anesthesia was induced and we finished the operation without further mishap. After these two episodes I decided that teenagers were not like normal people and since then all operations on this subspecies of humanity have been done either with straight local anesthesia, that is, sans sedation, or with full general anesthesia. I have to add that, at the time, my own kids were all sweet, innocent toddlers and young children. They’ve since grown and I am older and wiser.

But, what is the underlying mechanism for this devious transformation? Prevailing theories are that rapid hormonal changes coupled with the growing social pressures of the teen years lead to the instability of the teenage specimen. This explanation is at best inadequate. No, there is much more to the phenomenon and the answer, undoubtedly, is alien invasion.

During the seventh grade, usually a few months after the start of the school year the exchanges begin. Our teenage children are snatched away as they sleep and transported to alien space ships hovering just outside the Earth’s atmosphere, shielded from any prying military probes. Exact physical copies of our precious children are created and, unlike Stepford, where the wives were replaced by docile, compliant androids, the replicants are programmed to disrupt the lives of all the sane adults and younger children they encounter.

Because they are artificial they have no fear of driving too fast, or drinking excessively and, being perfectly engineered machinery, they believe it is beneath them to fraternize with imperfect biologically based beings like parents or younger siblings. Instead they prefer their own kind, congregating at malls, particularly around the Apple Store or in arcades where other machines can be found.

Oh, they are devious, that’s for sure; pretending to be sweet and innocent for a moment, filling their forlorn parents with hope that their baby has been returned, but it’s all a trick. Once rewarded with spending money and car keys, they revert to their real selves, congregating together to prowl the streets in packs and wreaking havoc at every turn. Of course it isn’t all bad. These alien creations have remarkable central processors that can soak up Shakespeare or trigonometry like a dry sponge. When properly motivated they are capable of performing a Vivaldi Violin Concerto or winning Olympic Gold in gymnastics. Through all this we cheer them on, pray for them and hope, deluding ourselves into believing that these ‘replacements’ are truly ours.

Is there hope for humanity; will we ever be released from these thorns in our sides? I don’t know what happens to the real children as they are held prisoner on these alien ships, but most of them manage to escape shortly after they enter adulthood. The vicious, unpredictable beasts are dismantled and our children, now responsible adults, return.

So, if your teenager is getting you down, acting in bizarre ways and causing you to reach for the Ativan two or three times a day, relax. Just say to yourself: “They’re not human, they’re not human, just be patient, just be patient”.

In a few years it will all be over. But, until that time, keep a stiff upper lip, hide the car keys and keep the Ativan close at hand.

Saturday, November 20, 2010

Jesus was a Wino...Like Me

A few weeks ago, in the midst of some heated discussion in the OR, my assistant made an interesting, perhaps profound comment. I don’t remember the topic, but the conversation must have wandered into religion and somehow the person of Jesus came up. Sometimes we actually have deep and profound discussions while slaving over hot gallbladders; this must have been one of those times. Anyway, as the conversation heated up, she blurted out:

“Jesus was a wino…like me”.

It sounded funny at the time, and I don’t think anyone in the room really believed it. First of all, although my assistant enjoys a fine glass of Chardonnay on a regular basis, in moderate amounts only (except on the rare occasion when she is celebrating something, when she allows herself a bit more), she does not fit the definition of a wino. There are various definitions of “wino”, but an amalgamation of them all would probably be: “an indigent person, usually homeless, who drinks alcoholic beverages, usually to excess”.

But what she said in the heat of discussion actually contains a great deal of theology and, if examined closely, one can find the gospel. So, let’s deconstruct this simple phrase and uncover its truth.

Jesus refers to Jesus Christ, the remarkable figure on whom the various Christian religions are built. Over two thousand years ago he was an itinerant rabbi hiking around ancient Palestine, trailed by twelve disciples, whose purpose was to deliver the “good news”, a message of God’s love, hope and salvation for all His people; the Gospel. During his three year mission He had no home and it is well documented that he drank wine, although never to excess. He performed many miracles; the first was changing of water into wine at the wedding feast in Cana. But, whereas his disciples may have become drunk on at least one occasion, (they seemed to have a hard time staying awake at Jesus greatest time of need in the Garden of Gethsemane), Jesus never drank inappropriately. Drunkenness would be considered a sin and he lived a perfect, obedient, sinless life, which uniquely qualified him as the perfect sacrifice to satisfy God’s wrath and to take our sins upon himself at the Cross.

So, he does not meet all parts of the definition of wino. Homeless, yes, indigent, yes, drank wine, yes, excessively, no. But, what about the Gospel? At the Cross, the sins of the world were heaped upon Him and by this act of love we are saved. When the believer stands before God for judgment,
God will see the righteousness of Jesus instead of a wretched sinner. This is the heart of the Gospel. At the Cross Jesus takes all the sins of the world upon himself and we, the sinful winos, are cleansed. Jesus becomes the wino in our place.

“He made Him who knew no sin to be sin on our behalf, that we might become the righteousness of God in Him.” -2 Corinthians 5:21

In this sense one could say that it’s true; Jesus was a wino. Perhaps it’s better said, “Jesus became a wino…for me”.

But, what about “…like me”. Can anyone say that Jesus is “like me”? Jesus left heaven; separating from all his glory, and became human, assuming all the frailties and weaknesses of humanity. He suffered all the temptations that we suffer and more. He was offered bread when he was starving, but rejected it, preferring God’s word. He was offered all the world, but chose the promise of God and Heaven and, finally, He refused to put God to the test, holding on to His faith and rejecting Satan. These temptations make Jesus “like me”, except he succeeded where we all fail miserably.

“Jesus was a wino..like me”. The Gospel shouts from these words and, as a result, hope and truth are offered to all of us.

Sunday, November 7, 2010

Grown Up

This post talks about "Toy Story 3 and contains spoilers, in case you haven't seen that movie


Last night I watched “Toy Story 3” with my wife and daughters. I thought the story was very touching and I found my eyes filling with tears at the end. Since then I’ve been wondering: what is it about this story that I found to be so moving? The ending was a bittersweet, but it was the best of all possibilities for the motley crew of toys. And, yet I felt far more sadness than anything.

As I reflected on everything the wonderful story contained I realized that “Toy Story 3” wasn’t about the toys at all. Just as “Ben Hur” was really about Jesus (the complete title is “Ben Hur, a Story of the Christ”), “Toy Story 3” is about Andy. Sure, the majority of the time the focus is on the plight of the toys, but at almost every moment it is the plight of Andy that is in the background.

We start with video of Andy playing with his beloved toys, games of make believe that demonstrate the unashamed imagination that is special to young children. But, the screen cuts to Andy preparing to leave for college. What will become of the toys; trash or attic or worse? At this point the viewer gets only a glimpse at Andy’s thoughts. He cares enough to put them away in the attic and he plans to bring Woody to college where he would likely end up as an ornament on a desk, seen, but not to be played with. It is a better fate than the attic.

If you’ve seen the movie you know about the plight of the toys, but one of the most revealing scenes is that of Andy searching for the toys he wanted to save and learning that they were accidently put out with the trash. Andy is visibly upset and then we don’t see him for a while. At that point perhaps he realizes that the childhood memory that he thought he was shuffling off to storage has been lostforever and we feel his loss.

The toys go through a number of misadventures until they find themselves, in a Jonathan Edwards moment, on the brink of annihilation, only to be grasped from the fire by the giant, divine “Claw”. They all make their way back to Andy who gets a second chance at redemption. Through the intervention of Woody he decides to give his toys, except for Woody, to Bonnie, a girl who we know will truly appreciate them and play with them just as Andy had done.

At the point when Andy stops at Bonnie’s home to give her the toys he demonstrates that he has not forgotten what the toys are, what they meant to him and what they still mean to him. He could have just handed the box to Bonnie or her Mother and drove off to college, but that wouldn’t have been right. He takes each toy, one at a time and lovingly hands it to Bonnie, making sure that she knows the true story of each one. And in the end he is left with Woody, who still plans to bring to college. But, Bonnie already loves Woody, just as Andy loved Woody when he was that young age. And Andy sees her love and gives Woody to Bonnie.

At this moment Andy finds redemption, just as Judah Ben Hur found his redemption through his three encounters with Jesus. Because, it is expected that Andy, having been true to his toys, would have left, gone on to the more important task of moving into college. After all he’s seventeen and playing with toys just wouldn’t be proper for someone moving on in this world. But, he stays and for the rest of the day he plays with his beloved toys and with Bonnie, recapturing the childhood he thought he had lost forever. And, it is at this moment that the tears start to flow, because for all of us we realize what we have lost. The childlike innocence that we used to have, imagination that can turn a piggybank into evil Dr. Porkchop, is lost; buried beneath the day to day routine that we call growing up and adulthood.

