Postcards

My friend’s son is dying. He’s eight, and the cancer is proving to be just too much. He is still fighting, and at least for the moment he is doing OK. But at this point, everyone agrees, it’s just a matter of time. I recently came across an old picture of my friend and me, long before she had a child or was even married. She was just a happy priest. And looking into her eyes I had to ask myself – how could she have known? How could she have known the joy that would come with her son, and the agony of dealing with his death? How could any of us have known?

It’s not entirely uncommon at nursing stations in hospitals to see obituaries hanging on the walls. These are of patients who have recently passed. It’s especially hard with younger patients – the pictures are senior portraits or of prom or something. And I find myself again looking into their eyes and asking how could you have known? How could you have known, when that happy picture was taken, the tragedy that would befall you?

These images form postcards in my mind. Postcards of happy people destined for sadness.

And of course, at this time of year there is a postcard that, if it didn’t actually arrive in your mailbox, I know you have at least seen it. It’s a picture of a babe in a manger, with a star overhead, on a mysterious night long ago. And I ask myself again: how could you have known? How could any of you have known how that life would end in unbearable tragedy, and then, three days later, provide hope through salvation for all humankind?

I used to ask myself this question: what could have been going on in the course of human history that prompted God to send Jesus into the world at the precise moment he choose? What was so bad that the world needed God on Earth in that moment? But now I ask myself this: Why is it that we are blessed to live our lives knowing of the miracle of Christmas? Maybe it had nothing to do with what was going on; maybe it had to do with what could go on in that knowledge of that hope.

It is that hope that makes looking at those postcards bearable. My Christmas prayer is that the love that entered this world in human form long ago continues to enter our lives each and every day. So that when we look at postcards we see not tragedy but glorious hope.

Merry Christmas!

(Beating) Hearts

I guess I can’t stop thinking about hummingbirds. The little engine that powers that tiny bird is a marvelous thing. The hummingbird’s heart averages 250 beats per minute, and it can be as high as 1200 per minute under times of stress. To put this in perspective, the human heart beats an average of 60-100 beats per minute, and never really gets above 200.


It must be loud, don’t you think? All that beating. So much work for such a small thing. The little “lub-dubs” must almost blend together.


The human heart, while it doesn’t beat as fast, is equally marvelous. Its complex electrical system maximizes its efficiency, making it torque in such a way to maintain blood pressure and deliver freshly oxygenated blood to each and every cell in our bodies.


Of course, during open heart surgery we often stop the heart. A machine that is roughly 5 feet long and consists of various tubes, pumps, and canisters, and which is run by a specialty trained individual, takes the place of the heart and lungs. Dark red blood is diverted from the venous system into this machine where it is oxygenated, turned bright red, and is then pumped back to the systemic circulation. And to make sure the heart doesn’t die during this process (it too needs oxygenated blood), we shut it down. It is infused with a cold cardioplegic solution (ice water, blood, potassium…) and submerged in ice. And that’s it – the heart stops, and the machine circulates the blood. A gentle and continuous hum replaces the familiar “lub-dub.” The monitors become irrelevant. The operation can proceed.


And proceed it does. Carefully placed incisions and even more carefully placed sutures are used to replace valves or bypass blocked arteries. The stakes are high – a slipped knot can literally end a life.


And then it is time to finish, and re-warm the heart. The ice is removed; the solution is switched to something warmer. The tubes are removed in sequence. And like a moon or the sun coming out of an eclipse, the heart comes back to life. A bit shaky at first, but in time a regular rhythm, and a good blood pressure. The chest can be closed; the operation is complete.


Except in our last patient. He was only in his 40s, and was the victim of advanced kidney disease as well as his heart troubles. A few hours after the surgery his blood pressure tanked, and his heart gave out. We started CPR. Now I was literally compressing his chest wall against his heart, forcing it to beat, willing a blood pressure. I could feel the ribs cracking under my compressions. Not good enough. We opened the chest with a slash of the scalpel and a few cuts of the wire-cutter. Now we could see the near lifeless, fibrillating heart. We squeezed it with our hearts in sequence (“cardiac massage”) a more direct form of CPR. A few shocks with the paddles…a tantalizing blood pressure…the cycles repeated…and then, nothing. No blood pressure, no pulse, no beating heart. Only death.


