Pranj

Forever Fallacies

2012-01-01T20:06:00.000-08:00

Places change
Places grow
We know that

People change
People move
We respect that

Thoughts change
Feelings change
We acknowledge that

Yet something must be constant
Something must last forever
We crave that

If that something doesn't last
We assume it failed
And believe that

A season is changing
We savor that
A relationship ending
We regret that?

We choose to burden the most precious of feelings with "forever" expectations
We turn the most successful moments into failed "forevers"
We turn away from the present if it has no "forever" guarantees.
And from the distance the fallacy called "forever" laughs at us.

Love and Let Love

2011-12-30T18:00:00.000-08:00

In face of a sudden disability or life threatening illnesses, we often find the sturdiest of relationships struggle and even end.
A third person looking at the picture from the outside wonders:
"How could she leave him just after he had a stroke? " How could he leave her when she was fighting cancer?"

On examining the story closely , it often appears that the illness doesn't make the healthy partner stop loving the ailing one.
When you promise someone you will love them to the end .. you usually do.

It is often the ill partner that finds it very difficult to accept that love.... confusing it with sympathy, feeling a sense of inadequacy, depreciation of self worth...all in all felling hurt instead of feeling loved. The anger at the illness is misdirected at the partner.
If you're the healthy partner and you find you inadvertently hurt someone you love all the time, you can only do it so much..... you leave.

I admit this is not the only reason why relationships fail when facing death and disability.....But this particular problem does beg the question.." If someone promises to love you saying- "Till death do us part".. then shouldn't you promise to "LET" that someone love you...no matter what?

There is often no lack of love..just lack of "let love"

The Quack Aisle

2011-12-25T19:38:00.000-08:00

If you've watched the movie Idiocracy (2006)and thought it was exaggerative- you need a current day reality check. If you didn't watch the movie..watch it !.
Whether humans over years get smarter or dumber, the buyers and the sellers should evolve together. The present day advertising strategies do make you wonder... Does the marketing industry really think the consumers are getting dumber?

Your shampoo has vitamins and antioxidants..Ever wonder why ? What next? "The Wholesome Breakfast Cereal -Great to eat and great to shampoo with?"
Your mineral water is oxygen enriched. Buying that is brilliant but only if you are a fish. Next time get a pair of gills free from the accessories isle.
The fried chips and ice-cream you bought are "zero cholesterol"? Good news ..they're all zero cholesterol .. Hope you also look for "Lead free milk-from the unleaded udder"

Advertisers, here's a suggestion. Say something like... "This can of coke will help you lose weight" with a fine print reading " drink it, place the can over your head and run a mile with it"
At least it's honest !

The Other Scarlet Letter

2011-12-02T23:12:00.000-08:00

Would you have his eyes, be as tall,
With the air around you envied by all?
Would you sing like him, get the words all wrong
Undaunted though, just hum along?

You’d be smart I know
And strong and free..
For there’s a part of you
That would come from me..

Would you love with all your heart
Like he loved your mother?
Would you have the same courage
And stand by your lover?

If you were born, your story you’d have to tell
Would it be one of love, or one of blame?
Would you tell it with pride or gulp words in shame?
If I had courage I’d hear it, but it remains unsaid.

Sans Expectation

2011-11-24T19:53:00.001-08:00

If I were writing a relationship column like Carrie Bradshaw for Sex and the City.. here's how it would go.

Flat fact- Expectations make and break relationships.
Quest: Can there be then a relationship without expectations?

The expectations of relationships we are born into are easier to figure out. Dad provides the roof over your head, mom brings a wholesome meal to the table, you share and squabble with your sibling....The tags "mom" "dad" "brother" are already there.
As you grow up some of these relationships evolve. Mom may become your friend...but Mom as a friend is still mom.
The expectation of the assigned relationship comes first. If you have a brother, you had to prove a "Brother" first, and then perhaps become "Best Friend" " advisor" whatever..
If your brother doesn't meet your expectations of a brother, you wouldn't become "just friends" or " partners." You would become, "Brothers that didn't get along"

(Ok I agree this part is way far more insightful to liken to Carrie Bradshaw..so lets try again)

The relationships we choose later in life are more complex because they involve choices.
We tag our acquaintances- Friend, Partner, Colleague, Lover, Companion, Spouse and so on.
We create these labels as we think appropriate for the person, then attach our own expectations to the labels and then hope they are met...
Whether you believe the connection is synaptic or spiritual..its still quite random...quite funny if you think about it.

Picture that in you are hiring for a movie that's in your head. You stop a woman walking by and you say to her " I believe you're Janet"
and right after, you follow it up with " Great ...now prove to me you're Janet... and you really can dance"

If Janet can dance, the expectation proves reasonable, the tag was right and the attempt successful... a successful hire..a successful relationship.
What if Janet can't take up your expectation challenge? Is it because..
You tagged the wrong girl and she wasn't Janet at all?
Your assumption that Janet is a good dancer was wrong?
Janet doesn't care about your stupid idea?
And if you didn't have a preset expectation..might you discover she is Jane and Jane actually is a good singer?

Often we don't elucidate expectations of relationships until we become acutely aware that they aren't being met.
We perhaps don't elucidate expectations because we are mostly unaware that we have them.
There is no pre-nup for a non nuptial relationship....There are no "emotions back" guarantees... The fine print is written in invisible ink.

Heartbreaks are unmet expectations..if there were no expectations, there would be no heartbreaks.
A relationship could be tailored down to one of few expectations..But can a relationship sans expectations be a relationship at all?

CB

Just changed her status to "Dead"..

2011-08-14T19:56:00.000-07:00

We have assumed you're not truly "in a relationship" when your facebook status says "single". Similarly then you can't be dead till your status says "deceased". Have you thought about who updates your status when you're dead? Its about time someone designs a virtual funeral so all dead people can be truly and completely dead.
Life insurance plans advertise about how they cover funeral costs. Folks often spend to reserve their spots in cemeteries and pick their own designs for their coffins. As our cyber existence today is often larger than the physical one, the concept of a virtual funeral would be a "killer."
Your will and power of attorney may hand over access to your bank accounts, but what about your email and facebook accounts? The virtual funeral experts I'm talking about will specialize in just that.
Think...Can your soul rest in peace if every 5 minutes you're receiving emails about earthly sales events, parties, discounts and more?
These folks will set up your own pre-selected auto reply for your emails " I am out of office till further notice... although if you get that notice you should be really freaked out"
or something like "Can't you see I haven't replied to your last four emails? In my case that usually implies I'm dead"
The funeral experts will also change your facebook status to something more interesting than just "deceased". Like for medics it wont say "dead" it will say "warm and dead"
Or still better you say something like "need lots of prayers folks..keeping my fingers crossed for heaven" and then few hours later your status will change to " Heaven it is!!.. here I come!..Just ran into Michael Jackson" followed by lots of thumbs up in "likes" and comments like "Please upload the pics soon" Now THAT will lay your soul to rest.
"Thanks to the heavenly Xanax, my soul now rests in peace"

You're the price I paid

2011-07-11T23:08:00.000-07:00

You were all I ever wanted
Everything I ever sought
I loved you very much
Yet not as much as I thought.

You and I would be perfect
We looked like we were meant to be
I would have said 'yes' had you asked me
Yet I prayed you would not.

There was a lot that I wanted
And everything comes for a price
There was something bigger than you or me
And you became my secret sacrifice.

The Armored and The Enamored

2011-04-02T17:07:00.000-07:00

The cold metal on your chest
Will hold you heart safe.
Love is like an arrow,
You have no time for pain.
No emotions must stall you,
You must blaze through this race.
You must fear no loss,
So you can't love again.