One of my favorite songs, since I was about eight or so, is “Puff, the Magic Dragon”. Years ago someone wrote that this song is about drugs, but if you read the lyrics it is clear that this song is about the losses we suffer when we grow up. Jackie Paper plays with Puff and the two go on the greatest adventures together, until Jackie grows up, Puff is replaced by other toys and forgotten. Without a little boy to bring the imagination there may be a toy dragon, but that is all there is, a lifeless stuffed animal. The imagination of a child brings toys and us to life.

Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee

Little Jackie Paper loved that rascal Puff,
and brought him strings and sealing wax and other fancy stuff. Oh

Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee
Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee

Together they would travel on a boat with billowed sail
Jackie kept a lookout perched on Puff's gigantic tail,
Noble kings and princes would bow whene'er they came,
Pirate ships would lower their flags when Puff roared out his name. Oh

Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee
Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee

A dragon lives forever but not so little boys
Painted wings and giant rings make way for other toys.
One grey night it happened, Jackie Paper came no more
And Puff that mighty dragon, he ceased his fearless roar.

His head was bent in sorrow, green scales fell like rain,
Puff no longer went to play along the cherry lane.
Without his life-long friend, Puff could not be brave,
So Puff that mighty dragon sadly slipped into his cave. Oh

Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee
Puff, the magic dragon lived by the sea
And frolicked in the autumn mist in a land called Honah Lee

Saturday, October 30, 2010

Project Run-Off

Elections come and go and every year it’s the same thing: a dozen or so men and women overwhelmed with their own sense of self importance vie for a spot on the ballot and then two or three square off in the election, hurling mud, false accusations and touting their own spurious virtues as they attempt to win our votes and “earn” a trip to Washington DC (or Austin, Albany or any of the other state capitols).

It’s time for a change. The election process in its present form is cumbersome, expensive and extremely annoying. It’s time to take a page from those people who know what the American people want and who know how to deliver it. It’s time for “Project Run-Off”.

Anyone who’s anyone knows that Gretchen recently stole the prize that Mondo deserved on “Project Runway”. Such are the vagaries of reality TV. But, the processes utilized by TV shows such as American Idol, Project Runway, Dancing with the Stars, among others lend themselves very well to our electoral system. After all, on most such programs a group of 10-15 contestants, most of which have had to demonstrate some prior qualification, compete week after week hoping to win the grand prize, some sort of fortune and fame. The process and result is similar to an election campaign, only a bit more entertaining and far more civilized.

So, starting with the 2012 Presidential campaign, which I’m sure will kick off the moment all the returns are in from the November 2nd election, all presidential wannabees will have to go through a grueling audition process, be selected by our panel of judges to go to the Elimination Round, scheduled to be held in Branson, MO in January 2011 and then be selected as one of the final fourteen candidates to compete each week on national television, starting during the sweeps month of May, with the finale in November 2012. In order to be truly fair and balanced, all networks will be given the option of picking up the broadcast.

Each week, the panel of judges will provide commentary and give their score for each contestant, but viewers also will vote, with eliminations based on a combined score, a la “Dancing with the Stars”. The panel of judges will consist of former president Bill Clinton, certainly qualified based on his past experience, former Hollywood Madame Heidi Fleiss, a woman well versed in intimate interaction with the rich and powerful, Iranian President Mahmoud Ahmadinejad, a man averse to everything American, but one that will surely provide even handed commentary and, finally, George, a bank teller from Piscatawy, New Jersey, selected to keep the panel connected to the common man.

Producer James Calhoun comments, “We want to flesh out the contestants. One week they may be asked to create a lavish state dinner for powerful heads of state, but with a budget of only $200, shopping limited to what’s on the shelves at the Pennsylvania Avenue Convenience Mart and preparation limited to two hours, utilizing only a single medium sized sauce pan and a hot plate. The next week they may be required to plan and carry out a military operation in Somalia, with a budget of only $1000, weapons limited to an arsenal of water pistols. The competition will test not only the resourcefulness, but also the character of the contestant.”

Director Clint Westwood added, “My favorite week will be ‘temptation week; each of our contestants will face some form of temptation, one that would not be uncommon to our president, but also selected based on the precompetition questionnaire each contestant will have filled out. It could be a White House intern offering sexual favors, a Russian spy with a sack full of money, a guest role on CSI or any of several others, some more unsavory than others. The goal is to demonstrate any character flaws before the contestant assumes the responsibilities of Commander in Chief, with his finger on that proverbial button.”

The competition will continue until there are only two contestants remaining. The final pair will live together in a one bedroom apartment for six weeks, cook for each other and have to perform a variety of tasks, sometimes working together, sometimes competing, all under the watchful eye of our judges and the our viewing audience. At the end of this period each will address the combined Senate and House of Representatives, laying out a program designed to face the challenges our nation faces today. They will then receive scores from our judges on creativity, originality and probable effectiveness. Viewers will then have twenty four hours to cast their votes, either by phone, texting or online, with each individual allowed one vote through each channel. The votes will be tallied by the accounting firm of Hood, Wink and Swindle and the results announced on the results show the following night.

We truly believe that “Project Run-Off” will make the election process more civilized, fairer and provide a far clearer image of our future leader. And, we will all be spared those boring, patronizing, insulting political ads that are a blight on our airways, stealing valuable airtime from truly important programs, such as “The Jerry Springer Show” and “Oprah”.

Saturday, October 16, 2010

Anti-Gravity

With election day right around the corner it’s time to start thinking about the 2012 campaign year. The usual run-up to the presidential election will feature the usual mundane ramblings by interchangeable Republicans and Democrats about taxes, jobs and the weaknesses and corruption of the opposing candidate. It’s time for a new party, one with a bold vision that looks to the future with imagination and a plan that will lift the people to previously unknown heights.

In this spirit the formation of the Anti-Gravity Party is now official. It’s time to look at some of the antiquated laws that hold all the world hostage to ideas that have grown old and stale. The Law of Gravity has been on the books for over three hundred years, ever since it was penned by Sir Isaac Newton. This law, brought into existence by only one man and never voted upon by a proper representative government, holds us down and limits the potential for growth by its very restrictive nature.

If the Law of Gravity were repealed just think of the endless possibilities. Currently, almost all our activities are limited to those areas close to our planet’s surface. Most construction is merely on the ground or just beneath. If gravity were eliminated, however, all the sky above us would be opened for the expansion of the human population. Food shortages would disappear as the burgeoning population moved to the sky, opening up precious land to agriculture. Energy shortages would become a not so fond memory as a world without gravity would allow for unrestricted mobility.

Of course, the elderly among us would be grateful for the potential health benefits. Bodies would no longer be subject to years of pummeling by the unrelenting force of gravity. The “settling” of so many of our body parts that accompanies the aging process, all mediated by gravity’s undiscriminating brutality, would be eliminated. It’s true that some Plastic Surgeons would see a loss of revenue as many of their procedures that were geared towards counteracting gravity’s long term effects would become mere footnotes in history of surgery textbooks.

So, it’s time to say “Down with Gravity, Up with True Freedom”, the Anti-Gravity campaign slogan. In the coming weeks more details about the Anti-Gravity Party will become available. Support is needed from everyone that is unhappy with the status quo. Donations as small as 25 cents will go a long way towards freeing humanity from the shackles imposed by the antiquated Law of Gravity. And, if this campaign proves a success other outdated precepts can be addressed. In particular, the Laws of Friction should bear some scrutiny, because it is clear that there is far too much friction in our world.

Thursday, October 7, 2010

Fearfully and Wonderfully

Psalm 139 declares that we are fearfully and wonderfully made. Over more than twenty five years spent caring for a wide variety of sick and injured bodies I have come to agree with the profound truth of this statement. The human body is constructed in a remarkable way that keeps it running during the most trying situations.

From the top of our heads to the soles of our feet our bodies are constructed to withstand extremes of temperature, assaults by invading organisms, physical and mental challenges and to perform with uncanny accuracy under the most arduous and taxing conditions.

So, let us start with the bottom of our feet. The plantar aspect or soles of our feet are a thick layer of skin and fascia perfectly suited for the stress and strain of upright walking. All the trumpeting of modern technological advances in athletic shoe design has not yielded any product that can claim to be superior to our feet. Indeed, recent research suggests that running barefoot or with a flat shoe with minimal padding is far superior to the thick soled, complicated athletic shoes that probably create more stressors for our feet than they prevent. It seems that Hobbits had it right.

Our bodies are maintained at a near constant temperature, 98.6 F or 37.5 C. We are equipped with very efficient heaters and coolers to keep us in the appropriated narrow range. If our body temperature starts to rise, be it secondary to a hot environment, physical exertion or some other factor we will sweat (or perspire if you are a lady). The moisture can cool directly, but the greatest cooling is a result of evaporation from our skin. External adjuncts, such as fans speed the process. Rapid breathing also can contribute to elimination of heat via the lungs. Of course this is carried to an extreme in dogs, who pant to cool themselves.

