Reflections in a Head Mirror

I am honored to be the host of the next edition of SurgeXperiences!

This is a “Blog Carnival” of blog postings that are related, however tangentially, to surgery and the surgical experience. The post will go live on Jan. 4, 2009.

Every blogger is welcome to submit a favorite surgically related post, whether you are a physician, nurse, technologist, PA, PT, NP, pump tech, patient, caregiver, videographer, hospital administrator, quilter, llama lover, surgical groupie, or friend of any of the above.

I will try to be a clever host, but, given the holidays and the need to recover from all of the potential meals and celebration, we will just have to wait and see what happens. If you want to submit, click on this link to go to the submission page.

Submission deadline: Saturday, Jan. 3, 2009.

C'mon, bloggers! Dazzle us!

Warmest wishes for the holidays! Peace on Earth.
-BHC

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God answers sharp and sudden on some prayers,
And thrusts the thing we have prayed for in our face,
A gauntlet with a gift in it.
-Elizabeth Barrett Browning    


The bitterly cold Saturday morning temperatures are hovering just below zero as I search for street parking in downtown Chicago. I am anxious to get to a medical meeting and worry that I will be late.

After circling the block a couple of times, I spot an empty space near the corner. I pull in, turn off the car, bundle up, and open the door. The cold rips through my clothes. I tuck my head into my collar and walk stiffly to the middle of the block where the electronic parking meter will print the receipt I will need to prop on my dashboard. As I try to read the instructions, I pull off my gloves, fish several quarters from my pocket, and feed them into the machine. This approach is pointless as each quarter buys only five minutes of parking time and I am not carrying nearly enough change for my three-hour meeting. I pull out my wallet, balance it on top of my gloves, and fumble for my credit card in the frigid wind.  

“Please.”  

I hear a voice over my right shoulder. I look up only long enough to see an older man wearing a worn overcoat, a thin stocking cap, and a several-day growth of white beard. I focus intently on my challenge, trying to ignore him. He is quietly talking to me, but my cap is firmly clamped over my own ears as the wind whistles around us. I do not hear him.  

“No!”  

I speak firmly. Finally, I grasp the credit card between my fingers and extract it. I slide it through the magnetic reader in the machine. Nothing happens. I look at the diagram and realize I have inserted the card backwards. My wallet balances precariously and vulnerably in front of me. I redouble my effort.  

I sense his presence as he waits patiently just out of my line of sight. It has been a long time since I have given money to a panhandler, and for all of the correct reasons. “Social service agencies are in place to help” … ”the money only goes for alcohol” … ”it does nothing to reverse the cycle of dependency” … ”our family contributes in many other ways.”  

“How you doin’?”  

My fingers are stiffening. As the electronic information on the credit card finally registers, my quarters drop and clatter in the coin return. The man stands patiently. He says nothing more. I actually know someone who carries a few coins specifically for use in these situations. What of grace? What of justice? The weather is brutal.  

I fish the quarters out of the machine; it is about $2. I look at the change. I see my breath as I exhale. Spontaneously and without looking up, I extend my right hand towards the man.  

“Will this help?”  

“Oh, yes, sir. I’m hungry.”  

He speaks without emotion. Out of the corner of my eye, I see that he is not wearing any gloves. My fingertips push the quarters into his bare hand, skin against skin. His palm is disturbingly thickened and hard. Why are his hands so heavily calloused? Does he have some skin disease? Is it a result of exposure? I press the gift into his grasp and then pull away.  

“Thank you.”  

“You’re welcome.”  

He takes the money and moves on. I complete my task and finally retrieve my parking receipt. When I look up, he has disappeared.    


The next morning, Sunday, I am back home and get pressed into service helping to distribute communion at church; my task today is to distribute the bread. For as long as I can remember, lay assistants were assigned the tray with wine; “This is the blood of Christ, shed for you.” This day, however, I have been asked to distribute the bread, a task for which I still feel somehow unqualified.  

Standing in front of the line of waiting congregants, my left hand holds the bread partially wrapped in a linen napkin. I tear off a small piece as the first person approaches with hands cupped. I look up, trying to engage his eyes; I have been in his home, I know his family, I know some of the challenges he faces. I watch as our hands meet. “This is the body of Christ, broken for you.” I press the bread firmly into his palm — flesh against flesh — my fingertips into his soft, warm skin. His fingers close around the gift and I pull my hand away, preparing for the next in line.    

“Thank you.”   He moves on.  

“You’re welcome,” I think to myself. I feel a twinge of recognition, and hours later, I realize why.  