When you win and hold your prize,
Standing proud and tall,
A hand may come to rest on your shoulder,
Without making a sound.
That hand will feel cold steel
And you wont feel that touch at all.
A teardrop falling on your armor
Will roll down to the ground.

Fidelity vs Commitment

2011-03-26T12:13:00.000-07:00

There are some stores and restaurants you like and visit very regularly.You have a favorite store for shoes, a favorite for books, a favorite restaurant for a certain cuisine..so on and so forth. You don't usually look beyond these regular places, unless you've looked there first.
If that's you, then you don't have a fidelity problem.

You can't subscribe to store memberships and reward programs though. You can't stand the thought of persuading yourself to go to a particular store to make worth a deal you once made. You would go there if the product were worth it, and we've said that before... You don't have a fidelity problem.
So do you have a commitment problem?

Relationships `A la Carte

2011-03-11T18:01:00.000-08:00

Words and feelings

2011-03-04T20:30:00.000-08:00

You hear words, say words..
Often perhaps think in words..
You express feelings in words...
Feelings though.. don't come labeled with these "word names"
They are what they are when felt..then you think about the feeling..give it a name and express it...and lose the feeling to the word

Anger as you first experience it, may " feel" like hurt
Weakness as you sense it, may feel like fear
Need may feel like longing
Joy could be just excitement
Envy maybe feeling of discontent with ones own
And Love at its own risk, may feel like you and I.

Snow Emoticons

2011-02-06T08:15:00.000-08:00

An inch of snow can stall a city that hasn't seen any in 25 years. The highways were closed. Cars were skidding on inner city roads. Those who had a choice, stayed indoors heeding weather advisory. I thanked my four wheel drive as made it to the hospital, past cars spinning and freezing on the sheet of ice.

On rounds I was discussing the weather with all my patients. "Have you seen the snow yet? Open your blinds, look outside your window !" I was trying to share the excitement. It was quite the same feeling I have when I wish my patients "Merry Christmas" or "Happy New Year".. yes its an exciting day..but not one you wish to spend in the hospital.
The different reactions are interesting.

Waking up..rubbing his eyes...."What what..where am I?"
"You're still in the hospital..remember you were in an accident..you're still in San Antonio..but it snowed in San Antonio last night."
"Aah.. ok". and he goes back to sleep..snoring.. thinking its not one of the things he pulls his weight up for...actually there can't be that many of those things in his case.

He's always smiling although he's been in the hospital too long.. "Really? where? ..lets you and I go make a snow man" Really optimistic since neither him nor I can go... Really optimistic..given its just an inch of snow.

She's fed up being the overnight admit..she knows she'll be out later in the day..says.."Oh whatever.. I'm from Chicago! "

She's been in the hospital the longest. I don't even know if and when she's going to make it out. The mention of snow brings a glow to her eyes " Yes, I had the nurses help me stand up so I could peek at it... How I wish I could go outside" We spend a moment of silence looking outside with a mixed feeling..
I don't know if she was in the city the last snowfall 25 years ago.. but I hope she's around for the next one.

इजाज़त

2010-12-07T18:59:00.000-08:00

दिल किया तुमसे बात करे
दिल किया तुम्हे जान ले
तुमसे प्यार कर सके मगर
दिल को हमने ये इजाज़त न दी

दिल को फिर भी प्यार हुआ
हम ने दिलको समझ भी लिया
तुमसे हम कह पाए मगर ये
इस दिल ने हमे इजाजत न दी

कुछ वादे इस दिल ने पहले भी किये थे
हम वो तब भी निभा न सके
अब तुम्हारा दिल हम तोड़ दे कभी
इस गुंजाईश को हमने इजाज़त न दी

I lost you today.

2010-11-26T19:33:00.000-08:00

"I just wanted you to look into my eyes and say it"

"But I did..as hard as it was, I did"

"Yes you did... but you said -I cant”

"Yes and that's what I said time and again. Why didn’t you stop asking?"

"I was waiting.. if not for you ..atleast for a day like this."

"And how is anything different today?"

"Today you didn’t say 'I can’t'... you said 'I don’t want to'”

Bloom Where you Are Planted

2010-10-08T19:39:00.000-07:00

Some of my schoolmates from St Joseph Pashan, might remember a poster in the school porch- A simple cherry blossom in pink and brown watercolor with a title "Bloom Where you are Planted."
Back then looking at that painting, I thought, "Well of course..that's pretty obvious for a tree" Thank God trees don't have a choice. Can you imagine a "tree lane" next to the bicycle lane....or imagine having to rake leaves from your porch after a "tree party." Perhaps you could call the "tree-ist" instead of your florist and say," We're having a reception at our farmhouse..could you send a couple of cherry blossoms" "Oh and have them run as fast as they can without spilling the blossom."

Anyways, turns out that poster wasn't about trees, it was about us. Perhaps some of us who lived by the dictum most closely, became teachers in the same school. Along the radius, some took other jobs in the city, some moved to other cities...some to other countries and continents.
Some of us were the planted seed, that grew as promised in the soil where we were planted. Some of us were the dandelion seed.. hitchhiking on the wind till we found our own soil. The former are bound by their roots in the soil..the latter by the heart of the tree that said goodbye to the seed.
I wonder if the dandelions can ever return with the ease of the feathery seed..or must they wait for a tree lane for an uprooted tree?

I'm still fifty nine

2010-09-23T21:54:00.000-07:00

I am still fifty nine
and you must be sixty today….somewhere.
Are you everything you always dreamt of
Are you ranked high amongst men
The one’s whose opinions you may care about?
Are you flying your jet to the island home you bought?

Is your pretty wife by your side….
is she the lasting beauty you sought?
Did you raise one son and one daughter
like your perfect family had to be?
Did they give you a hard time growing?
were you there for them enough?
Is your son like you? handsome rough and tall?
Does he fool around like you did, or did he tie the knot?
Did a daughter’s love transform you
to the man you didn’t know you could be?
Did you find enough courage as she held her knight’s hand
and said goodbye dad?

Are you well my love, do your old bones hurt in the cold?
When you wrap yourself up for a hot cup of tea…
Do you sometimes think of me…back to memories still untold?
Would it have been different? Would it have been at all?
Do you wonder “She must still be the same… Unreal, headstrong?”
Anyways…today here I am fifty nine …. and see you’re already sixty
..somewhere.

The shadow

2010-08-30T20:18:00.000-07:00

It's day 40..he hasn't had a single drink. He can't be certain enough to declare that he' s quit.
Every step, his shadow follows him like it were a deep black pit...Its perfectly framed to engulf him. He treads with care, not to stumble in. You can't see his struggle... you may think he's on a jaunt.
If only you could see his shadow.

Its month 40 ..she hasn't seen him. She can't be sure she's over him. That music brings another memory that she struggles to lock away. She buries it into her shadow that treads close at her feet. She brings smiles wherever she goes, fighting her own tears.
If only you could see her shadow.

The laborer's wife.

2010-08-23T19:34:00.000-07:00

His fingers on the piano work magic.
His music is mesmerizing.
When he plays, you forget about the world.
When he plays, he forgets about you.
You're the pianist's wife.

He's a kind a man. He lives for the world.
He forgets his own when giving to another.
He 'll give his own morsel to the hungry.
And unknowing, he'll give away yours.
You're the philanthropists wife.

He has big dreams and you are in every one of them.
You want to see what he sees and believe in him.
Yet life isn't a dream and you wait for him to wake up
So that someday your own dreams come true.
You're the dreamer's wife.