Conversely, our body is constantly producing heat. Routine, but essential metabolic processes all generate heat. In a cold environment this metabolism speeds up and more heat is generated, often manifested by shivering. Similarly, in the course of many illnesses a patient develops a fever. In the most extreme circumstances an ill patient will develop uncontrollable shaking called “rigors”. Such shaking is the result of rapid muscle contractions designed to generate heat and rapidly raise body temperature. In such situations the “thermostat” is turned up. Body temperature rises from the normal 98.6 to 101 or 103 or even higher. During the rising phase the patient complains that he feels cold and will attempt to cover himself to conserve body heat until the new temperature set point is reached. Although such high fever is a cause for concern and does carry its own set of risks, there seems to be some benefit, aiding our body’s fight against invading pathogens.

The fever may persist or it may dissipate, at which time the patient will usually have profuse sweating that lowers body temperature, the fever “breaks”. The fever must play a role in repelling an invasion by micro-organisms. The higher body temperature seems to have an inhibitory effect on certain viruses and bacteria. In the post operative patient fever is very common. Low grade fever, below 101.5 is probably secondary to a systemic inflammatory response unrelated to infection. Above this level, there is more concern that an infection might be present.

In any scenario, the fever has a purpose, be it fighting infection or assisting with the healing process and is one example of the amazing intricacies of human physiology.

Fever, of course, is a very common occurrence, be it a simple cold or life threatening sepsis. There is an aspect of human physiology and anatomy that is very important to our well being. Our bodies are built with long tunnels passing into and through us. The aerodigestive tract allows us to exchange a variety of elements with the outside world. The tracheobronchial tree starts at a shared entrance with the digestive tract. In the pharynx the two systems divide, with the respiratory limb ending in the lungs, two balloon-like structures that constantly inflate and deflate, exchanging inhaled oxygen for carbon dioxide, a byproduct of cellular metabolism. This essential mechanism keeps us alive. In fact, the first two letters of the ABC’s of trauma resuscitation are Airway and Breathing, (the third is Circulation), the jobs performed by the lungs.


But, it is the efficiency of our lungs and airway in light of constant bombardment by potential pathogens from the world around us that is truly remarkable. Our upper airway is equipped with mucus membranes that secrete mucopolysaccaride chemicals that trap invaders so they can be expelled or killed. Our upper airways are also outfitted with cilia, tiny hair-like structures that rhythmically beat and carry foreign particles away from the lower bronchial tree. We have the ability to cough, an extremely efficient mechanism that clears uninvited strangers from our lungs and trachea. Finally, our alveoli, the tiny balloons where gas exchange occurs, have all the components of our immune system standing at readiness to attack any invaders that make it to that level. Should this final line of defense be overwhelmed by bacteria, viruses or merely large particles, infection and/or impairment of gas exchange occurs. Pneumonia results from micro-organism infection of the lungs. Smoking damages cilia and allows particulate matter to reach the ends of our airways, eventually causing damage that is irreversible, the common condition called Chronic Obstructive Pulmonary Disease (COPD).

The other fork of the aerodigestive tract leads to the esophagus, stomach and the small and large bowel. While the lungs are efficiently scavenging wayward invaders, the gastrointestinal tract has learned to live in harmony with such organisms. Technically, the GI tract lumen is outside our bodies. It is a long, tortuous tunnel that snakes its way from our mouth to our anus. Inside this tunnel trillions of bacteria reside in a symbiotic relationship; welcome, as long as they stay in their place.

The numerous types of bacteria play a crucial role in maintaining normal physiology and immune function. It is likely that the resident bacteria stimulate a variety of immune functions, particularly during the early developmental years. The bacteria help with digestion of certain nutrients, breaking down complex polysaccharides into more digestible forms and also play a key role in the enterohepatic circulation of bile salts. In addition, the GI flora help with the absorption of certain vitamins and play a protective role for their human host by preventing the overgrowth of harmful bacteria within the gut lumen. As long as these tiny helpers stay inside the tunnel of the GI tract they are our friend. If they escape and invade surrounding organs or spaces, then they are most unwelcome. But, the normal GI tract physiology is a wonderful example of symbiosis between vary disparate organisms.

It is easy to see that the human body is an amazing creation that is well suited to living and flourishing in a hostile world. But what is it that sets the human apart from other animals. Other animals may run fever and are also bombarded by microscopic invaders. Is there anything that sets the human apart; an attribute that screams: “I am unique to the Homo sapien; you won’t find me in a dog or a chimpanzee”?

GK Chesterton said it was art that separates humanity from all the rest of creation. The ability to paint, write, sculpt, play or write music is the sole province of mankind. The ability to appreciate such endeavors is an even greater exclusive human attribute.

But what is it that allows a Bach to write music that soars, a Picasso to create unique, expressive paintings or a Charles Dickens to string together a series of words that actually make sense and have the power to entertain and inform? There are two components of the human body necessary for such creation. The first and most obvious is a brain, an organ that is incredibly complex, with mechanisms that are poorly understood, but capable of the most astounding achievement. Every original thought, every idea that became a concept and then a commodity started in the recesses of someone’s brain.

A mass of neurons, synapses, electrical impulses and chemical transmitters work in harmony to produce a thought. This thought may be the next logical conclusion from a series of previous thoughts or it can materialize from nowhere, an inspiration from an unseen Muse. Thoughts may be fleeting or they may coalesce into ideas. Eventually the idea comes to fruition and a new creation emerges. Humanity lurches forward into new realms with every thought and idea. Unfortunately, some ideas seem to cause us to step back.

The passage of idea to commodity requires that some form of work be performed and the principle agent of such work, particularly in the arts, but also in most other endeavors is the hand.

A complex organ made up of skin, bones, nerves, blood vessels and muscle, the hand is capable of turning black and white notes on a page into the sweet sound of Rachmininoff’s Piano Concerto Number Three; it can mold and shape a lump of stone into Michelangelo’s David. This incredibly versatile organ allows us to surpass all the rest of creation, to create the art that we all appreciate.

It is possible to provide substitutes for our hands; amazing creations have come from people who have lost the use of their hands. But, as we marvel at the human capacity to adapt to such disability, consider what these talented individuals could have done. Substitutes for our hands can be fashioned or trained, but they remain substitutes, at best performing nearly as well as a normally functioning hand, but never surpassing the hand.

A whole book could be written on the amazing design of the human body. Many of the intricacies are still being discovered, but it is this remarkable design, this body so perfectly suited to thrive in the world that surrounds us, that allows someone like me to slice a patient open from stem to stern, root around inside for a while, stitch the wound closed and then see that patient walk into my office a month later entirely well. Truly amazing.

Saturday, September 25, 2010

Surgical Education

It is predicted that over the next ten years, as the baby boom generation ages, that there will be a shortage of available general surgeons to address the expected surgical needs of this aging population. Indeed, many general surgery residency programs have been finding it difficult to fill all their categorical positions, that is those positions that lead to a finished general surgeon. As more and more of the population reach retirement age, it is anticipated that the incidence of GI cancers, breast cancer, peripheral vascular disease and many other maladies prevalent among this age group will increase and there is a growing concern that the already overworked specialty of general surgery will be unable to adequately meet the challenge.

The recently passed Healthcare Reform act has squarely attacked this growing problem with several new and innovative pilot programs. The Simian Surgical project, previously reported on these pages is one such program. Another pilot program, to be headquartered in Phoenix, Arizona, is the ICS Surgical Education Program. This ground-breaking initiative, funded by an NIH grant through the recently passed healthcare bill, has as its goal to seek out highly skilled young persons and train them as surgeons. Currently, it takes many years to train a general surgeon. Four years of college, followed by four years of medical school and, then, five to six years of surgery residency is the current pathway to becoming a general surgeon. The new, innovative program will streamline this pathway considerably.

Dr. Albert Scheinbach elaborates, “Recent studies suggest that highly skilled technicians can adequately perform the necessary surgery to prevent the shortfall of qualified surgeons that this country may face in the coming years. Our aim is to find the future stars of surgery at a young age, perhaps as young as nine or ten, train them in the most modern techniques, utilizing the most modern equipment available and prevent what could be tragedy for so many of our elderly.”

Dr. Scheinbach explained that the initial phase will be one of recruitment. Carpet advertising in the most popular and widely read graphic journals*, as well as recruitment in various projection oriented arcades should allow the program to find young men and women with appropriate hand-eye coordination to perform the many surgical procedures at the highest possible level. It has been clearly demonstrated that surgical skills are directly correlated to scores achieved on “Donkey Kong”, Super Mario Brothers” and “Need for Speed”. However, besides demonstrating the necessary hand-eye coordination the recruitment process will also require the applicants to be able to fill out the application; the prospective surgeon will actually have to have the skill to legibly write their name and address, including postal code, on the form that will be available with the advertisement. Once accepted into the program, a vigorous, but compassionate educational and training regimen will commence.

From the comfort of their own home the student will be sent a weekly package containing the training materials, including educational manuals and anatomic parts. An instructional audio CD written by James Weldon Johnson**, famous spiritual composer, will accompany the material and will provide the student with detailed directions to allow him or her to complete the required tasks. At the end of the semester the student will be expected to return all the body parts properly assembled and fully functional. Those that pass this portion of the training will be allowed to progress to the final examination.