I walked in half-way through his autopsy the following morning. His chest cavity was spread open, empty. The heart and lung had already been removed – the perky pathologist gestured to their place on the table beside our patient. And his heart sat there, totally lifeless. There was no coming back this time.


It used to beat 60-100 times per minute. Now it was on a counter. It used to move oxygen all around his body. Soon it would be cut up into slides for the pathologist to review. It weighed over 300 grams, more than 100 times the weight of an average ruby-throated hummingbird.

Birds of a Feather

When I used to visit my grandparents’ home in Maryland, one of the highlights was looking out the window at the hummingbird feeder. I know that sounds a bit odd – what little boy likes to watch miniature birds drink sugar-water? – but it’s what we did. Maybe part of the joy was my grandmother’s enthusiasm for the whole thing, or perhaps it was just the novelty of it all (if we had hummingbirds in Philadelphia, we didn’t’ know it). Either way, when we eventually moved to Maryland ourselves and my grandmother gave us our very own hummingbird feeder…well, we were all excited.

Just recently I was visiting my parents, who now live in Maine. My grandparents have sadly passed away, but my own parents still get lots of joy watching the hummingbirds of the northeast devour their sugary meals.

But something caught my eye. A hummingbird, dead, was on the deck. My father said he had watched several male hummingbirds take nose-dives at that bird, literally beating the life out of him. He must have encroached on some bird’s territory, or flirted with some bird’s mate. His life ended in a brutal way. And it was crushing to me.

How terrible, that birds should act this way. You’d think birds – especially the smallest ones of all – would somehow unite. Can’t they just happily fly around and eat their sugar water?

Of course, the irony is appalling. I’ve spent the last month at a trauma center in Reading, PA, where I witnessed all manor of evil. Assaults, beatings, shootings, stabbings…what we do to each other is enough to crush any Christmas spirit that is supposed to be swelling inside me. Peace on Earth, and goodwill towards man? Not in the trauma bay. And apparently, not even in the hummingbird kingdom.

It must make God cry, to think we are no better than the hummingbirds. Maybe we should all just drink our sugar and go home to bed. Try to resist killing each other, if at all possible.

Advent is a time of watchful waiting. A time of increasing darkness with the promise of eternal light at its end. And it is that hope, that promise of peace, which must keep us going forward.

Do you hear when I hear? (or Tapping, Part II)

Pagers are funny things. I keep the volume on mine cranked up, so that if ever I do get a few moments of sleep while on call the thing will surely wake me. But during the day, when I am awake, the volume seems unnecessary. At any rate, this page started off like most others – a distressingly loud sound, getting progressively louder with each series of beeps, alerting me to an extension I didn’t recognize. A nurse answered. There had been an accident – a young man put his arm through a window and was being rushed to the OR. The attending surgeon would need assistance. OR #2 – hurry.

I hustled with excitement. Serving on the trauma service, this is what we live for – real emergencies that needed fast, definitive treatment. I began to gown up, preparing for the worst. Hat, mask, eye-protection, boot covers…the patient suddenly arrived. I was right – this was going to be messy.

The injury was to the right arm. It was in that soft area opposite the elbow, where they draw blood from (the antecubital fossa). The wound was jagged, and deep. There was blood everywhere. The upper arm had a tunicate around it, which, quite simply, was keeping our patient from exsanguinating.

We were repairing the bleeding, and when we though we had things under control we removed the turnicate. At that moment a gush of blood came pouring forth. We'd missed something big. I’ve seen plenty of bleeding before, but this was the first time I’ve ever heard bleeding. It’s rhythmic, pulsatile jets screamed to us – act fast. Act now. The life of this young man was literally rushing out of him. Instruments were handed to us immediately, their steal handles snapping shut one after the other. Sutures came next – blood drenched hands tying small knots. They have to be placed carefully, otherwise they will slip. Then scissors. Our movements were dance-like – well rehearsed and purposeful. And finally…silence. The bleeding had stopped. The only sound was coming from the monitors – a rhythmic beeping which reminded us the rhythmic bleeding we had heard for real just moments before.

And now it was back to the ICU. That pager of mine just wouldn’t stop.

On Sleep

Growing up, the time right before I fell asleep was always my favorite time of day. After a hectic day, there was something magical about being still. You can’t rush falling asleep, and I never did – I would be alone with my thoughts until the new day’s challenges would come.