He labors dawn to dusk
Comes home with some bread
You share it over a bowl of soup and then tidy up.
You both then sit back and watch the moon rise.
Yet you complain you're only a laborer's wife?

Of Knowing and Learning

2010-07-01T18:27:00.000-07:00

The more knowledge one gathers, the easier it should become to stand one’s ground. Yet on expert forums and panels the common answers are “We’re not sure” or “We don’t have great data on that.” There are more "maybe" and "possibly" answers than there are " yes' es" and "no' s." There is more of "I believe that... " than " I know that." It is often frustrating and appears pointless to the audience, that is discomforted by the shaky grounds.
On the other hand though, the more learned we are, the more unassuming we become. What we would prefer to see as black or white, we are now able to place into a spectrum with lots of grey shades in between. We stop denying our gaps in knowledge and embrace them. It excites us to imagine the possibilities, should these missing pieces of information come by. One piece of new information might change the way we know everything else as we know it today. The learned then aren’t just the people who know. They are also the ones that know they don’t.

A heart stabbed, a soul touched.

2010-06-15T20:19:00.000-07:00

We want to 'do it all' to save the lives we can and some of us are fortunate enough to be working in a system that makes it possible. Its challenging but possible to give a patient a 100 of units of blood the same day and not run out of blood in the blood bank. Somewhere in the course of this expensive heroism, we regularly question the goals, expected outcomes of the resuscitation and the likelihood of making it there.
Sometimes, the 'do it all' you feels like an idiot. You just performed a major trauma surgery , administered 50 units of blood, spent 10s of thousands of dollars on a dying 80 year old.The next day, he's your poster-child for a success story until you meet the family and are disillusioned. They place pictures of him in the room...you see a cheerful him sitting on the couch surrounded by family, fishing and golfing with his buddies. In discussion with family you realize he would not have wanted to have a breathing tube, be placed on a ventilator after having lived a very complete life. In discussion with family you withdraw care and rightfully so. However you cant help feel yourself undo everything you just did, and in a very expensive way.
A cynicism sinks in when you've had several of such events in a row. Then all of a sudden is a moment..one that brings the same surge of emotions as when you see a rainbow spring up from nowhere.
He has a gunshot wound that's blown up half his head, and you're trying to figure out of he's alive. Suddenly he holds your hand using the other half of his brain.
You've decided you may have to amputate a dying leg for loss of circulation and inability to restore it. Suddenly it gets a pulse back indicating its got good circulation and now may actually live.
He's had 5 surgeries in 3 days, a 100 units of blood, appears to be heading to muti-organ failure. Yet only a week later he's sitting up, grinning, "Now can I have some water?"
His heart for a few moments was in your hands as you were doing internal cardiac massage through an open chest. You see him holding the hand of the physical therapist, attempting to walk.
You want to be the "do it all" all over again.

The everyday Lie Chart

2010-06-12T21:03:00.001-07:00

Getting a haircut! Is an app for that?

2010-05-15T13:53:00.000-07:00

I'm not scared of a bad haircut, I detest the whole process of getting one. I have a hairstyle that's traditionally "bad haircut proof"..No I'm not bald.. I wear it straight and long like it wants to be.. that way I don't have to get it pruned every 15 days. Whenever eventually I do have to surrender to the salon chair, I'm usually saying something like, "just level it" "just trim it"."just 1/2 an inch..okay fine one" It would be great it if the stylists could do just that and do it without conversation. On the contrary what usually follows is:

"layers or no layers?"
"what the heck....layers"

"short, medium or long?"
"I guess long"

"Straight at the bottom or like a U"
"like a U perhaps?"

"Steep U or shallow U?"
"Shallow me.. oh I mean U"

"Or we can do a V"
"V can do a V?""Why would I want a V" "cant U just do a U?"
"I can do a U"

At this point I've had it, and we're done ..or so i think
Then there's act 2..

" What product do you use..you're hair is so dry."
" No its not, its fine"
"You really should try one of our conditioners on the shelf"
"Oh that one... yes I remember..that's actually is the one I am using everyday"
"Really? your hair doesn't feel like it. You use it everyday?" "You wash it everyday! You blow dry it everyday?! and you use nothing to protect the color from he sun?

By this time my hair is stripped not only of moisture but all self esteem.
"You're sure you're a stylist and not from the Child protection services? "You 're not going it take away for 'hair abuse' are you?"

I'm thinking" What have I done to wrong all the hairstylists in America?" And the answer comes back to me:

Flash back one
Patient: "It's laparoscopic surgery, does it still hurt?"
Me: " Well its surgery, its not a haircut"

Flash back two
Patient: "So the surgery is outpatient, it takes 2 hours, so I should be back in time to feed my cats right?"
Me: That's if everything is straightforward and uncomplicated. You have to make alternative arrangements : You're going for surgery, not a haircut"

Flash back three
Patient: I'm sorry I had to cancel my appointment. My hairstylist only had time that afternoon, and then she's not available for a whole month"
Me: Oh really that's a pitty... because at our clinic if you get a biopsy, you get the a haircut free.

Flash back four
Patient: While you're in there for the appendix doc, could you do some liposuction?
Me: Sure thing, why don't you ask the anesthesiologist at your head to give you a haircut while we're at it!

We're both 28..but I may actually turn 30.

2010-05-08T15:41:00.000-07:00

As a doctor you don't give a person a fatal illness, but you're often the bearer of the bad news. They don't have a potentially fatal condition until you tell them they do. As of that moment they start dying.
There's a way of dealing with elderly patients with such diagnoses.You acknowledge their life experience, you spend time being the listener, you provide reasonable expectations, respect their wishes , keep family members updated, try and provide comfort.
There's a way of dealing with young kids, based on their age and understanding.We all know there's nothing right about a dying child. Those who are good at it, treat the parent as the other patient. Parents need to be reassured they did nothing wrong and you will stand by by them and their child. They need to see that you will leave no stone unturned to give their child the best shot at life, or quality of life.
There must also be a way then, of dealing with someone your own age but what is it?
We're both 28 thinking we have "our whole life" ahead of us. We're both on the way to translating our hard earned degrees into career goals. We both have families that need us around. We're both complaining we're about to turn 30, yet only one us might make it that far. You can empathize but how do you say it? explain it ? defend it?

Can the bars be left open 24 x 7?

2010-05-02T14:24:00.000-07:00

I believe the last people who made that appeal for sake of a better night life, were fined for wasting the Delhi High Court's time. In different parts of the world people have debated whether bars should be open until midnight, 2 am or 4 am. When a new bar opens up near a residential locality, people are worried about its implications on safety, morality etc, perhaps appropriately so.
I think the worry is not about what happens when a bar opens..but what happens when it closes ..everyday. If you open a bar, I say just leave it open. In fact have a whole complex built around it...with a police station, nurses station, cab station, new T-Shirt station (Oh no.. leave the the lawyers office or marriage bureau out)
When the bars close at 2 am here.. there comes a wave into the trauma bay..of stabs, gun shots, motor cycle and car crashes...and the classic.. "beer bottle to the head assault" A lot of scratched and bruised folks..throw up then sober up over the next few hours in the emergency room. If the bars didn't have to close, these guys could just throw up there, slop down there, eventually sober up there..walk to next counters, get their ibuprofen, get the new T shirt, take a cab ride and go home..or wherever.... It really could save a lot of resources!

The soul of the surgery waiting room.