The final exam will be administered by the surgical staff of the University of Phoenix, International Correspondence Division, and will consist of a didactic portion as well as an actual operation. Dr. Scheinbach explains:

“The home centered education portion is not considered completely adequate training to allow our students to enter the operating theater unattended. The candidate for graduation must demonstrate the necessary dexterity to be a safe surgeon. The final exam will consist of a series of simulated procedures utilizing a standard model, Operation*** and then a computer graphics module****; successful completion of this phase is followed by an actual operation. The candidate will be assigned a random operation ranging from a simple appendectomy to a pancreatoduodenectomy. These highly skilled young people will be required to perform the assigned procedure assisted by standard operating room personnel. A grade of 70 % on this portion of the exam will be necessary to pass and be issued a diploma. The graduate will be bestowed with the degree ‘Doctor of Surgery’.”

A spokesman for the Obama administration stated that the supposed complexities of most operations are exaggerated and overstated. We believe that any properly trained person, with the necessary manual dexterity and assisted by the computer modules that our team has developed, can successfully perform most of the surgery necessary for the aging baby boomer population. He added that, initially, these newly trained surgeons will provide service limited to Medicare patients. It is anticipated that as the program becomes established and the significant cost savings are realized private insurers will jump on the bandwagon.

The initial pilot program will have 500 participants with initial training expected to be completed by January 2012.


* “Teen Titans”, “Astonishing X-Men”, “The Incredible Hulk”, “Spiderman”
** “Dem Bones, Dem Bones, Dem Dry Bones” Lyrics and music by James Weldon Johnson
** “Operation” Hasbro toys recommended for ages 6&up
**** “Virtual Surgery, For the Beginner”

Saturday, September 18, 2010

After Horton

Dealing with Tragedy

It’s been decades since the near disaster; the time when all of our society hung by the thinnest of threads and only the strength and fortitude of one small boy saved us all from our short sightedness. As I look back over the years I am astounded and a bit saddened by what has happened to all of us that were engulfed by the events of the day.

Of course the exploits of the two heroes have been widely reported in the tabloid media over the years. Horton, the noble steadfast beast, remained true to his principles for a period of time, but even he was unable to avoid scandal.

The sordid affair with Miss Maisey producing a bastard child eventually drove that pachyderm to a lifelong addiction to peanuts. Although he protested loud and long, claiming that he had only the noblest intentions, the product of their illicit union could not be denied. Horton did acquit himself to some degree over the years, raising his elephant bird son, eventually sending his unique offspring to veterinarian school before the lad was tragically crushed while caring, ironically, for an elephant at the Miami Zoo.

Horton overcame the subsequent depression and, after a stint at the Betty Ford Clinic, went on to star in several movie adaptations of his life and win an Oscar nomination for Best Supporting Actor for his role as lead elephant in Tarzan and the Leopard Men. After penning his memoirs he settled down in The Bronx, where he continues to live with his wife, Esther. In a recent interview he was quoted:

“I’ve lived a long and full life with enough adventure for ten elephants. I have to say that through it all I’ve remained true to my principles treating everyone equally, with compassion and the right amount of love and kindness. And, for those of you that have tried to wrong me over the years” he added while popping a peanut into his mouth, “I have to say, be careful, be very careful, I won’t forget…I’ll never forget.”

The other hero of note was Jo Jo, only a young boy at the time. But, it was his timely “YOPP” that saved us all. Of course, he was celebrated in both print and electronic media and his fame spread. Only a few years later he went on tour with his rock group, “Jo Jo and his Yo-Yo’s”. They played to packed houses for two summers straight and there song “Yipps and Yopps” stayed at number one on the Billboard charts for five months straight.

After a few years, however, his star began to fade. Addiction to heroin plagued him and less than ten years after reaching the pinnacle of success and fame he was found dead, with a needle in his arm, at a crack house on 17th Street. His band tries to carry on without him and you can still see them on Thursdays, here in town at Lena’s CafĂ©.

Mother Kangaroo tried to rise above her role, claiming that her only crime was ignorance and that Horton should have been more forthright and insistent regarding his claims. She said in the weeks that followed the events that she feared for the safety of her young son, that a crazed, wild elephant posed a great danger to the jungle. She realized later that it would have been better to humor Horton at the time, but she was trying to set a good example for her son; that it is always best to confront danger, rather than hide.

She eventually, after her children were grown, had a brief affair with a Tasmanian Devil, before marrying the Lorax and finally settling down. They formed the nonprofit organization, “Green Against Pollution” which championed “Green” technologies and fought against waste and exploitation of our natural resources. Mother Kangaroo’s most successful campaign was against the use of beezle nuts and beezle nut oil, citing the considerable smoke that could pollute the air when this oil is used for cooking as well as the dangers of intoxication when excessive quantities of this particular nut are ingested.

Her son, Angus Kangaroo, made a name for himself some years after the near tragedy. His book, “Momzilla, Life in the Pouch”, hit number one on the New York Times best sellers list and stayed there for sixteen straight weeks. He eventually came out and spoke out strongly for “Kangaroo Rights”, battling years of built up prejudices against Kangaroos and their many marsupial relatives. His second book, “I have a Pouch and that’s OK”, although not selling as well as his debut, received much critical acclaim and raised awareness about the plight of marsupials everywhere.

The greatest tragedy that followed our near demise was the suffering of the Wickersham Brothers. The guilt of having nearly destroyed an entire civilization was more than the three of them could handle.

The eldest, Hiram Wickersham, was found hanging from a beam in his jungle apartment only three weeks after the events. The note only said “I’m Sorry…I’m Sorry”.

Elrod Wickersham, the youngest, immediately hit the talk show circuit, claiming that he never wanted to boil that dust speck, as was widely reported. He was only going along with his brother’s wishes and claimed that he never intended to go through with the horrible deed; that he would have stopped them before it was too late; that he also feared for his own life and that if he interfered he would have found himself belly up in a boiling cauldron of beezle nut oil. Of course, he became an outcast from society, never able to clear his name and eventually joined a monastery in Perth.

Ambrose Wickersham, the middle brother, earned even more notoriety in the years to come. He never apologized or denied any wrongdoing in the Whoville affair. In fact, in the aftermath not a word was heard from him. Two years later he was photographed throwing stones at an elephant in the Houston Zoo and it was only a short time later that his hatred for all elephants came to light. It seems that the Wickersham’s father was crushed to death by one of the elephants in the “Outback Circus”, part of a combined elephant/monkey act. Although an investigation proved the death was an unavoidable accident, Ambrose was never able to forgive the elephant and harbored a lifelong enmity towards all elephants, be they Indian or African. Only a few years ago he died in a manner similar to his father. He climbed into the elephant enclosure at the Sydney Zoo and taunted the residents until they charged him and he was trampled. The death was ruled a suicide by the Sydney Coroner’s Office.

Valad Vlad-I-Koff, the eagle that cast our home into the vast field of clover actually came out unscathed. He claimed that he was trying to save us by hiding us from the vicious mob and deranged elephant in one place where we would be safe, the field of clover. I almost believed him at the time, but later eyewitness accounts refuted his claims. Still, he became a successful businessman, starting “Eagle Courier Services”, a company that specialized in overnight deliveries. Rumors abounded a few years ago that the company was involved in delivery of illegal drugs and merchandise, but these allegations remain unproven and Valad sold the company only last year and retired to Palm Beach, Florida.

As for me, the Mayor, I have weathered the years, staying in my position as Mayor of Whoville for forty one years. The near disaster led to a call for more safety measures and plans were made to construct a bright beacon that would make our presence known to the smallest being in the outside worlds. In addition, work was begun on a powerful amplifier, something to make all the outsiders aware of our presence. Political infighting stalled all these projects and then the faltering economy and shrinking tax base forced us to abandon them completely. I never married, as my child hood sweetheart, Cindy Lou, chose to marry that professional baseball player instead. I heard that he has mistreated her terribly, but I can’t say for sure.

So now I spend my days walking in the park, feeding the ducks and reminiscing over those old days. Every day I stop and admire the statue of Horton that sits in the middle of Whoville Park. The ears and trunk have turned green over the years, but the statue still stands as a reminder to all the generations of Who’s, reminding them and us of the fate that we narrowly avoided.

For those of you that don't remember "Horton Hears a Who" here is a link to the text of the story by Dr. Suess http://www.johnhenrybikes.com/newsletter/horton.htm

Saturday, September 4, 2010

Airport Security

I recently had the pleasure of flying from Houston to Albany, NY, the occasion being a visit to my parents. As always, I arrived at the airport more than an hour before my scheduled departure time, even though I only had a carry on bag. These days you never know about the line to pass through the security checkpoint. Thankfully, the line was pretty short and I was able to spend my time sitting by the gate, instead of standing in line.