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The following is feedback received for this blog: You are one of the bloggers I hope to meet someday. We do think alike. Christ came for those people, and sees us as you saw him - I know you know that. Thanks for the moving story. - Rob http://distractible.org God bless you for this post, at this time of year. Earlier this year, our church and my children's school prepared shoe boxes to distribute to eastern European orphans at Christmas. Each box cost me £25 to fill with things they don't have and will love: a comb, hairbrush, face cloth, soap, sweets, etc. Other mothers at the school complained that £25 was a lot of money when you've got presents of your own to buy as well. I remember thinking at the time that £50 was a pale shadow compared with the money I was going to spend on my daughter's Wii and my son's Scalextric. And tonight I stood in the supermarket, among the throng of people hurtling their gargantuan trolleys of "need" up and down aisles, buying last minute bits I needed. Now I am reminded: how much stuff did Jesus "need" to be born? Thank you your story. - Jabulani Thank you for this moving story. Are you an elder in a church? If only every elder/deacon (session members) in my church knew each member of the congregation as well as you do. I feel this is important in dispensing the elements of Holy communion. - Jeff http://jeffreyleow.wordpress.com I read your story several times. I am like your friend- I carry money with me to give to people who ask. I also give my mittens or gloves to the person if they have none. A gift is just that- a gift. If someone spends the money I give them on something "inappropriate", it's not my money anymore, but theirs. Whatever they do with it is their decision. God bless us all our failings as human beings- as well as blessing our gifts.

What, exactly, is Surgery?  

At its most basic, much of Surgery is a goal-oriented process by which something that is detrimental to the patient is removed in a way that will improve the patient’s well-being. The surgeon’s task is to accomplish the goal while carefully balancing the risks and benefits.  

On a practical level, however, much of Surgery boils down to this: The surgeon must decide where to cut between something that is coming out and something that is staying in. The surgeon repeats this process until all of the tissues have been separated, whether it takes ten minutes or ten hours. Once the operation is under way, the surgeon and the assistants work hard delivering as much light as possible to a place where light might rarely penetrate. The surgical field must be dry, well-illuminated, and as accessible as possible.  That’s it.   

When all goes well, the procedure develops a momentum and moves along steadily. Once the problematic area is exposed, each movement has a purpose; each activity makes the next one possible. No matter how simple or complex the operation, the surgeon is always preparing a number of steps ahead.  

When Surgery goes poorly, the surgeon is unable to smoothly complete the necessary tasks in a logical sequence. Using this definition, even “simple” surgical procedures can go poorly. My worst days in the operating room occur when each step of a procedure requires a specific instruction to the assistants: “Put a retractor there and pull that way,” “Get the suction and clear away the blood,” “Leave that area alone for a while and help me expose this,” “Move your hand so I can see better." Objectives that appear obvious to the surgeon can seem to be lost on the trainees.  

During my best days in the operating room, my resident and I are in sync. We anticipate each others’ actions. While one of us is blotting the field, the other is adjusting the lights or the retractors. While one of us is dissecting a delicate structure, the other is carefully widening the exposure. Few direct technical instructions are needed; we might talk about the anatomy or the cancer, but there is rarely the need to say, “Retract this,” or “Put a clamp on that.” 

Years ago, I realized that Surgery sometimes resembles Dance. Just like beginning students of the tango or the waltz, young physicians tend to focus on the “steps” needed to get from Start to Finish. But learning the “steps” is only the beginning of learning how to operate.  

You see, Surgery, at its most glorious, is a form of choreography — a whole team that seems instinctively aware of each other’s movements and focus. When the “Dance” goes well, surgeon, assistant, and technician all drive the procedure forward.   

Just like the action on a dance floor, Surgery can be exhausting and, at the same time, totally exhilarating. When things go well, the process is very special. When the Dance feels effortless, I cannot imagine any other line of work.

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The following is feedback received for this blog: Well "choreographed" surgery can also be beautiful to watch. Just like dance. - http://sterileeye.com   Hi -I found you through Dr Rob's recent post. Just want to say that I enjoyed this eloquently written post and the idea of surgery being analogous to synchronized dance. Great blog and I am blogrolling you! :) - SeaSpray seaspray-itsawonderfullife.blogspot.com

In the practice of our days, to listen is to lean in, softly, with a willingness to be changed by what we hear.
-Mark Nepo (Cancer survivor and poet)    


My happiest times in the office are when patients tell me stories. Some people just can’t help themselves; they easily share their experiences of illness, children, lives, or struggles. More often, though, the stories need to be called out. These accounts, the hidden or subtle, are often even more interesting. When the office is slow, I might hear an elaborate tale. When things are hectic, I might have to survive on a vignette or an update. I have shared many of these stories through my blogs and essays.  

This practice of intentionally listening to and recounting patient stories falls under the broad heading of “Narrative Medicine.” Medical schools around the country are modeling curriculum and seminars on the Program in Narrative Medicine  developed by Rita Charon, MD, PhD, at Columbia University in New York. Every medical school hopes its graduates will be good listeners. Good listeners make better caregivers.  