2010-04-25T18:08:00.000-07:00

There's some baggage ,some reading material, ipods and laptops and on a cursory glance it resembles a hotel lobby or airport lounge. These people however are waiting not for a table or flight, but for a piece of news. Some have been praying. Some are having conversations they wont remember but serve well to distract them. Some family members are updated by nurses with messages like "the surgeons have found what was bleeding and have it controlled" and they get busy on the cellphones updating the rest. The moment of truth though, is when the surgeon him/her self walks into the waiting area. Some family members during the wait have probably pictured the conversation you are about to have, in 10 different ways it could play out.. imagining the best and the worst.
The ritual is -you wash up, make sure there's no blood on your clothes or shoes, put on your white coat and go out to the waiting area. As you approach the front desk, you have a sudden audience- some hundred pairs of eyes are looking at you. Sometimes, especially in more emergent operative settings, the surgeons haven't had a chance to meet the family before hand. These family members don't know who they are expecting and so they are all anxiously looking at you wondering if you're the one.
The receptionist calls out for the family you're there for.. " Family of Mr. XYZ ...are you ...." A "Here" or "Yes" usually interrupts the first call itself. As you and the family member step out together towards a private discussion area, you're being silently watched for cues- the slight furrow on you forehead or the twinkle in your eye never said more than they 're saying in that minute.
When you interact with patients and families in the pre-operative setting, they still have a sense of control- they're judging your looks and ways to gauge your knowledge, experience, confidence etc. This time its doesn't matter..you've already done something to their loved one..it better be the right thing..you're about to say how it was..it better sound good. They believe you've done everything you could, it better have been enough.

Stop Nodding!

2010-03-28T19:09:00.000-07:00

Ok.. Indians are made fun of for the "Indian head nod" where the others can't figure out if they are nodding their head in approval or shaking it in disapproval. Atleast that's what they say.. these 2 dimensional thinkers.. distracted by the new discovery of the 3rd dimension.
Whichever way you nod, I don't have a problem with it.. where I do have a problem is when you do it. You nod in response to a question..but provided the question was posed to you in the first place. You've been taught to not answer out of turn. Does that not apply to nodding? You think your head doesn't make a sound when you nod out of turn? Nod in the background?..nod in the field of vision? Think again..
Consider this scenario.. Nodding assistant..Lawyer's office..the lawyer says.."Sue the doctor.. you could have died!" His assistant in the background dutifully nods in approval. Now you're thinking.. Does that nod mean.. yes I could have died? or does it mean I stand a case? Is that nodding assistant making money for the law firm by his power of persuasion? did the nodder have a bad outcome with the same doctor? Is he the doctor's disgruntled ex-employee? Does he get money for nodding? Is he even listening? You didn't come to the lawyers office to get the nodder's opinion..so why doesn't Mr Noisy Bobble-head get it.
Another scenario ..the smart-ass class nodders. Your maths professor says- you arrived at the correct answer, but you could have done in fewer steps had you followed the XYZ method. You're trying to assimilate this XYZ process and then you notice the kids in the first row are nodding. As the teacher explains..the nodding row is staring at him, not taking notes, but looking him straight in the eye nodding.. hoping he'd notice ..that smart-ass bobbleheads already know! The nods are saying " Oh yes thats the right way" "Ofcourse I always use XYZ method" "I'm the smart guy professor" "I'm smarter than that dud professor" And as you can imagine half of these nodders have no idea what the professor is talking about.. but hey! no-one says its dishonest if you're only "lie-nodding"!

White balance

2010-03-11T23:14:00.000-08:00

Most people learn about the concept of white balance, while learning about photography.Most digital cameras come with an auto white balance feature, so I didn't learn about white balance until I held a laparoscope. As you set up your laparoscopic camera for a surgery, you hold it against a clean white lap sponge and hit the WB button. You tell the camera, "this is white in this light environment. So the temperature of light falling on this sponge may make it appear a little yellowish, bluish whatever, but with my human brain.. I'm seeing it as white.. and so show me everything else using that frame of reference" (you can tell I'm no engineer, they must do more than just talk to instruments to make it work)
If you ever introduce the camera into the abdomen without having appropriately white balanced, you simply annoy yourself and everyone else in the room...everything on your monitor looks "more orangey" to your "white balanced self'. For some reason, anytime I witness this chaos I have a distracted moment of fascination about this phenomenon of white balance.
Each of our minds must have a reference framework related to our education, experience, upbringing, philosophy etc, in the light of which we witness everything in our environment..as good or bad...smart or stupid..fun or boring etc. A part of that framework I think of as our internal White Balance..For example, I am 'white balanced' to be disgusted if you smoke in my face. We know these reference frameworks are meant to affect our thoughts and decisions, making each one of us different and unique. However, its a little discomforting to think that this white balance part of it..would affect perception, far before it would affect cognition and decision. From the nature of my white balance am I failing to appreciate some colors in their true shade? Do I reset that white balance from time to time as I grow up? Are the partners I see eye to eye with, able to the same things at all?
Oh and if your monitor screen suddenly looks more red than orange... its not the white balance.. its blood!

To my three sons...

2010-02-28T13:23:00.000-08:00

I have three letters to write to the three of you as I find the strength to grab a pen. Perhaps I will write just one and finally introduce you to each other. This may hurt or annoy you or you may find something to learn from my journey. Whatever it does, in my mind it will bring you closer to the real me.

To my middle one,
Your father and I, coming from similar backgrounds, sharing certain values and goals, we had decided to get married. In out late thirties, neither of us believed in love stories or perfect marriages. Literally we were bored enough living single , that we decided to give marriage a shot. We were drawn to each other since the time we met. A few easy conversations over coffee were all it took. The goal was to keep the conversations over coffee going and that we did. We seemed like the perfect partners at work and at home. We cherished every moment we spent with each other and more so around you. We were there for each other a lot. We achieved big dreams together. He was a good husband and a great dad. In my heart I respected him, in the world I flaunted him, in my last years I truly miss him. You were a lot like him, responsible hard working and balanced. You were ambitious, rebellious and not demonstratively affectionate.. those attributes were mine. We did not see much of you once you moved away to follow your dreams. We could never stop you, as much as we wanted you around. You were like the kite that would soar high if we cut the string. You should have no remorse.. you soared, you made us proud.

To my eldest,
You would be the eldest if you were born. Your father and I were still kids when we met. We had no responsibilities, no sense of worldliness and were simply crazy about each-other. We'd laugh , fight ..and just easily make up. We whiled our time away thinking we still had a lifetime ahead of us. In the midst of all this you were an accident, at least that's what I was convinced to believe. If you were born you would have two parents with no income, no social standing, who would be blaming each other for the rest of their lives.. for a problem called you. For me it was more than just that. As of the moment I saw your heart beating on the ultrasound, my self-image became a blur. I was the now the same person that I gossipped about and pointed fingers at. That moment was also an awakening which had me question every relationship I had with anyone. Your father an I had parents who would not support a decision to bear you, infact would be devastated to hear about you. We lived in a hypocritical society that would subject all of us to a life of condemnation. The same pride our loved ones had for us would be replaced by humiliation. To me all their love and respect suddenly appeared conditional and had depreciated. I longed for no more named relationships than the ones I already had. All this perhaps went into undermining the relationship I had with your father. In spite of what I did to you, if I make it to heaven.. I want to hold you if only once.

To my youngest,
Your father and I came to be great friends, sharing memories of the lives we’d lived. I had lived longer than I had intended to and for the first time in making a friend, I did not care if he smoked or had a reputable job. He perhaps thought along similar lines and we shared an easy, unconditional relationship with no expectations. It was the kind of relationship that in my earlier days I had neither valued nor sought.
I call you my youngest because you came last. Although you were much older when I met you, you were there when I needed a son most. You perhaps missed your mother and I had a lot stored away to give. You were simple, so naïve in fact that if you were my real son I’d be embarrassed. You we affectionate, going out of your way to help those who may not even care to remember you. The world would be a better place if more of us knew how to raise sons like you.