As I approached the security checkpoints, I performed the usual preparatory actions: had my boarding pass and ID in hand for the security guard and then went through the ritual partial disrobing. I put my laptop computer, wallet, keys, cellphone, watch, belt, shoes and my bag in the gray plastic bins and prepared to pass through the metal detector, clutching the waistband of my pants, lest they unceremoniously slide down to my knees. I managed to pass through without setting off any bells and whistles, sat down to get myself dressed and while doing this thought about this ritual I had just experienced.

I suppose it makes sense to separate metal objects I guess, although these days I think most explosives are made of plastic of some sort. Taking the belt off is necessary because most belts have some metal in them and could set off the metal detector. Removing the shoes is in response to the shoe bomber, Richard Reed, although I suspect there are some shoes that could serve as terrorist weapons without any hidden explosives.

I thought about the “Shoe Bomber” and removing one’s shoes. Shoes at the time were a fairly good hiding place; something ubiquitous and unassuming. The requirement that shoes now be removed and scanned seems to be a perfectly reasonable response to that past event. But, wasn’t there recently an “Underwear Bomber?” It seems to me that an appropriate similar response to this new threat is called for. Unless this issue is properly addressed underwear will remain a viable option for transporting bombs. I realize that it is not practical for every passenger to remove his or her underwear while passing through security. The time for each passenger to remove their underwear and then dress would be way too long. Plus, I could see some people wanting to go through the line even if they weren’t flying anywhere. One solution would be to make it illegal to fly while wearing underwear. Of course, objections to this plan would inevitably be raised by the pro-underwear crowd and it is likely that the ban on flying with underwear would probably be found to be unconstitutional by the current Supreme Court.

Perhaps, random underwear checks could be done. Every tenth person could be required to submit to a thorough undergarment inspection. Passengers who objected to such violation of their personal space could be given the opportunity to declare that they are sans underwear, which could be confirmed by a quick peek which would add a mere few seconds to the security process. Women wearing thongs also could make such a declaration. After all, no respectable bomb could fit inside a thong.

There are a few other flaws in the current screening procedures. I’ve recently learned that terrorists are finding newer and more clever ways to smuggle their explosives aboard. Apparently, plastic surgeons are being recruited to perform breast augmentation on would be suicide bombers, utilizing breast implants filled with explosives. If this is true then a new line of security becomes necessary. Personnel with special training and very experienced in examination of the breast would become necessary to discern the subtleties inherent in an explosive breast implant.

With the changes that have come in health care I see this as a new and potential lucrative revenue stream for general surgeons and gynecologists who have suffered decline in income as reimbursement has fallen for traditional health care. In addition, there will be a need for proctologists as terrorists go beyond shoes and underwear and start carrying their explosive devices inside body cavities. In order to perform complete exams only proctologists capable of palming a basketball would be qualified.

It is possible that future screening procedures will require several stations. I can just hear the chatter: “Right arm up over your head…Left arm up…bend over…next…hey captain, come check these out…next”. I think retired doctors would be best suited to such work.

These security measures may seem drastic to the typical lay person. But, dangerous times demand appropriate and effective methods to outwit the evil forces that lurk in the shadows. These few modest proposals would go a long way towards deterring these desperate, would be assassins and would help make our skies safe for us and for our children.

Saturday, August 28, 2010

Genius Phones

F. N. Stein and IBS Computing announced today that they have completed design and construction of the next generation of smart phones. The new ultra portable phones are completely implantable, combining the latest in biocompatible materials with the most powerful nanotechnology ever developed.

“This new technology far exceeds the technology offered by the existing I- Phone or Android systems. The Q Phone, as it is called, comes in two parts which are implanted under the skin of the user, a receiver implanted in front of the ear and a transmitter implanted beneath the buccal mucosa within the mouth,” stated Dr. Stein, CEO of F.N. Stein.

He went on to add that the convenience and power of these phones will bring new meaning to the term “smart” phone.

“If the existing technology is called smart, these will have to be dubbed genius”, Dr. Stein gushed. “It will no longer be necessary to carry your phone in your pocket or on your belt and you can get rid of those ugly Bluetooth ear pieces once and for all.”

Dr. Stein went on to explain that the new phone automatically integrates with signals from your brain to dial a contact in a nanosecond. Conversations are completely private as the transmitter can send a clear signal even if it is only the faintest whisper. Incoming calls are audible only to the receiver and text messages are transmitted directly to the cerebral cortex. It will no longer be necessary to fumble with your phone or push buttons or “swipe” icons back and forth. The Q Phone is 100% intuitive and functions are executed with only a quick thought.

“The Q Phone goes far beyond “hands free”, Dr. Stein proclaimed. “It’s almost speech free. The controversial ‘driving while texting’ debate will become ancient history as these phones free the driver to concentrate on the road, even while sending out and receiving messages with just a thought.”

There are already hundreds of thousands of useful and unique “apps” for the Q Phone. Besides the obvious GPS or reading apps, the new technology expands the possibilities, making this phone truly worthy of the name “genius”.

Expected to be among the more popular applications is the new Date Buddy. This completely free app will be your coach during those trying moments when you are trying to make time with that hot babe at work. Instead of the usual fumbling for the right words, the Date Buddy will automatically monitor the conversation and transmit witty sayings to the subscriber, guaranteeing that the target will be swept away by the users dashing and debonair manner.

For the user expecting to appear on “Jeopardy” the Q Phone has instant access to the entire Internet, discreetly and secretly. The Wikipedia app can bring the entire online encyclopedia to the tip of your tongue instantly guaranteeing that even the dullest user will appear intelligent and sophisticated.

“We’re expecting to be able to release these implantable phones before the second quarter of 2011. We’re still working out a few bugs with the implant technology. Right now it requires a visit to the doctor to have the devices properly implanted. We’re hoping that a self implantation kit will be feasible before the final version is released”, Dr. Stein reported.

There was no immediate comment from representatives of Google, makers of the Android platform; however, Steve Jobs was quoted as saying “This implantable phone is pirated from technology developed by Apple. The IPhone 5 was slated to be such a device. We intend to file a patent infringement suit in Superior Court next week.”

Dr. Stein laughed off Mr. Job’s comments, saying that he had been working on this sort of device for decades.

More information is available at http://www.geniusqphone.com

We at “Heard in the OR” will keep you posted as this story develops.

Saturday, August 14, 2010

Don't Think

I read a missive from hospital administration recently, posted on the wall in the physicians work area at one of the hospitals. The message read something along these lines:

“Per JCAHO* regulations physicians should refrain from writing orders allowing for a range of medication to be administered. Specifically, pain medication orders should not say:

Dilaudid 1-2 mg IV Q3h prn pain

Instead such orders should be written:

Dilaudid 1 mg IV Q3h prn moderate pain
Dilaudid 2 mg IV q3h prn severe pain

Orders written in the former manner, allowing for a range of dosage allow the nurse administering the medication to make independent judgment decisions. Such decision making is not permitted under the nursing licensure.”

My reaction to this directive was that the lunatics are in charge of the asylum and everyone should run for cover. Nurses are to become robots, methodically passing out meds and dutifully charting when the patient last belched, while ignoring their patients overall wellbeing. I asked several of the nurses in various hospitals their opinion of this rule. I pointed out that, to me, there wasn’t any difference between the two orders. What they said was a bit disconcerting. The nurse is supposed to ask the patient about the severity of their pain and then medicate accordingly. So, if the patient responds that he is feeling severe pain he is given the higher dose, no questions asked.

Now, I’ve been in practice for over twenty years and I can tell you that pain; its intensity, quality, severity and every other aspect is the most subjective of clinical symptoms. I’ve had patients, who have undergone a very minor procedure, tell me the pain is the most excruciating they’ve ever felt, while others, who have just undergone a major abdominal surgery with a stem to stern incision, report only mild discomfort.
There are patients who appear nearly comatose after surgery, barely arousable, but will state that their pain is severe and will request their medication every three hours on the dot. In this situation, what is the nurse to do? Blindly administer the higher dose prescribed for severe pain or actually think that the patient’s pain may not be as severe as reported and give the lower dose, and/ or call the doctor to have the medication adjusted.

No matter what, a good nurse has to use her best judgment to care for her patient in the most compassionate, but also clinically appropriate, manner possible. Patients, who are human, have widely varying ideas of what the hospital experience should be, particularly when it comes to pain. For some, pain relief means completely numb from head to toe; for others it means just enough medication to have the edge taken off. Most are somewhere in the middle. The nurse serves as the doctor’s eyes, learns to make a proper judgment and provides a continuous image that complements the snapshot the doctor receives on daily rounds.

The idea that nurses not be allowed to think echoes the words of one of my medical school instructors, Dr. John Adams. In the early 1980’s I was at the University of Rochester Medical School in upstate New York. Dr. Adams was the classic curmudgeonly surgeon. Loud, intolerant of ignorance or incompetence by subordinates, he often chastised the residents on his service for writing orders with a dosage range in the way that is now prohibited. He must be working for the JCAHO, because his exact words were:

“Don’t write Demerol 50-75 mg IM q3h. That allows the nurse to think; we don’t want the nurses to think. Their job is to do what they are told to do.”