Over the past two years, the Medical Humanities Program at The Medical College of Wisconsin has developed a Humanities Track for first year medical students. Part of their experience involves shadowing practicing physicians during their office encounters. These students might not understand the intricacies of sub-specialty medical care, but they do understand people. During this first exposure to clinical medicine, the students start to build skills that will help them later listen to the story lying beneath their illness.     

I ask my students to write, not about the disease, but about the person. With the students’ permission, below are two examples of what they have submitted.  


I had a blind patient with recurrent cancer. Here are one student’s reflections about the office visit:    

The human fight for survival and well being is incredible.  People will go to the ends of the earth to live a happy full life.  I was fortunate to meet an amazing patient that I will never forget.  The patient had been blind since a young age and had been diagnosed with cancer for many years. His cancer was [extensive and recurrent]. It is not his blindness and loss of voice that I will always remember, it is his fight and spirit that will never leave me.  This patient would not give up his fight with cancer and would go to the ends of the earth to defeat it. Every punch that cancer threw at him, he countered with two or three punches of his own.  Sometimes we have bad days and let little things bother us. This patient did not know what a bad day was. This is a perfect example of living life to the fullest. To go through life without vision is amazing in itself; but to not be able to talk and battling cancer on top of the blindness is unimaginable.

Here is another submission. A man who had his voice box removed several years before came for an office visit. He could only talk using an electrolarynx (a vibrating device that he holds against his neck). Here is what the student remembered of the encounter:  

Someone in the room curiously raised the topic of Mr. M’s age.  Before anyone could reveal his age, Mr. M quickly turned it into a quiz, “How old do you think I am?” he asked with an anticipatory smirk.    “77.” said the other student in the room.  “69. 82.”    Finally Mrs. M answered with a roll of her eyes, “He will celebrate his 90th birthday during this month!”  Mr. M laughed. It was the kind the laugh where the shoulders bounce up and down with a big grin but no noise actually comes from the vocal folds.   If someone in Mr. M’s situation wanted to find a reason to complain and find misery, he could find several reasons to.  The fact: life is never going to be as easy as it once was. Did that mean the rest of his life had to be less fulfilling and enjoyable than it once was?   What made him different? Was it the fact that he had only minor complaints from an otherwise successful laryngectomy? Was it the fact that he made jokes using his artificial speaking mechanism?  Was it the fact that his dear wife of many years was by his side at the appointment, asking questions and holding all of his prescription bottles?  Was it the fact that he smiled a lot? Was it the fact that he held his hands up in triumph when none of the patient care staff could guess his age? Maybe.   All I know is when I have my 90th birthday, I want to be 90 years young!

The experience of having first-year medical students shadowing me in the office is interesting and, quite frankly, lots of fun. I sense that the early immersion into Narrative Medicine reinforces their understanding that the patient’s story is critical to understanding their illness. Hopefully, being a good listener now will prevent decent medical students from becoming miserable doctors later.  

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The following is feedback received for this blog: Dr. Campbell: Thank you for your nice comment on my posting at the NYU lit med blog. I welcome the opportunity to talk with you about my project...and to visit you and your colleagues sometime to discuss it...all best, Steve Langan

 Pick battles big enough to matter, small enough to win.
-Jonathan Kozol    


She sits in the chair, rocking back and forth and talking very fast.  

“Doctor, I have tried SO HARD to quit!” She is clearly troubled. “I had cut down from 23 cigarettes per day to 17 cigarettes per day, but yesterday was really hard and I smoked 27! I feel so awful! I know you hate me! I know I have to quit!”  

The discussion varies only slightly each visit. She developed a tobacco-related tongue cancer many years ago that was successfully removed. Since then, she has had a couple of pre-cancerous spots, as well. She knows that smoking is dangerous; she probably realizes this more acutely than many other smokers.  

Unfortunately, she also has a long history of psychiatric disease. She is meticulously compliant with her psychiatrist’s regimen of medications and therapy. As a result, she is able to function most of the time. Still, she cannot quit smoking.  


The combination of tobacco use and Psychiatric Disorders and Substance Use Disorders (PD/SUD) is a bad one. Despite declines in tobacco use among the general population, the rates have shown little improvement among people with PD/SUD. While about 20 percent of the general population smokes, rates of smoking among these patients vary from 35 percent (for people with panic disorder) to 50 percent (depression) to 60 percent (PTSD) to 80 percent (alcohol dependence) to 88 percent (schizophrenia).  

Medication use is more difficult with these people as well. The most effective medications are currently varenecline (Chantix®), bupropion (Zyban®), and nicotine replacement. Unfortunately, varenecline is not recommended in people with depression or suicidal tendencies. Many of these people already take bupropion as an antidepressant. Finally, nicotine products (gum, lozenges, or patches) can increase anxiety symptoms. Cessation can lead to exacerbation of manic depressive disorder.    


So my tortured patient, and all smokers with psychiatric disease, has one more burden to bear. At each visit, I encourage her to quit smoking but know that she continues to fight many, many demons. Smoking is merely one of them.