My favorite prayer – at least one of them – comes from the 1979 Book of Common Prayer. I remember it echoing around a nearly empty Cathedral on so many late afternoons, with only a boys’ choir and the stained glass to hear it. I suppose it sums up what I wished for in sleep

O Lord, support us all day long until the shadows lengthen and the evening comes, and the busy world is hushed, and the fever of life is over, and our work is done. Then in thy mercy grant us a safe lodging, and a holy rest, and peace at the last (BCP 833).

My nights now are a little different. About every third night, while on-call in the hospital, a busy day makes one excited for a few hours rest. But sleeping right next to a pager – a pager that is sure to go off at any moment with something as trite as a Tylenol order to something as magnanimous as a gun shot wound to the chest – sort of ruins the tranquility of that time of day. Sleep is now rather anxious.

I often feel guilty at how I must look in the early hours of the night, recently awakened, seeing a new patient. Sometimes they apologize for waking me up, as if their illness is a mere inconvenience for me. I politely do what I have to do, and get back to resting if at all able. It’s amazing how focused one becomes on sleep. I am reminded of Psalm 121: “he who watches over you will not slumber; indeed, he who watches over Israel will neither slumber nor sleep” (3b-4).

One of my favorite stories of Borges is The Secret Miracle (http://fortunaty.net/com/textz/textz/borges_jorge_luis_the_secret_miracle.txt). An author is to be executed, but before he is sentenced to death he prays for one year’s time to complete his literary masterpiece. He is brought before a firing squad, but just before the bullets hits him time stops. His consciousness, however, remains, and he can finish his work in peace, in his mind. At the moment the final verse is complete, the bullets resume their course, and the author is killed.

What an amazing thing, to be in a state of productive, restful, sleep, and to die once it is complete? ML is an 86 year-old female. She had atrial fibrillation, multiple gastric ulcers, ischemic colitis…we repaired her stomach, removed her colon, put her back together as best we could. With our help, she lived for about two days. She looked like she was sleeping. She was just lying there, still, not doing anything. I don’t know what she was thinking. Last night, she died peacefully with her two sons at her side.

Make no mistake, I’m sleepy! And so off to bed.

Thinking Thoughts

One of my favorite things about living in Philadelphia is the Rodin Museum, the second largest collection in the world (behind only Paris) of the sculptor’s works. Outside the museum, in front of a beautiful stone gateway, sits a caste of The Thinker, Rodin’s best-known piece that depicts a man hunched over in deep thought.

There is a small but lovely garden between The Thinker and the entrance to the museum, a garden that is truly a wonderful place to sit and think. I’ve often found myself there on quiet afternoons, looking at the trees, peering at the fountain, and letting my thoughts wonder. What could The Thinker be thinking about for all these years? What was so important? Has he got it figured out already? I’ve just spent the last hour reading on hemodynamics and the oxygen carrying capacity of blood – do you think he thought about any of that? Or was there something more important, more pressing?

Eventually, in the garden, I find my eyes drifting towards the main entrance to the museum. It is adorned by Rodin’s largest – and final – project, The Gates of Hell. It is 6 meters high and contains 180 figures; it is meant to depict a scene from Dante; it is terrifying. It is the only sculpture I can imagine that somehow, despite its location in a dark entrance to a museum, can completely captivate the mind of someone who is trying to get some peace and quiet in a lovely garden in the middle of a city. It screams at you. It shrieks. You have to take notice. And sitting there, nearly at the top of it, amidst all the demons and souls, is a miniature The Thinker. And he’s still thinking.

I guess one of the scariest things about death is the eternal loss of consciousness. Of course, on one hand this is silly – you can’t be aware of a loss of consciousness, so how can there be anything to actually fear? Yet in another sense it is nauseatingly horrifying to imagine just how long eternity is. Some have written that hell might not be so bad, given the choice, since at least there is a presumed level of consciousness. And with consciousness comes hope. Of course, Dante thought of all this – his gate of hell carries the inscription “Abandon all hope, ye who enter here."

At the burn center – as in any ICU – we have a lot of patients who are on “life support.” That is to say, they are so sick that we are breathing for them (mechanical ventilation), feeding them (via percutaneous endoscopic gastrostomy tubes) and assisting their heart (with inotropic agents, vassopressors, or aortic balloon pumps). All of them are heavily sedated – they have to be, otherwise they will fight the ventilator and be in agonizing pain. I have no idea what their level of consciousness is. I do know that for some of them there is great hope of recovery, while for others there is practically none.