Who would have thought chauvinistic Dr. Adams was such a visionary?

Actually, I don’t think that he had such a low opinion of nurses, rather, I believe, he was trying to drive home a message to the residents and students: orders should be clear and specific. Such clarity allows the nurse to perform her task efficiently and provide the patient with the best care possible. Doctors and nurses are a team, working together to help an individual who is sick or injured recover and return to a normal life.

Years ago I read a study on factors affecting outcomes on critically ill patients. I don’t remember which journal it was in, but the study looked at ICU patients and a number of variables that could have an effect on the patient’s recovery. The only variable that made any difference was the quality of nursing care.

This makes perfect sense to me. The critically ill patient requires continuous monitoring. Most of the time it is the nurse that is at the bedside checking vital signs, urine output, oxygenation and every other parameter that may be indicative of the patients well-being. The best ICU nurses will pick up on subtle changes that could be harbingers of impending deterioration in the patient’s clinical condition. If such nurses are shackled by the “don’t think and don’t make judgment” rules, these critically ill patients will suffer.

Besides acting as physician’s eyes, nurses also provide a level of protection for the patient. If an order is written or a medication prescribed that seems to be in error the nurse is there to question it. Despite what some doctors may believe, we physicians are not perfect and sometimes errors are made. A vigilant nurse often picks up on this, questioning the order; calling the doctor for a “clarification” (correction). Sometimes it is an omission that needs to be brought to the doctor’s attention. In all situations the nurse is the patient’s advocate, doing his or her best to smooth the often bumpy road to recovery.

Doctor’s, by necessity, approach patient care from a very different angle than nurses. Medical School and residency teach us the underlying pathophysiology and the clinical manifestations of various diseases and medical conditions. We take this information and establish a diagnosis and institute a therapeutic plan. Our primary purpose is to see that the disease process is properly treated and see the patient to a complete recovery or at least keep chronic diseases under control.

Nurses share in this goal, but along the way they are often called upon to provide comfort, counseling and to allay fears. The nature of their profession allows nurses to do this in a way doctors cannot. The best nurses always seem to find the time to sit with their patients, provide reassurance and still manage to do all the ridiculous charting and filling out of seemingly endless forms that generate reams of paper that no one ever looks at.

In the middle of these essential activities the nurse often have their carefully planned schedule disturbed by a million other tasks, usually accommodating the interruption with a smile and a shrug of the shoulders. I know that when I have asked nurses to help with a bedside procedure they are only eager to help and always insist on finishing up all the cleaning and reordering of the patient room when I am finished. I sometimes wonder if it is eagerness to do all they can to help or if they really want to be sure that the patient’s room is properly returned to an orderly state.

Nurses are truly amazing in their ability to calm anxiety, inform ignorance, allay fear, provide comfort, stroke egos (especially OR nurses), see us all at our worst moments and invade our most intimate places and do it all with a smile and a wink that says “I know you don’t feel well now, but just give us a little time and you’ll back home with your loved ones before you know it.

I may be a bit biased towards nurses. After all, I married one; Laura, my wonderful, beautiful, intelligent wife of twenty five years, the cutest little nurse I had ever seen, always took the time to talk to her patients, share their feelings and make sure that all their treatment was delivered in the best, most professional manner. When we first met I think I used to exasperate her by my asking for patients’ vital signs and her appraisal of their condition. But, we shared our concern for the patients’ well being and have continued to share for twenty five years.

Nurses and doctors, along with surgical technicians, respiratory therapists, physical therapists, occupational therapists, speech pathologists, patient care aids and all the other allied health personnel, share a common goal; that is to treat the sick and injured and allow them to return to happy, healthy, productive lives. The doctor provides the diagnosis and overall therapeutic plan, institutes the plan’s delivery and makes alterations and interventions when necessary. The nurse provides the monitoring, the immediate delivery of therapy, nurturing, comforting and compassion on a continuous basis. If our nurses are not allowed to “think” our patients will end up suffering, with longer stays in the hospital and some, I am sure, will never leave the hospital.

It is something for all of us to think about.

*Joint Commission on accreditation of Healthcare Organizations

Sunday, August 8, 2010

Backyard Nature

The World Around Us

This evening I sat in my backyard next to our swimming pool and watched the myriad activity in the bushes and the trees that line the rear edge of our yard, separating our home from the neighbor behind us. From the near edge of the pool I watched as a Cardinal timidly foraged for food beneath the bushes. He would pick up a few seeds, stop and look around, then pick up a few more. This went on for about five minutes and then he made his escape, taking short hops through the bushes, presumably returning to Mrs. Cardinal.

A few feet away, a much bolder Blue Jay was in engaged in similar activity. Bolder than the bright red Cardinal, the Jay took few pains to hide himself and loudly announced his presence, once he had returned to the safety of some higher branches. The big black crows are even bolder, every Spring staking claim to the small park in front of my home. They can be seen on the ground and in the trees at the four corners of the park, a bit reminiscent of “The Birds”, although I don’t think anyone has ever been attacked.

I live in a suburban area, close to some wooded areas and several bayous. Surprisingly, this populated neighborhood is teeming with a variety of wildlife. Besides the aforementioned birds, there are finches, doves, squirrels, rats, field mice, frogs, lizards, a rare snake and at least one turtle. Sitting outside in the late afternoon seems to afford the best view. The heat of the day has diminished and nighttime predators are not on the prowl.

So, in the early evening it is possible to see numerous lizards scurrying about or catching the last few rays of the departing sun. If I watch closely I can usually see lizards racing along the top of the fence or sunning themselves on top of the stone Hippo statues that guard our pool.

In a few weeks I will be treated to the hummingbird spectacle. Every year for about two weeks, in late August and early September hummingbirds stop in Houston on their way south. We always set up a feeder and manage to attract some of these diminutive birds. Watching their social order is sort of a metaphor for humanity. Usually, one hummingbird will claim the feeder as his own. He will take a drink and then fly away to perch on the nearby tree, all the time keeping his watchful eyes on “his” feeder. If any other hummingbirds try to approach he will swoop in and chase them away. Of course, the other hummingbirds want their fill of the sweet, fake nectar, so they will team up. One pretends to go in for a drink and allows himself to be chased away and, during this pursuit the others will saunter in for a leisurely swig. Not unlike many people really.

The rats and mice that I see create something of a dilemma. I know that they are vermin and carry disease, but it just doesn’t seem right to kill them. For a while we had a bird feeder in the backyard. This feeder fed not only birds, but also squirrels, mice and rats. There were several nights when our dogs would be outside barking nonstop and, when I investigated, I found them looking up at one or more rats taunting them from a branch high above the ground.

My dogs, actually, are very efficient at keeping our home free of such vermin. Before we took down the birdfeeder I found five dead rats in a week’s time. One afternoon I inadvertently witnessed the spectacle. In the middle of the day the three dogs, two Basset Hounds and a West Highland White Terrier, were outside barking in the continuous manner that signaled that they had something cornered. When I checked it out I saw them standing around something that was on the ground. Before I could intervene, Genevieve, our fat Basset Hound made a surprisingly quick lunge and in an instant a big rat lay dead. Don’t let anyone tell you that Basset Hounds are slow and lazy; she made very quick work of that execution. Needless to say, I took the bird feeder down that day and didn’t find any more dead rats.

There have been other rodents that have invaded our home. There was the time I went to check on our dogs early in the morning. They had been doing there nonstop barking routine, but by the time I went to see what all the fuss was about the noise had stopped. When I checked on them I found a baby possum lying stiff on the floor by their doggy door. I looked at it, lying rigid on the floor and assumed it was dead, but then my wife and I began to wonder; there wasn’t a mark on the little beast. We picked it up in a towel and carried it outside, locking the dogs inside. We laid the little critter among the bushes behind the pool and, as we suspected, the baby possum picked its head up, looked around and scurried away. It seems that possums really do play possum.

More recently, I sat and watched a field mouse make its was around the side of our house. It saw me studying its movements, but pretended I wasn’t there as it walked between our garbage cans and then stopped at our back door, reared up on its hind legs and pushed against the doggy door. Luckily, for the mouse, it was too small to push the door open, because just inside the door, asleep on a cushion was our West Highland Terrier, Coconut. I am sure that Coconut would have made short work of that mouse. Unable to break into our house, the mouse went on his way, still unperturbed by my presence.

In my recently released novel, “Joshua and Aaron”, the hero, Joshua Smith is given a pair of “goggles” that allow him to see the teeming life that exists apart from humanity, in the city around him. He is told that “we see and hear what we’ve been trained to see and hear.” There is a wonderful world around us; full of life; a gift from God. All we have to do is take the time to sit and watch; it’s a spectacle better than anything television or the internet can provide.

Sunday, August 1, 2010

Dr. Write

CC: SOB and Abd pn.


