Reflections in a Head Mirror

... [Former Delta pilot] Bill Mazzone, who flew jet airliners for 23 years, said it’s just as possible they got caught napping. "It’s kind of like being in an operating room. You know the physicians and the nurses…are listening to music, telling jokes, they’re doing what keeps them alert," he said. "Things are happening that if the public knew about it, they wouldn’t understand it, but it’s done. They’ve got the same thing in the cockpit."
- Associated Press story, "Could Letting Pilots Take a Nap Make Flying Safer?"  which appeared after a Northwest Airlines flight missed Minneapolis. (Published 10-24-2009)


When I was in medical school many years ago, I was assigned to a surgical service that also had two first-year surgical residents known as "the interns." As a medical student, I was required to stay in the hospital every few nights to help one of them.

Internship was very demanding. The young, newly minted physicians were exhausted from being on-call every other night. Much of the night work was of no educational benefit. Each lab and X-ray report needed to be tracked down from a different corner of the building. All night long, they walked all over the hospital preparing for morning rounds. Just when the interns thought their work was completed, they would get called by the Emergency Room or the floor to see a patient, start an IV, replace a urinary catheter, draw blood, or disimpact a rectum (don’t ask). As the interns stumbled through their assigned tasks the next day, one of the senior physicians would invariably tell them how much easier things had gotten over the years. At the time, I remember dreading my own upcoming internship.

One day after a particularly difficult night of call, one of our interns was standing across the operating room table from me. We were both holding retractors as one of the attending surgeons worked deep in the abdomen. I held a long, curved metal retractor that pulled the liver up and out of the way; the intern held a broad, flat metal instrument to retract the stomach. No talking or extraneous noise was tolerated so we stood silently, leaning slightly backwards — still as posts — hoping to avoid attracting attention. Neither of us could see what the surgeon was doing.

The case dragged on for a long time. I glanced up at the intern and noticed that his eyelids were getting very heavy. Suddenly, he fell over backwards, crashing into a rolling table full of instruments as he headed to the floor. The retractor in his hands flew up and landed with a clang clear across the room. Total chaos ensued.  

Within moments, the intern was sent to the lounge. I don’t think he ever scrubbed in with that particular surgeon again, and I am pretty certain he ended up in ophthalmology.

When I ran across the pilot’s comments comparing airliner cockpits to operating rooms, I paused for a moment. Yes, both pilots and OR personnel review checklists before we begin. Yes, we do best work when we are relaxed, careful, and attentive. Yes, there is often conversation and music while we work.

But, naps? Um, I don’t think so. Not a good idea.

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The following is feedback received for this blog: I agree with the analysis and I always objected to this comparison of the Operating room to aviation for the following reasons; Many air planes are a like but no 2 patients are When the pilot is tired a flight is canceled but when nurses have to work a double shift due to a sick call we do not cancel the shift, we go on. An air plane is a mechanical device our patients are not. In a flight events are most of the time predictable but in the operating room they seldom are. So what is similar? thanks - Gaby Cohen I have been a Surgical Tech for 16 years, yes you get tired, but you do everthing you can to keep yourself alert. Granted when you are "just holding retractors" it is difficult. That's when you try to make eye contact with your Circulator to say, "Help, this is very tiring!" Usually they pick up on what you need and start up a small, quiet conversation. To help keep everyone going!!!!!! They may even ask the Doctor if they can turn on some music. Most of the time the Doctor will say sure!

I wanted a perfect ending. Now I've learned, the hard way, that some poems don't rhyme, and some stories don't have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what's going to happen next. Delicious Ambiguity.
-Gilda Radner


Several years ago, we attended Milwaukee Irish Fest, the annual musical and cultural experience of everything even remotely Irish. While wandering the grounds, we discovered the band, Schooner Fare, a trio of singer-songwriters from Maine that captivated us with their tight harmonies, their musicianship and their enthusiasm. It was a great show.  

After the performance, we bought a CD and made our way to the tables outside of the stage where the singers were signing autographs. We reached the front of the line.  

As we greeted the performers, I was appalled. Two of the three were smoking cigarettes. “You depend on your voices to make your livings!” I heard myself saying. “I take care of people with throat cancer. What are you thinking?” 

I do not remember their responses, although they acknowledged that they knew the habit was bad. I quickly wondered if I had overstepped my bounds. I thanked them and left.  

For a few years after that, Schooner Fare continued to perform at Irish Fest and we continued to sit in the audience and cheer. Then, suddenly, they were no longer on the schedule. It turned out that bass player and singer Tom Rowe had developed throat cancer and died while receiving chemotherapy at age 53.  