Blood on my feet..

2010-02-15T18:43:00.001-08:00

The one thing I cant stand about being a surgeon is blood stains on my shoes.
I've been given many suggestions...

Have one pair of shoes for the OR, another for the outside...well that works in elective surgery setting.. not when "the patient's hypotensive..where is the surgeon?".." Oh she's changing out from 'pretty' to 'not pretty' shoes" ..And I think if you've left such a pair in your locker for years.. you better be wearing gloves when handling it. (If our species becomes extinct I hope some dinosaur discovers your shoe...It must be like a human DNA library by now..)

There's always time for shoe covers.. yes..but those papery things are good for a drizzle ..not a downpour.. (that has nothing to do with my surgical technique) And they slip ..a student steps over them...and often at the end of the case I'm only wearing one of the pair..and yes I need a pair of gloves to take those off...

Hydrogen peroxide..my favorite chemical reagent ! Thanks to peroxide ..some of our male scrub techs..(who should know better) wear pink shoes... remember ..white canvas + blood.+ peroxide = permanent pink) but it works.. don't use it on suede (actually don't wear suede)

Wear Crocs and wash them..I 'm still trying to figure what genius came up with the idea of making a pair of easy to clean plastic.. that's so comfortable and convenient and decided to put holes it it? ( Are we loosing a lot of blood?.. my socks are wet!)

My favorite is... Shop for a new pair frequently .. the shopping part is fun.. but where do I dispose the old one ? Although the hospital isn't paying to rid my personal trash ..the red biohazard bag is the only right place for it. If I wrap a pair in 4-5 plastic bags and throw it the community trash..I feel like a criminal..and I think some homicide detective is going to find it..or worse some genocide detective..

I could wear bright red shoes and never have to worry about them ..except that with green scrubs I would look like a an upside down parrot or a holly tree!

Price tags

2010-01-23T20:30:00.000-08:00

Customers are bought with discounts,
Employees with perks and raises,
Kids with toys and candy,
Pets with pats and some food.
Votes are bought with promises,
Followers with speeches,
Whores are bought with money,
Wives with commitment.

Hey Rebel

2010-01-10T20:04:00.000-08:00

Those who fear the chaos of free thought write rules..
Those who think they can read your mind write exemptions to these rules..
A revolution takes place because you still think the way you think.

Fidelity for purchase

2010-01-01T14:28:00.000-08:00

If airline miles had asset value, I’d own the tropic of Cancer.
If store rewards came in trophy form, I could fill a shelf.
If brand memberships count, I don’t have a commitment problem.
But then if the Starbucks classification was universal.. I would be tall.

This little piggy went to market..this little piggy went online..

2009-12-27T13:40:00.000-08:00

ABC is 'brrrr ing' I hate the cold..
DEF thinks he's getting old
GHI got a parking ticket
JKL is playing backyard cricket
MNO has burnt her toast
PQR is flying to the coast
STU is trying to study hard
VWX got a silly birthday card
YZA is now really single
BCD loves the Xmas jingle
EFG needs a long vacation
HIJ just got a chilly sensation
KLM spotted a rare bird
NOP indulges in rice and curd
QRS is on cloud nine
TUV says tiramisu is devine
WXY needs to stay sober
ZAB waits for call to be over
CDE hates his neighbour's puppy
FGH says "so mean how could he"
IJK loves her new I phone
LMN is bored- at home alone
OPQ needs a big bear hug
RST has a stomach bug
UVW loves the old facebook better
XYZ cant think of what to twitter

"Thats alright..I've lived a good life"

2009-12-19T18:47:00.000-08:00

He was almost 80 and looked a lot better than his CT scan. My sense of urgency wasn't as contagious as I wished for it to be. I was calling the radiologist, the blood bank, the OR, the ICU and my attending with a lot of "STAT" "please" "Urgent" words amidst puzzled onlookers.
He needed an operation.. his gut was dying...the clotting factors in his blood were depleted to dangerously low levels and is heart was too weak to take a sudden load of a plasma transfusion. In the face of this situation, he looked comfortable.. infact quite cheerful.
I had a long discussion explaining the problem. "If I don't operate on you, you are likely to die from the condition" "I want you to realize that the chances of you dying from the operation and having complications post-op are also very high."
In such situations we occasionally have had patients saying "No matter what, I don't want an operation" and we have to respect such wishes. Something about him assured me he wasn't one of them. Most will say "Do what you think is best for me doctor"..and others look at family members for advice.. My patient didn't have any family...His power of attorney was with an ex..which is one of those awkward situations. "So you think she'll make the best decisions in your interest if you couldn't make them?" " As good as anyone else I guess" he replied.. like he didn't really care.
He asked me, "So you want to cut my belly open and fix me?" "Yes, I think its your only chance of surviving..but I want you to understand the risks involved in the operation" He still didn't seem to care though... I was starting to wonder, "Does this old grandpa get it?" as he chatted on "Wow! female surgeon from India..you should be proud."
My smile was shortened by the thought if his dying gut and as if noticing he said,
"Its alright... I've lived a good life..do what you must."
On this free pass.. we did the surgery..he did well.. the third day on rounds I heard that he had an episode of confusion overnight..didn't listen to the nurses..didn't know where he was.. "Oh no delirium..just what I was worried about". I woke him up.."Good morning.. remember me?" I was relieved as he said.. "Oh yeah! Ofcourse you...you remind me of the maidens of my time..( On no !) your're the belly cutter!"...
Ya right ...that's me ..belly cutter :)

Kilauea

2009-12-13T19:12:00.000-08:00

She reminds me
She thinks for herself
She knows she can have her way
She is mighty and all powerful
She will have her last say

Is she an angry lover
A loving mother
A temptress
An empress
What is the burning desire?

In her fabric of fire
Her golden attire
She burns her own path
Yet she travels it again

Her sheen, her glitter
She gives to the cerulean water
She rages, she cries
She melts, she sighs
Then she does it again
As if to remind.

The Love Eclipse

2009-11-15T20:10:00.000-08:00

Spontaneous, exciting

Addicting, consuming

Enabling, weakening

Self destructing, everlasting

Medical tattoos

2009-11-04T19:34:00.000-08:00

Jewelry can be lifesaving..I'm not talking about the bullet bouncing of a large pendant you wear on your neck. I'm talking about the bracelet that reads" I have hypothyroidism/ hypoglycemia/ seizures / I'm allergic to Penicillin etc" In all these days I haven't seen any patient walk in with one of those.. I guess they aren't in vogue.
What is in fashion here is piercings ... on any and every part possible.. I hadn't imagined that a surgery residency would teach me how to remove a tongue ring.
The other thing that always seems to be trendy is tattoos (I dont know if they are in vogue or not..you don't really change the tattoo with your fall wardrobe) but there is enough tattooed folks around to say its popular. If you walk in with a stab wound to your abdomen... you probably have a large tattooed portrait on your abdomen.I don't know if the correlation between stabs and tattoos is statistically significant but what I do know is -it ruins a piece of art when I make an incision on your midline. When possible we make every effort to realign the design to symmetry when closing the incision..but it isn't always possible.. So I have some suggestions for the folks who get tattoos and then their gunshot and stab wounds..
1. Tattoo the skin over your 2 best forearm veins (when I am in shock find my antecubital veins for IVs right here..)
2. Tattoo the skin over you radial artery for an A line
3. Tattoo the perfect spot on your 2nd intercostal space (when I have a tension pneumothorax please put the dart here)
Or if you want to add a sense of humor you can flash a sign for the EMS ( I dont think your dart is in )

ICU psychosis...a patient condition?