HPI:
65 y-o WM w/ hx of CHF, CAD, IDDM, Htn, &SLE was admitted @BMC c/o CP, SOB, LUE edema and UTI for 7 days. Pt. also c/o no BM for 1 wk. and + LGIB. Pt. also c/o abd. Pn and N&V for 2 wks. (-) flatus x 3 days.

PMH:
As in HPI. + CHF, CAD, s/p CABG, LGB, BIH and ORIF LH.
NKA
MEDs: see list.

FH:
n/c
SH:
Cig: 2 ppd x 30 yrs. Etoh (-) ret.

ROS:
See HPI

PE:

VSS, AF
HEENT: NC/AT, PERRLA, EOM’s nl,
Neck: NT, (-) Br.
Pul.: Cl. To A &P
CVS: RRR, nl S1S2 w/o m, S3 S4, (-) JVD
Abd: (+) BS, w/o HSM, B9
Rectal: WNL
Ext: w/o C, C, E, pulses 2+
Neuro: NLS

A/P:
65 yo WM w/ MM Probs. Plan CT A/P, CXR, EKG, CC cath.
Consult GS, Card, GI, Pulm.
CCM.

I will happily accept any one's translation of this perfectly plausible History and Physical.

Saturday, July 24, 2010

Donuts

A Tribute

I brought a dozen donuts home this morning. I stopped at “Riley’s Donuts” on my way home from the hospital and picked up a variety of donuts and kolaches. There is no great, special significance about donuts or kolaches except that the act of bringing donuts home after making rounds at the hospital is a tribute to Dad.

Donuts a tribute to Dad? It isn’t hard to understand, really. Growing up on Sunnyside Road in Scotia, New York, Dad worked as a doctor, specifically a Urologist in solo practice. Every weekend, unless he was out of town, he left at about 8:30 am to make rounds on his hospital patients. At the time I didn’t really understand what “rounds” meant and even on the rare occasion I accompanied him, I still didn’t know. (Accompanying him to the hospital meant sitting in the lobby, being watched by the volunteer in the Gift Shop). I always had this vision of him walking in a great circle, somehow seeing his patients along the way.

Anyway, he usually returned home at about 11:00 and when he walked through the door I would look to see if he was carrying anything besides the newspaper. A single bag meant Dunkin Donuts, always welcome on a Sunday morning; two bags was even better, deli from Gershon’s. I recall that he returned with one or the other about half the time.

I never knew if there was any rhyme or reason to the appearance of these goodies, but I know I looked forward to them. I suspect now that he really liked donuts and corned beef and Mom certainly didn’t mind not having to prepare anything.

Dad was a bit mysterious in ways like this. He would do things seemingly for no obvious reason, as if it was expected, that it was part of his job as dad. Saturday mornings he would make pancakes for everyone before he left for work. Usually he was gone when I came downstairs, but the pancakes would be waiting there, sometimes a little cold, but always delicious; they were one thing that Dad was very adept at cooking.

The other unexpected, but always welcome, treat was going to “Twin Freeze” for ice cream. This was, and still is, the ice cream half of “Jumpin’ Jack’s” drive in in Scotia. Until I was about eleven I never realized that Jack burgers and loaded steak sandwiches even existed; the food part of the drive in was a separate building. Jumpin Jack’s, to me, was only Twin Freeze and the soft ice cream was a special treat. Even today, it is one of my first stops when I visit Scotia. Growing up, it was an often unexpected pleasure to take the short drive around the lake to Twin Freeze, to check out the special flavor of the day, but almost always settle for a hot fudge sundae with chocolate ice cream; an indulgence that was usually consumed by the time we pulled in the driveway at home.

Of course it wasn’t just desserts that were special to Dad. He had nine sons and, although he was always interested in whatever activity we were involved with, the one thing that he would do with us was teach us all to sail. My brother Charlie wrote about family sailing’s origins on Collins Lake in a small pram in his book “Centerboard”, but for me sailing began with the “Rebel”. The “Rebel”, nicknamed the “Tub”, was a boat that was kept at our summer camp on Sacandaga Lake. Dad was always looking for a crew, and when I became old enough I was drafted. He taught me the intricacies of tacking, luffing, coming about, hard to lee and all the other components of sailing that were necessary to navigate the ever changing winds on Sacandaga Lake.

But more than the sailing lessons it gave me time alone with him; time to talk about what he thought was important, raising his family, being a doctor, plans for the future. I was never a big talker, but I was a pretty good listener. Dad could be stubborn at times and he occasionally clashed with some of my brothers. Sailing gave him time to soften his resolve and find a compromise. I learned a great deal from him at these times. And, there was the time we sailed through the swarm of bees. We never knew why they were out there in the middle of the lake, but we managed to sail right through the heart of the swarm, thankfully emerging unscathed.

Other things about Dad stick in my head. When something adverse happened, which was unavoidable in a family with nine boys, he always responded with a cool head and kept everything in the proper perspective. If there was a car accident his first thought would be “is anybody hurt?” Damage to the car was secondary. He intervened when necessary, but allowed us all to grow and develop in our own way. I think he was pleased with the three of us that decided to go into medicine, but he was just as pleased with my other brothers in various other professions.

Dad loved us all although he very rarely said it. His concern for each of us as different individuals showed this love and even today, if some difficulty arises, I will frequently stop and think “What would Dad do?”

Dad just celebrated his 95th birthday. He still shows concern for me and always asks about my family’s well being. He suffers with so many of the ravages of advanced age, poor eyesight that keeps him from watching his beloved Yankees as closely as he’d like, poor hearing, congestive heart failure, arthritis. He would say “It’s tough growing old, but it’s better than the alternative. When I wake up in the morning and I’m still breathing; it’s a good day.”

And so when I buy donuts on a Sunday morning it’s a tribute to Dad. But, also, like Dad, I really like donuts.

Thursday, July 22, 2010

Summer of 1974

The summer of 1974 stands out in my mind, mostly because of the days I spent in Saratoga at the famed racetrack. I was sixteen and the first part of the summer was spent at driver’s ed., where I did my best not to cause any angina among the various shop teachers who were earning extra money putting their lives on the line with a bunch of neophyte drivers.. A few odd jobs painting houses and such gave me a bit of money to waste at the track when it opened in August.

In those days the meet was only four weeks, but it had already started to take on the aura of prestige and celebrity it currently enjoys. Its legend as the graveyard of favorites had been reinforced the previous year as the great Secretariat, fresh from his smashing Triple Crown performance went down to ignominious defeat at the hands of the unheralded Onion, appropriately trained by the giant killer Allen Jerkens.

But, it was now a year later and the track beckoned again. Even though I had gone through driver’s ed I still didn’t have my license so transport to the track became problematical. When I couldn’t bum a ride from any local acquaintance I would walk over to Route 50, stick out my thumb and hope for the best. I usually started at a about 11:00 am, allowing myself plenty of time to make it by post time at 1:00.

Of course sometimes I was picked up very quickly and arrived very early, with an hour or more to kill before the first race. I took full advantage of these times to visit the local attractions or have lunch somewhere on Broadway. My favorite ways to pass the time, however, were either going to the National Museum of Racing or walking through the Rose Garden at the Yaddo.

The museum was almost always empty when I went. I would walk into a dark entry and as soon as the lone woman saw that she had a customer the lights would go on and I would wander through the rooms, perusing the paintings of famous horses, looking at famous silks and just enjoying the history that was recorded. The previous year I had written my term paper for Frank Palmer’s tenth grade Social Studies class on the history of thoroughbred horse racing, most of the details elegantly plucked from the pages of the Encyclopedia Britannica. The history I had actually learned seemed to come alive in the sculptures and paintings in that museum.

My other favorite attraction was the Yaddo. This is a mansion that had been built by financier Spencer Trask and, in 1900 was converted into an artist’s retreat. The very impressive mansion was off limits to visitors, but anyone could walk through the Rose Garden which was situated a short walk from the road and, besides providing a very peaceful way to kill time, also allowed me to speculate on what it was like inside the home and at times made me wish that I was a starving artist, just so I could go inside.

The main focus of those excursions to Saratoga was the racetrack. My interest in horse racing started at age nine when I won $4.20 on the first wager I’d ever made, hooking me with the delusion that I could actually generate some sort of profit from being smart, at least smart enough to pick a few winners. So, the money I earned from various odd jobs went straight to my pool of cash designated for the track.

The track that year had a few highlights. The first memorable occurrence was Maria Isabel. She was not a person; she was a filly running in the ninth race one day. She stands out for two reasons: she was the single best bet I’ve ever seen in any race, at any track, in any year since I started betting on horses and I made the largest wager on her I’d ever made up until that time. Anyone not familiar with the intricacies of handicapping the races may not appreciate what she was, but based on her past performances and conditioning she appeared to be at least five lengths faster than any of her competitors. Her times were about a second faster, she was running at her optimum distance, she had just run a credible race against better horses five days before and she was going off at 7/2, an excellent price for a horse that looked so outstanding on paper.