I still think of him as a talented songwriter, a confident and energetic performer, and a crowd-pleasing musician. He had a versatile and expressive voice. For me, it remains eerie that this person, whose talents I truly enjoyed, was taken by the kind of cancer I have spent my career battling. The day he died, the outside world crowded close to my professional world in a new and uncomfortable way.

Tom Rowe’s death still saddens me whenever I listen to one of his rollicking bass lines or hear him harmonize on one of the band’s albums. I still wish that there had been something I might have said to him on that day, long ago, that would have made a difference.

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The following are comments received for this blog:

I am not usually a blog stalker, however I have checked daily for your most recent post for several weeks. You are the master of capturing and articulating the most poignant of moments and events. I first came across one of your posts last December while meandering around the Froedert Web site. I was scheduled for a bilateral reconstruction procedure and was trying to find out a little more about your fine facility.

I work in a small hospital South of Madison as the nurse manager of surgical services. I have been drawn to the intimate stories you share, in particular "The Christmas Card" "Surgery as a form of dance" and your other touching moments reflective ot the bond evolving between patients and their physicians through this journey of life. Two years ago, I had the fortune/misfortune of being told I had cancer by my Gen. Surgeon who I have worked closely with for 15 of my 27 years in nursing. (Nurse/physician and OR Manager/ Surgeons a whole different relationship)! I remember that day in a slow motion, multicolored heightened awareness, in white hot detail like it had occurred this morning. Dr. B could not have been more caring or compassionate as he gentle broke the news. As I listened, my brain firing in multiple directions, it hit me like a blow; I had always respected this physician's position and thought I understood the difficulty of his role, but now here I was exposed and devastated with a completely new appreciation for this man (and the horror of his job) who was soon to become my lifeline.

Dr. Campbell your pieces speak to my heart both as a health professional and a cancer survivor. I have a tremendous appreciation for your skill as a physician and cancer specialist and your other God given talent.......sharing your stories. Keep them coming! I'll be here patiently waiting.

Thank you
Tracy

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I work at Ft. Detrick in Fredrick Maryland, half of the base is used by the National Cancer Research Institute. As I go across the base I see little knots of cancer researchers puffing away. Every one of them thinks they will stop one cigarette short of cancer.

- Mark A.

A woman has the age she deserves.
-Coco Chanel
    

She sweeps into the office with a flourish, filling the place with her commanding personality. Because she can be curt, some of the staff members avoid her. She usually refuses to step on the scale to have her weight checked and reveals her septagenarian status only with reluctance.  

Long ago, I recognized her as being “old school” since I have known other women of a certain vintage who were outspoken and uncommonly crusty. She reminds me of a few of my parents’ friends who engaged confidently and forcefully in every social interaction. She remains stylish, if a bit dated, and is fond of expensive perfume.   

Her office visits have never been complicated. Her cancer was successfully removed with a surgical procedure over five years before and, except for some scar tissue and dryness, she has no other problems. She has no difficulty talking and she remains cancer free. Everything, from my point of view, is perfect. She is one of my “saves,” someone who had been cured of cancer with one of my surgical procedures.  

“Everything looks fine, Mrs. Anderson,” I told her at one of her visits. “You are doing great! No sign of the cancer. There is nothing worrisome.”  

She glares at me. “Nothing, eh? I would NEVER have another surgery! Never!” She continues. “This life is terrible! Why can’t you do something about the dryness? Why does my tongue feel so tight all of the time?”  

“Oh,” I think.  

“And another thing! Why does my tongue burn so much when I eat Mexican food? I used to love spicy foods, but I can barely tolerate them anymore! Oh, this is terrible!”  

So it goes. I try to explain the mucosal changes. Scar tissue is less flexible. The linings are thin and sensitive. Things are never the same.

She is not satisfied.  

As she gets up to leave, I find myself apologizing. “I wish things were different,” I say. "See you next year?"  

“I'll call when I'm ready to come back," She turns as she reaches the door and tosses me a patronizing look. “Oh, it’s OK, I suppose,” she decides. "I know you did your best.” Then she gathers herself up and heads down the hall.

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The following is feedback received for this blog: I love older people; one day I want to be one ... in fact, one day I want to be one just like this! - Jabulani Congrats on the save. That must feel so good. sounds like she enjoys complaining... but underneath it all appreciates that you saved her life. It must be frustrating to have some of her concerns. I'm the polar opposite of that. My Mother spoke what she thought and could come across hard. when she really was not that way inside. years a go when my firstborn was a baby, I decided to sell cosmetics for Mary Kay so I could make my own hours, have an income but choose the time I could be with my baby. They had a saying in reference to having a skin care program... that I still abide by today..although now with a different company. At 20...you have the skin you've inherited. At 40... you have the skin you've made. And at 60... you have the skin you deserve. - SeaSpray seaspray-itsawonderfullife.blogspot.com

Insight, I believe, refers to the depth of understanding that comes by setting experiences, yours and mine, familiar and exotic, new and old, side by side, learning by letting them speak to one another.
-Mary Catherine Bateson    


Last week, a group of third-year medical students completed their first rotations through Surgery. They spent eight weeks doing things that no normal person would ever be asked to do. Many days, these students arrived at the hospital at 5:30 a.m. to begin 30-hour shifts seeing patients, checking laboratory reports, making rounds, and observing surgery.  