2009-10-29T20:42:00.000-07:00

I they don't come in crazy..we make them crazy. A week in the ICU can play havoc with a patient' neurotransmitters.
The 70 year old appears alright despite the rib fractures...the first conversation is somewhat like this:
P :Hello Mr James, I'm Dr Gadgil, I'm the senior resident looking over the ICU tonight..are you doing alright?
J:Oh Yes..did you say Gad-jill? And (squinting at my badge)..I'm afraid I couldn't pronounce your first name "
P:I'm going to test you on that tomorrow..but for now I want you to work on your breathing.. ..I need to get to 1500cc on your spirometer...you don't want to get a pneumonia..nice slow deep breaths"
3 days later when I'm on call again..
P :Hello Mr James, you may remember me from the day you came in.. I'm Dr Gadgil
J: Gadgil!
(I'm thrilled.. he's not saying Gad-jill..)but then he repeats
J" I'm Dr Gadgil"
P" No Mr James, I'M Dr Gadgil!
J: No....slurrrr...Dr Gadgil !
P: Do you know where you are?
J: Gadgil (I could ask him who shot his neightbour's dog..and he'd give me the same answer)

When I come home after my 30 hour shift in the ICU..I notice I can still hear the beeps of patient pulse-oximeters and vent alarms for an hour or 2 before I fall asleep..This tinnitus I have named "ICU white noise"
Given our patients are sleepless for days in the same environment.. with cocktails of medications..well wishing-ly pushed down their nasogastric tubes and IV s...where 2am and 2 pm aren't that different... it isn't surprising that they would become delirious...and sometimes psychotic.

Tragedy and stupiditiy

2009-10-03T17:20:00.000-07:00

If you've watched "America's funniest home videos", "funniest baby videos", "planet's funniest animal videos" and the like.. you know it. Comedy is tragedy..but happening to someone else. When the somersaulting bike rider lands on the fence and then in the trauma bay..the bleeding broken idiot is usually not funny.
Nevertheless sometimes when the patients tell you their stories it really makes you want to say.."Just what were you thinking?"
A victim of a flash burn says.. "I was trying to light the barbecue..kept trying..finally I just threw some gasoline on it".. Another say's "I was lying in the chair..I was really drunk..drenched in beer and then I lit a cigarette".
A near electrocuted guy complains "I told my kids they cant leave the electric fan plugged in all the time..the bill is too much.. finally today..I sawed through the wire..but the fan was still plugged in"
"I was on the tree ..trimming the branches.. I cut a branch it fell..I was on it"said a 93 year old.
"I was riding on a car..like on the roof of the car....actually no! sitting on the window of the car" ..makes me wonder if the cars need.. "teenager seats"
I found a book called " Death by Stupidity" : The 1001 Most Ridiculous, Bizarre and Astonishingly Idiotic Ways People Have Kicked the Bucket. Its disturbing but we do write ..read.. and enjoy such stories.

When I'm gone

2009-07-07T18:59:00.000-07:00

I will be gone, I have somewhere to be
I will be gone you must forgive me..
I won’t look back, and neither must you
No hurt, no blame, no fight was true..

Why you, why me?.. midst streaming tears
You may question, as you fight your fears
You don’t need a shoulder, you cannot lean
You will follow your fancy, live our dream

The script was written for a you and a me
Now its you alone, playing the part of “we”
If I were there, I’d say what you're thinking I would
I’d be doing just what you know I would.

When you want me you'll find me, and you know how..
You'll sit back and remember some carefree time.
That moment you'll bring back with your smile,
That's where I will rest a while.

Unknown Eddie

2009-05-20T21:02:00.000-07:00

When trauma victims are brought to the ER without government issued IDs..they are registered under temporary names. Unknown Abel..Unknown Bing.....alphabetically until unknown Zen...going back to unknown Adam..and so on..
Unknown Eddie may have regained consciousness and told you his name is Christopher Lee..or his family that arrives tells you he is their son..Krishna Murlidharan...but until someone has a picture ID to show for it..he's Unknown Eddie. When providers are accessing the health information of that patient... its all under the name unknown Eddie...just as if Unknown were his last name. "Have you drawn labs on Unknown Eddie yet?" "Can we look at the X ray of unknown Eddie yet?"..and we learn to match their faces..with these given unknown names...so when the real names do come by, we have to relearn the names.."Discharge Juan Lopez? Who's that?..oh the one who was unknown Eddie..ya..ok ..discharge him."
It happened once that the nurse called me talk to the family of an unknown Eddie.. they had just arrived at the hospital after hearing about the accident ..were inquiring about their son's condition.. As I shook hands with the mother..I said unhesitating,"Are you the mother of unknown Eddie?" She said "who?"a little confused.. I quickly corrected myself...and proceeded to give her the updates she needed..so she probably didn't think much of my blunder..."Are you the mother of unknown Eddie..what was I thinking?" I laughed at myself.
There is no humor though..as the mysteries of the unknowns unfold amidst the chaos of the trauma bay..it only gets tougher as you come to know ..
that the two Unknown patients who survived their gun shot wounds ..actually shot each other...one killed the other's family ..and the other doesn't know they're dead.
..Or that unknown Kelly lying on the stretcher next to the dying unknown Jim is his wife ..and now his widow.
..Or that the unknown unidentifiable pedestrian struck by a car on his evening jog..who we couldn't save despite all effort ..was actually our own beloved ER physician.

Matrimon-hilarity

2009-04-02T21:00:00.000-07:00

I myself..STOP start again
I’m a simple……….. Ok you are a guy.. you are simple whether you know it or not.
I’m a Green card holder…like a pocket folder, letter holder, desktop organizer?
I’m a modern …so you’d marry a widow? Consider adoption instead of IVF?
I’m a forward minded …smoker? atleast one ex-girlfriend? boyfriend?
I’m a handsome.. and who’s picture was that?

looking for a good natured, very fair slim girl with good family values.
(Barbie doll in a saree with hands joined in a “namaste” )
who is flexible and very accommodative .. (you’re sure you don’t want a haversack?)..
who’s homely (Barbie is at home when I’m home) but has a career (just so she’s not “jaanu you love me na” 24x7)
who is smart, educated (barbie is programmed for filing tax returns)
Anything else?… “No.. I said… I’m a simple”

Elevator conversations

2009-03-12T18:59:00.000-07:00

The first two people getting onto the elevator occupy will usually occupy 2 corners..the 3rd and 4th occupy the two remaining corners..the 5th stands in the middle. Not knowing where else to look ..all five people start looking at the floor numbers as they flash by on ride up. When one person gets off, the middle guy takes up the safety of the corner thats now vacant. Thats typical elevator body language.. by the book.
Then there are elevator conversations. People who would pass eachother without a glance when walking in the hallways are forced to acknowledge eachother by the confines of the elevator.
You may smile, nod, say 'hey' ..and then go back to looking at the numbers.
If you're riding up together at 6 in the morning ..you each probably have a coffee in your hand and its a weather conversation like "ooh its freezing outside"
If its mid day..really busy.." these elevators take forever"..your going from floor 2 to 12..and frowning at those who get on at 4 get off at 5 and get on at 9 to take off at 10. "Why can't some people walk up a flight?"
If its mid day and not so busy, someone's saying " long day huh?" "Yeah....." "Is it friday yet? "
"Hey Hold it" someone yells and sombody inside the elevator sticks their hand between closing doors..We dont trust friends and family in the world today ..but think electronic doors will never fail us. Someone recounts a story of how XYZ once lost his fingers in a closing elevator door. Someone jokes... the medicine doctor sticks his hand to stop the closing door..the surgeon sticks his head.
Then there's elevator conversations you dont want to have..
"Acchoo" " Allergies?" " No..the flu and its killing me..acchoo"
Or somthing like
" Someone looks excited" " Ya I just got released" "from the hospital? " " No ..from jail"..
You start looking at the numbers as they flash by..agonizingly slow.