Seeing her in person did nothing to shake my confidence, so I bet $15 to win on her, a huge amount of money for me in those days. The race went exactly as expected, even though in midstretch she was briefly blocked. She found a hole to sneak through, however, and won going away by three lengths. I remember my hand shaking a bit as I cashed my tickets and I felt a bit of trepidation as I contemplated hitchhiking home with what seemed to me to be a lot of money in my pocket. One of the memorable things about that day was that I had a hard time finding a ride. As it turned out I did a lot more hiking than hitching and didn’t walk through our kitchen door until about ten pm. That single bet is so memorable that Maria Isabel is mentioned as a best bet of the week in my novel “Joshua and Aaron”.

The most memorable thing about the track that summer was Ruffian. Anyone that has read my books or visited my website knows of her significance. She was a two year old in 1974 and was the most impressive, overpowering filly the racing world had seen, perhaps ever. The tone for her career was set by her maiden victory by fifteen lengths, running 5 ½ furlongs in 1:03, equaling the track record at Belmont Park. She was coming to Saratoga undefeated and never headed (that is she had never been in second place at any point of any race).

She was running in the Spinaway Stakes against a local favorite, Laughing Bridge, who was owned by local businessman Neil Hellman. Laughing Bridge had been very imposing in stakes races earlier in the meet and their showdown received much hype in the local papers.

I convinced my mother to let me drive up to the track that day, with an older friend accompanying me to make it legal. The day was a bit showery, but the track was labeled as fast. When we saw Ruffian in the paddock my friend and I were both struck by her appearance. She was big for a two year old filly, but she also was a bit washy (sweaty), perhaps appropriate for the humid day, but it seemed to be more sweat than I would have expected.

Ruffian was the overwhelming favorite despite all the attempts by the local media to build up Laughing Bridge. In typical Ruffian fashion she jumped to the early lead, passing the quarter in a quick 22 1/5 seconds. She maintained her lead at the half in a quicker 44 4/5 and at the top of the stretch showed me something that impressed me more than any horse I’d ever seen. As if she were toying with her valiant competition up to that point and she decided it was time to put all the false media hype to rest and she proceeded to run away from her overmatched competition. She pulled away by almost thirteen lengths in the dazzling time of 1:08 3/5, which equaled a long standing track record; remarkable for a two year old filly.

Of course Ruffian’s racing career became legend and her end was tragic, as she broke down during her match race against the top 3 y-o colt Foolish Pleasure the following year and she had to be destroyed. Still, her brief racing career captured the imagination of millions and, for a short time, she became a symbol for women’s rights.

After that summer, I don’t think I ever hitchhiked again. My wife still thinks I was crazy for doing it, but those were different times; sometimes it seems like a different world. I don’t make it to upstate New York during racing season very often these days and the times I have gone to the track it’s not the same. There are no more free seats at the top of the stretch, the crowds are overwhelming and the quality of the racing seems to have diminished. Still, the summer of 1974 remains a fond memory; a reminder that summer days could be carefree and the only worry was how to get home from the track.

Saturday, July 10, 2010

Talking to Patients

Years ago I read an article about what patients could or should expect from a visit to their doctor. There were four patients that recounted their experiences during recent doctor’s appointments. The length of time they had to wait, the details of their visit including actual time spent with the doctor were included. One of the patients complained that the doctor spent most of his time talking to her. I would bet that this particular doctor was the most thorough and conscientious of all the doctors that were presented in that article.

When a patient walks into a doctor’s office for the first time, the doctor faces a myriad of possibilities. In my practice, which is general surgery, I usually assume a new patient has or is suspected of having a surgical problem. Of course this differs from the primary care physician setting where the problem could be anything from headache to hemorrhoids. It is the primary care doctor’s task to sort out all the endless possibilities and determine the best medical approach for each. This is their great challenge, one that may be faced twenty times a day or more.

Fortunately, for me, the surgeon has a task that is a bit easier, at least initially. When I am asked to see a new patient, most of the time there is some information that comes with the request, usually something short and simple, ie: Gallbladder disease, abdominal pain, cold leg, etc. This very brief summary gives me a bit of direction, although occasionally it can lead in the wrong direction.

So, the first, and often the most useful, thing that I do is to sit and talk to the patient. Probably 98% of the time the patient will tell me what’s wrong and all that I need to do is confirm this presumptive diagnosis with the physical exam and appropriate testing. This is true for almost any condition, be it acute appendicitis or hemorrhoids.

But, how does simple talking do all this? The things that go through a doctor’s head, at least mine, when I take a history from a patient are myriad. First and foremost is, “Is this patient ‘sick’.” By this I mean does the patient seem to have a severe, possibly life threatening condition that warrants immediate hospitalization and possibly emergency surgery? Patients that cannot sit up, are afraid to move or are unable to give any history because they are too ill usually need to be in the hospital. It is one of my unwritten rules that patients that look sick usually are. Experience teaches doctors, particularly general surgeons, to be vigilant, assume the worst and do all that we can to achieve the best outcome.

But, I’ve strayed away from the point of this article. Talking to patients is the single most important part of patient visits. When I went to medical school the greatest amount of time was spent on learning the natural history of the many various diseases, all the possible presenting symptoms and signs and how to obtain this information from a sick patient. Unlike House I don’t believe that patients always lie. Most want to get better and most of the time the questions that I ask cannot be answered in misleading way. Starting with the simple question, “What brought you in here today?” and then paying attention to the patient’s answer will, in a few minutes, provide almost all the information necessary to begin that individual on the road to recovery.

Approaching a patient with abdominal pain provides an excellent example. In the days before routine CAT Scans the evaluation of patients presenting with abdominal pain required the skills of a detective; the history and physical exam, along with limited diagnostic testing, were the mainstays of diagnosis. The abdomen, in the days before CAT Scans and MRI’s, was a black box filled with vital organs and often inaccessible except through surgery.

The abdomen is usually divided into three segments, epigastrium, which is above the umbilicus (belly-button), mid-abdomen, the level of the umbilicus, or hypogastrium, which is below the umbilicus. The first thing I will usually ask is where did your pain start. Sometimes I get an answer like “In the bathroom”; some people are so literal. But, once properly directed, the starting point of the pain will go a long ways to narrowing the choices for the offending organ.

Epigastriium usually means stomach, duodenum, gallbladder, liver or pancreas. Mid-abdomen refers to the small bowel or the right side of the colon and hypogastrium usually refers to the left colon. These divisions are in no way arbitrary, rather they correspond to the nerves that supply the various organs and where the nerves will refer pain. For instance, the gallbladder sits in the right upper abdomen, but very often gallbladder pain is felt in the middle. This is because the visceral nerves refer the pain to the middle. Only after a gallbladder becomes more inflamed do the parietal nerves come into play and the pain then becomes localized over the offending organ.

Duration, quality and associated symptoms all direct me to a working diagnosis that only needs to be confirmed. Physical exam, blood/urine tests, imaging studies primarily are used to confirm the working diagnosis and to eliminate other possibilities. I’ve learned that relying solely on imaging studies is often misleading.

For instance, just recently I was called from the Emergency Room at one of the hospitals and informed of a patient that the admitting physician wanted me to consult. The ER physician said she had right sided abdominal pain and that an ultrasound had revealed gallstones. The white blood cell count was elevated, but she was otherwise stable. This patient, as presented to me, was properly admitted to the hospital, but a patient with these clinical findings generally is not a life and death emergency and can usually be seen later in the day. It is very rare for uncomplicated cholecystitis (gallbladder inflammation) to require immediate surgery.

I saw the patient a few hours later and the history that I received led me to very different diagnosis. Her pain was in the right lower abdomen, unusual for gallbladder disease, and she said it was very severe. She also had a history of severe cardiac disease. There was associated nausea and constipation. Physical examination revealed severe tenderness in the right lower abdomen and no tenderness in the right upper abdomen, where the gallbladder usually resides. I began to be concerned that she could have had appendicitis, which would require emergency surgery. The other possibility I considered was ischemic colitis (inflammation of the colon caused by poor blood supply), also a serious condition that could be a life threatening emergency.

When I checked the tests that had been done I saw that a CAT scan had also been done, which seems to be almost routine these days. The findings were thickening of the cecum, which is the first part of the colon, and a normal appearance of the appendix. With all this information I determined that the patient likely had ischemic colitis, but that surgery was not necessary at that time. The following day she had a colonoscopy which definitively confirmed the diagnosis and she is now recovering; responding to the non-operative therapeutic regimen that was started. She still has her gallbladder and her asymptomatic gallstones.

What is apparent is that properly talking with the patient, obtaining a clear history, points the physician in the right direction. Talking to patients is a skill that is easy to develop and actually saves time and money. It often takes no more than five minutes to gather the most pertinent history from a sick patient and, as I’ve shown, the rest of the workup flows out from this relatively short, but very informative interview.

So the next time you go to your doctor and he or she spends most of your appointment talking to you, be thankful; thankful that you have a doctor that cares enough to take the time find the right answer in the right way.