Just recently, The Thinker was temporarily moved to inside the Philadelphia Museum of Art, while some construction takes place at the Rodin Museum. There now sites just an empty pedicle where the statue usually sits. It’s like he finally figured it out, and quickly got up to do something. And so maybe it’s time to take a break from these eternal questions and just focus on living actions. To just do. It’s worth a try.

Hoya Saxa

Around Christmas time, at St. Mark's, we sing one of those less traditional hymns that I positively love. I say that it is less traditional only because I never sang it growing up, and it doesn't exactly make the list of common carols one hears in shopping malls in December. Amazingly, and wonderfully, we sing the same hymn around Easter. The verses of the hymn track the life of Christ, and the refrain hits on even nature's amazement: "and every stone shall cry."

And every stone shall cry. And every stone shall cry! What a powerful image - that the wonder of God was such that stones wept.

I know many of you know that I recently returned from a trip to Haiti, where I worked at part of a medical clinic. The clinic is connected to a school. Before I went down on the trip, I had watched a DVD which chronicled the history of that school, from its beginnings in the back room of a mud hut to a beautiful structure with over 1,500 bright and happy minds. One of the things that makes those minds happy is food. You can't reasonably expect a child to learn if he or she is literally starving. And so they embarked to start a school feeding program, to ensure at least one meal a day for their students. And in the DVD I was struck by something one of the school workers said. She said that there were children who were literally so thirsty that they would suck on cool rocks they would find in the morning, covered with the slightest bit of morning dew. Children literally trying to suck water from a stone to avoid thirst. If stones are still weeping, it is surely in Haiti.

And yet stones are capable of causing great pain. I am now working at a burn center outside Philadelphia, and we are treating an 11 month old who fell into a pit of burning coals at a camp. His tiny hands wrapped around the coals. A confused, frightened child, falling towards fire, puts his hands out and clenches what he can – the instinctive grasp of a child working against him. Hopefully, he won't need surgery.

The news reminds me that today is the 40th anniversary of the landing of man on the moon. And if ever there was a rock that inspired and filled a generation with wonder and amazement, then surely it is that small rock orbiting our own planet. One upon a time I dreamed of walking on that rock myself, and while my current life and dreams are far from that, it is always something that I cherish in my mind.

And so here I sit, alone in a library, between patients and the OR, thinking of all these rocks and what they have meant to so many different people in so many part of the world. The constant theme seems to be one of action. Stones react, they can give, they hurt, they inspire. There is motion in all this, a motion that we, as bystanders, are privy to if only we look.

And so let us look!

Ready to burn

Just got back from a wonderful long weekend at my parents’ home in Maine. And while there was more than the usual amount of clouds and rain, there was enough sunshine to fully appreciate the awesomeness of the ocean: its expansive power, it’s mystical beauty, its endless bounty. There was a moment, in the boat, cruising home one evening on the sparkling water with the golden trees lining the banks that I thought to myself…this is good. I could do this.

Air travel is a funny thing. The flight from Maine to Philly is just over an hour. My suitcase was waiting for me on the baggage carrousel, and within minutes of touching down I was waiting for my ride. On one side of me a train buzzed by, while on the other buses and taxis lined up. I crossed the busy street, peering down the lane of speeding cars to spy my ride…in such a short time, it seemed, I had come so far.

Just over a year ago I graduated medical school and began internship. Just over a year ago I was new at this game – expectations were fairly low, to be honest, and a watchful eye was never far away. And now I sit on the brink of year two. Expectations are now fairly high, and to be honest I am a bit nervous. I begin at the burn center. In bed one is a nine-year-old boy who has already undergone multiple surgeries. In just one short year, I feel, I have come so far.

And what is there to do but push onward. With the taste of lobsters still fresh in my mind, I’m ready for anything.

Solstice

Today is the summer solstice, the day when sunlight stubbornly sticks around, refusing to leave. Its counterpart, the winter solstice in late December, is historically linked quite strongly to Christianity, as the celebration of the birth of the Son of God – the Light of the world – ushers in a season of increasing sunlight. Christmas literally comes in the darkest days of the year, and its promises of salvation are accompanied by longer days. In some way, I figure, the summer solstice is the culmination of that promise, the day when we are supposed to have realized the full potential of Christmas’s gift

Today is also Fathers’ Day, a day when we remember the love of our fathers, the gifts they have given us, and the sacrifices they have made. I spent today volunteering at my church’s summer camp, helping to prepare meals and do odd jobs. I spoke to my father from the camp – he was proud of me.