Its not always about saving a life

2009-02-05T08:11:00.000-08:00

Heroic measures were underway to save a life- A patient stabbed in the chest. It took a trip to the operating room..blood products.. pressors...and a lot of critical care monitoring before we were perhaps caught up ..and maybe this patient had a chance of making it ..if we kept going. When patients are brought in to the trauma bay..the doctors don't know much about them..they do what they think is in the patients best interest.
On meeting the family, a different story was revealed..He was an 80 yrd old...suffering from a terminal condition. He had signed orders for a "do not resuscitate" or DNR order..so in the event of a cardiac /respiratory arrest..he would not want to be shocked ,administered life saving drugs ..would not want to be placed on a ventilator. In short he did not want his life to be saved. Further , he did not want to die in the hospital in his last days of his terminal illness..So he had stabbed himself.
After discussion with family , medico-legal advisors we made a decision for " comfort care only" i.e the patient would be placed on a morphine drip for pain control and allowed to die peacefully. It was the right thing to do. Its not what you do for all suicide victims because usually they do what they do..in an altered state of mind..and regret it later. But this patient had clearly documented wishes in a competent state. It was unfortunate that he had to take the step of painfully stabbing himself.
In the first 4 hours of caring for the patient, I was anxious to stay on top of the resuscitation.and once the decision was made to withdraw care, I began to hope we hadn't done too much.. I prayed that after he had gone through the pain of filling paperwork..and then the pain of stabbing himself...he wouldn't wake up in a brief moment to realize that he was infact dying in the hospital.I prayed he'd die quickly..he did.

Tumors do grow on holidays.

2008-12-24T18:30:00.000-08:00

The hospital is usually be the last place anyone would want to be around Christmas. Half of the operating room staff is away..we can only run so many operating rooms.. You may drink 'n drive .. get your fractures fixed... but your tumors can wait out a few weeks.
Elective hernias and gallbladders go, "Doc can we do this in the second week of Jan?" "Ya.. Sure"
Then there is the discharges based on emotional needs "I'm not a 100% better but I need to be home for the holidays, doc..you do understand..."
The screening mammography and colonoscopy clinics have an extraordinary rate of "No shows." ...What if you find you have a worrisome diagnosis just before the holidays?
So far..still fair.

Going down the elevator I met an elderly patient in his wheelchair, being assisted with his discharge to home..
"Merry Christmas ! You get to go home on Christams eve"
" Well I'm not so excited doc, I'm going to an empty home.. except for my two parrots..that reminds me I also need to get the bird- food"..... "I wonder if I'll even find a ride before the stores close"
" Your parrots will be happy ...celebrate..give them your breakfast cereal with all the nuts instead...you have that at home."
"Yes doc..better that ..than to be here"

Come Christmas day and..there come the trauma emergencies...
Travelers in road traffic accidents..
Domestic violence from unaccustomed clustering of families
Self inflicted gunshots and stab wounds..saying" I was lonely on Christmas day"

It was our first day of surgery clinic after the holidays. "That wound looks great..you're doing a fine job taking care of it." I said. "Thanks doc, thats some good news... in a long time" "What did you do for the holidays doc?" "Not much I was working..the hospital was still quite busy..people do fall sick on holidays."
"Yes doc, I lost my mother on Christmas day..she died in her sleep rather peacefully" "I'm sorry to hear that..holidays are the worst time for such bad news..everybody around is smiling expecting you to do the same in return..you feel guilty whether you smile or not..must've have been hard." "You hit the nail on the head doc ! ..thats exactly what!" He was almost ecstatic. As I was putting away the dressing supplies I said.."I have a theory .. I think tumors still grow on holidays" "I think you're right...they must be"

Material girl..

2008-11-25T18:46:00.000-08:00

Fine..you needed a daily wear diamond
Did you have to pick the one tagged “get the relationship free!”

You picked the pretty pointy shoes to flaunt at your wedding party
For the long walk you got the non-abrasive back up guy?

You spent a fortune on a wedding dress and felt sorry you’ll never wear it again
Now if you had your second chance, you’re still buying a new one !

Your doctor robot'cised

2008-11-11T13:03:00.000-08:00

Seeing the the RP-7 Remote Presence Robotic System at the hospital I'm rotating through.. I'm looking for situations to justify the 120,000- 200,000 $ cost.
Situation one... You're in the hospital bed..in the middle of the night you develop a bizzare rash, swelling..or your surgical incision just doesn't look right. Your nurse looks at it..and debates whether to call your doctor in the middle of the night or to simply wait until morning.
Situation two... Your regular doctor is at a conference in Hawaii..his faithful partner is pondering over your condition...the complicating fact is that this new doc has never seen you before.
Situation three.. (you don't witness this one).. you're kind of dying in the ICU...a team of doctors hovering over you..but the boss is missing.. he's on the phone..the numbers from the beeping monitors and emergent lab slips are being read off to him. He wishes he could be there in that moment.
Solution of the 21st century..your doctor's robot just walks in...a virtual visit almost real. Thank God your doctor carries his laptop wherever he goes..and there's always a Starbucks cafe around where he logs in remotely.. He sees you on webcam..accesses your data from the hospital's electronic records. The robot you see in your room is his proxy ...you see eachother on the monitors..talk to eachother just as you otherwise would ..the one thing he cant do perhaps is touch you. But he gives directions to your care..writes orders..and moves on to grab the coffee..catch his flight..or rolls back to sleep..whatever.

Beyond Knowing

2008-10-04T07:46:00.000-07:00

I might have not thought much about my meeting with a 94 year old patient..if I hadn't recently read Janis Amatuzio's book "Beyond Knowing" As a forensic pathologist, Dr. Amatuzio's position seemed strategic.. witnessing descriptions of interactions between the living and the dead. The beauty of the book is ..the experiences are not dramatic..they are believable..infact they are routine....subtle...beautiful.

She was a 94 year old tiny lady , visiting the clinic by herself to address a small surgical problem. I had done reviewing her history, done my physical exam and was waiting to discuss the case with my attending. Meanwhile we talked about her family ..then my family ...we talked about the the lady who helped with her housework once a week.. her pretty black canes with the golden handles. My little lady was calm, smiled little..but was happy to talk.."When you're old.. there's not too many people you can talk to..without sounding like you're complaining" "You get lonely..most of the friends who can just listen ..are dead"
As I was leaving her room..I thought we'd talked about everything possible..but I stopped. " I'm sorry I didn't ask before..why did you have the hysterectomy? And did you have any problems during the operation?"
"Oh! that was 40 years ago" she replied.."Yes I almost died..there was major bleeding.. they almost lost me..the operating room was thrown into chaos, 8-10 people were running around..in and out of the OR..the surgeons were trying to do all kinds of things to my body to bring me back"... "AND I WAS WATCHING"
Having recently read the book... I stopped and listened.. as she continued "I sort of had an out of body experience" She wasn't excited, she wasn't looking at me for a reaction..she was as matter-of-fact as she'd been through the rest of the conversation.
"In that little time.. I was somewhere high up in the sky ..holding hands with my mother-in- law..who loved me so much. We were happy, smiling and prancing around..there was no pain..it was beautiful.. And I looked back at my body from outside... the next thing I knew I was back in it.. and I felt pain again." She went on to say.."Two weeks later I recovered, my husband was driving me home and I asked to stop by my mother in law's house .... I wanted to tell her what happened."
I interrupted her, "So your mother-in-law who you saw ..was alive when all this happened?" "Yes..but my husband said..lets not bother her so late..you get some rest..let's see her in the morning" ...And you know what..she died that very night before I could meet her" She continued, "My mother in law loved me a lot ..trusted me to take care of her...more than she did her daughters. God has been kind to me... it meant a lot for me to know.......she was going to be ok"