In the operating room, these students saw, heard, and experienced many unthinkable things for the first time. They held retractors for hours. They felt the warmth of another person’s intestines envelop their hand and forearm as they listened to the surgeon describe findings deep in the belly. They watched as a heart resumed beating after bypass or transplant surgery.  

The students also spent time talking to patients and learning their stories. Many of the students were present as a person that they had gotten to know died.    

When I was in medical school, the end of the surgical rotation meant merely that it was time to move on to the next, certainly less intense, clinical experience.

For this group of students, though, their teachers planned something different.  

These students were offered the opportunity to prepare a creative piece to reflect on what they had just experienced. Almost half chose to write a poem, create an essay, or paint a picture.    

This was not your standard bookshop reading! There were poems about bowel movements and horrific odors. There were pieces about cardiac arrests. There were appreciations of patients’ stories. There were evocative poems about sick children. Some of the pieces were very funny, some displayed great tenderness. Many of the students admitted that this was their first attempt at reflective writing or verse, yet all of the pieces reflected their shared immersion in a rich, vast, and powerful experience.  

When the session ended, all of the participants and their classmates sat stunned. As one later shared, “I've experienced many emotional moments throughout the past two months and it wasn't until this hour did I finally have time to realize and reflect on my personal experiences and their impact on my life.” Importantly, one student wrote, “I learned that perhaps I do need to put some effort into maintaining empathy.”  

Medical school involves thousands of hours of instruction. This was unique. This was a single, planned, intentional hour of reflection.   

Perhaps none of these particular students will go into a surgical field, and that is just fine, yet I hope that one of them becomes my own physician when the time comes. Having heard them read and reflect, I know that I will be in good hands.    

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The following is feedback received for this blog: Interesting post. It takes a special person to want to go through all that. Has to be a calling! certainly... most people could not withstand the rigors of a medical education. I never realized how empathetic doctors are toward their patients until I joined the med blogosphere. I'm glad to know they are. :) I thought surgeons weren't supposed to have feelings though. ? That they were supposed to be the non-feeling specialty? generally speaking. - SeaSpray seaspray-itsawonderfullife.blogspot.com Thanks for the comment! "Surgeons weren't supposed to have feelings"!?! Ouch! Occasionally, a little empathy slips out! Actually, a research study a few years ago confirmed that medical students that have higher empathy scores are more likely to go into primary care specialties, so I guess you are on the right track. -Bruce It's not that we don't have emotions, or are not caring; its that we have learned to suppress our emotions in order to perform the incredible tasks that are required of us. If a surgeons hand slips, or his concentration wavers, even for a second, while performing a routine operation, loss of life can ensue. Procedures tends to be much more routine and methodical when you have the distance separating you from what you are actually doing. It is this ability that makes us successful as surgeons. I would hate to have an overly emotional, frantic surgeon's hands in my abdomen while I was bleeding out. - Steven Savage Dear Dr. Savage, Thanks for your comments. What you say strikes at the heart of one argument I have heard about the ACGME's core competencies for residents. A resident can excel in all of the competencies and still be technically dangerous surgeon. Still, I don't think that a side effect of including reflective or narrative experiences in a Surgery clerkship is to make surgeons more caring or less capable of making hard, rational, dispassionate choices. There is value in having a person whose hands hold my life in the balance being a person capable of insight and compassion. Think of Richard Selzer, Sherwin Nuland, Pauline Chen, Atul Gawande, and Loyal Davis...all renowned surgeons, accomplished writers and keen observers of their own motivations and their patients' dilemmas. These people, at least in their writing, did anything BUT suppress their emotions. Thanks again. -Bruce Both...very interesting comments! :) "technically dangerous surgeon. " Scary thought... that someone could have a surgeon like that. God Forbid! I'd take a competent surgeon over a sensitive one... but if I can have both..then that's just icing on the cake. If you haven't read this..one of my favorite surgical posts is Dr Schwab's "Taking Trust". I believe he wrote it in October, 2006. A moving post. :) - SeaSpray seaspray-itsawonderfullife.blogspot.com