I was feeling good and happy when I drove home. But as I was nearing my apartment, a homeless man at an intersection caught my attention. I guess I’ve grown used to the homeless of this city – some of whom I know by name – but I still find that I am often unprepared to look at them. This gentleman was younger – in his late 30s, maybe – and he looked disturbingly numb, like he was ashamed though not yet scared of his situation. He held a sign with messy writing that read “homeless please help a vet.” I didn’t have a dollar on me. I looked at him through the glass, mouthed “I’m sorry,” to which he subtly nodded in acknowledgement, the corners of his mouth trying to make a smile. My eyes caught a small bag of chips I had in my car – I was too embarrassed to give it to him.

And so on this day, the Solstice, the reality is plan. There is good work being done, lots of it, and the rays of the sun make that visible for all to see. But those same rays point to the work, the seemingly endless work, that still needs to be done. And so I give thanks for the opportunities to do that work, and ask for strength and courage to accomplish it.

Happy Fathers’ Day!

Rituals

Every morning, upon awaking, I begin a series of rehearsed activities. I brush my teeth in the same order, wash and dry in what, to me, seems the only logical way to do so, and comb my hair just as I have for, well, for years now (though some wish that weren’t the case!). This, to me, is nothing but my morning routine – familiar, effective, practical.

In the hospital, we have recently spent a good deal of time teaching the new medical students how to present a patient in a formal manner. The concise and orderly manner of stating an update, vital signs, physical exam findings, laboratory date, and finally the assessment and plan. It is effective communication, to be sure, but its strict order assures that nothing is forgotten. Because when things are forgotten, patients suffer. And so somewhere, now, we begin to assign a certain meaning to routine behavior. It helps us better understand what is going on.

The operating room takes this meaningful routine to its medically-logical extreme. Checklists are run, instruments are counted, the steps are articulated…and all the while a patient lays strapped to a table, his viscera exposed, his whole self reduced to flesh and bones. This routine, here, in this place, has bordered on the ritualistic.

Every Sunday in church we witness and partake in many rituals. Words are spoken in precise order, movements are calculated, and there is even some counting….and all the while a sacrifice on a table is taking place. But throughout it all I find myself asking, for whom are we performing these rituals?

If the answer is for God, then that answer is both terrifying and silly. Do we really think God would refuse to hear the prayers of the faithful because they were not accompanied by the perfect sequence of genuflecting? And if God is that particular, than I, for one, am in deep trouble.

Perhaps we do it for ourselves. Perhaps in performing rituals during worship we somehow ascribe a certain level of meaning that we, has humans, need to have. It doesn’t add meaning, in this case, but it helps us better understand all that is going on.

That’s all for now – I’m off to bed, with a new set of routines and rituals to undertake in the morning.

Back for more

I haven’t written for a long time. It’s not because I haven’t had things to say. I think it’s because I’ve had too much to say. But too many thoughts, especially when kept inside one’s head, are not good for anybody. So here’s to more writing. Not necessarily good writing – I’m going for quantity here.

I am nearing the end of my first year of general surgical residency. It’s been a hard year. It’s been a long year. But it’s been a good year. I am so much smarter than when I started. I realize that’s the hope, the goal, the necessity, but let’s be honest, goals aren’t always achieved, and it’s nice to be on the positive end of an investment. So here I sit, ready to end this year and get on with the real stuff of surgery. Let it begin.

But there is one nagging thing that keeps me mind away from the grind. I recently went on a trip to Haiti, to Quanaminthe, where I worked at a medical clinic. As little as I know in the grand scheme of things, I was told I was fully prepared for what I would see. In some ways I was, but in many I was not. Sure, I can read about malaria in a text book and figure out a way to treat it. But I wasn’t prepared for the extensive need I saw. Sure. I had seen poverty, but I had never seen in while attempting to fix one aspect of it that is so tied to finances, to structure, and that relieves on a society to deliver.

So now, at the start of year 2, I am working on two things: how to become the best surgeon I can be, and how to attack health-care delivery in Ouanaminthe. Here we go.