Sworn to silver

2008-08-25T17:28:00.001-07:00

One quick flawless operation.. a predictable outcome ...a patient that transforms back to a healthy being..a surgeon that flirts with a gold medal moment.
One struggling attempt for another struggling life... a surgery in hope of buying time..or perhaps just easing the pain...a surgeon that plays knowing...the game is for the bronze.
Most days its neither bronze nor gold. ...you know you've done it....but you wish there wasn't as much of a blood loss..wish you had better tissue to work with..wish you hadn't taken that long ....wish you knew all the answers. You grasp on tight to that medal...you call it silver.

Reality

2008-07-28T15:24:00.000-07:00

Ask reality where she lives
She'll say ...somewhere in between

Between impossible and easy
Between forever and the end
Between an idea and its contradiction
Between the heard and the said

She's caught inbetween..

Between its my fault and its yours
Between I dont care and I do
Between I cant do it and I wont
Between I mean it and I dont

She is
Between the understood and that not yet
Between where you think she is.. and where you think she aint.

Humbling highs

2008-07-19T19:54:00.000-07:00

I was flying on short notice in the middle of the day from San Antonio to Waco on little jet.
Arriving at the hospital there...
Its a familiar scenario.. the operating room, the surgeons, scrub techs....but it feels wierd when...
You haven't met the person you will operate on..
You wont run into his/her family after the surgery...
The anesthesiologist has left the room while the surgeon's still finishing up..
The surgery is sucessful..but the patient is dead...
I guess thats why they don't call it a surgery..they call it an organ harvest .....2 kidneys...the pancreas...the heart.. 2 lungs..the liver..... the end of one life..a new beginning for six.

Cheers to life...to life.. and to life!

2008-07-10T16:57:00.000-07:00

Our thoracic surgery clinic celebrates survivorship of patients who are disease free 2 years aftter resection of esophageal cancer. They're given a bottle of champagne with a set of glasses. One such 67 yr old cancer survivor I met, was a survivor in several respects. At the age of 17, he had a car crash that had him land up with a tracheostomy. In his 20s he had a rollover accident which gave him a craniotiotomy. He went on to describe that at age 35 his truck had a collision with a train, and had almost bled to deathl. "Just how do you manage to do that?" I asked him,"A car crash, a rollover ...a train collision..are you trying to have a race with God?" " No," he replied " I drive him in my car."

Would you rather be a snake?

2008-06-16T16:56:00.000-07:00

In any service industry customer satisfaction is important, and the health industry is no exception..yet you can’t please everyone. There are crazy people, unpleasant people and absolute jerks everywhere.. and so they are abundant in the patient population too.. All doctors wish they could manage the disease without dealing with the craziness. Make the exception of psychiatrists here… they get paid for that part. Their notes are quite entertaining---the patient says he has lived a hard life and explains “If Jesus were to slap me, I’d nail him back to the cross” …so you see mortals like us can’t fight that. Our plan with patients of this group is “restart all home medications (mood stabilizers/ psychotropics etc) and discharge home as soon as possible.”
Oh yes.. you don’t have to be crazy to be a difficult patient…. sometimes you just have to be in the hospital sick bed long enough. There is a very rational dimension to those mood swings, temper tantrums, attention seeking behaviours…Healthcare workers are supposedly trained to take that deep breath, take the "I undertstand stance"....they're taught that its never personal... but all too often, we decide that there's only so much one can take...Now if you are a senior resident, you tell your intern “ From tomorrow that’s your private patient” If you’re a nurse, you go overboard documenting how many times you tried to explain…and then ask the charge for a patient reassignment. ...But If you've seen that adventurous nature biologist on the National Geographic Channel..that guy that is bitten by the snake whose habitat he's trying to protect...Ya, that macho guy who after catching the snake should be saying..."..Got you brat! ..I'll kill you! "... That guy goes, “see this poor little thing..I can tell it's stressed.” ..ever wonder how he knows that its part of the job?

What you want to hear...

2008-06-02T11:24:00.000-07:00

As I headed to get a cab back from the airport, I was happy to be greeted by a cheerful woman in her late 40s. She asked me where I worked, what I did and then said " I get you're a surgeon, but do you know something about heart attacks?" She then went on to say that her mother had died of what appeared to be a heart problem, and she had never been at peace with herself since..as she did not quite understand the circumstances of her mothers death. She spoke hurriedly making sure I understood the details before I reached my destination. As I pictured, her mother had suffered a silent heart attack and passed away peacefully, but abruptly...leaving her daughter to ponder about what she might have done differently. She had taken her mother out for dinner the previous night and the cold had caused her to shiver. She wondered if that may have caused strain to her heart. She also stated that the doctor had changed some medication 3 weeks before her death and whether that may have been a contributing factor. She also asked why the paramedics didn't allow her to give water to her mother. I provided her all the explanations she requested. I hoped to make her realize that she didn't need blame herself, her docs, her paramedics or anyone.. I went far enough to say that I would wish for a death like her mother's. We waited at my doorstep for another 15 minutes..she seemed much relieved ..she said, "You know doc, you're telling me exactly the things I want to hear" I realized that I was and it was an opportunity that I didn't often have. In our day to day life, we often wish we could say " No its not cancer" .." Yes, you're going to recover a 100 %" but all we can say is the truth as we see it.
So this particular conversation was a luxury in a long time....She stopped me as I turned to ask this one last question," So do you think she is looking after me from wherever she is?" I didn't know why she would ask me such a question....but then it was her day to hear what she wanted to hear.

Descriptions of truth

2008-05-17T15:05:00.000-07:00

Let a point of truth be represented by a finite point in a 3 dimensional space. Every attempt to describe the truth would be like a vector supposedly aimed towards it. Some vectors would pass near it, some far from it, and some would probably touch it.
For a moment now think that the truth is probably not a point, but a segment of finite length in this space, because no vector that would touch it, can actually encompass it, except an ideally placed one. Arguments then would be represented by opposing vectors that all actually run parallel to this truth segment, seeing it but from a distance. Once again no ideal vector is actually the truth, it is only an attempt to describe it. So truth then must be more complex than that, like a part of a plane in this space. The descriptions of the truth then would be infinite lines trying to describe it.. sometimes running parallel to it, sometime part of it, sometimes intersecting it and making at one point an illusion of knowing it.

An enforced heroism

2008-05-11T12:43:00.000-07:00

Whe young couples think they are ready to have kids, they are infact only ready to have perfectly normal kids. At the point you think you can make room in your life for a newborn, you are still thinking of a baby that in a few seconds, will breathe fresh air without needing a ventilator... will go to the newborn nursery and not be whisked away to emergent surgery ...will not need special nursing, special schooling.........A normal life is what most of us have taken for granted.
Every rotation on pediatric surgery, makes me question this wisdom. If you think normal childbirth is a stress on your marriage, career, all your mental, physical and financial resources, a variation of normal might be catastrophic...Will the relationship you take so much for granted.. survive it? will your career ammbitions live through it? Of thousands of young parents,some even in early 20s , life expects a heroism that wasn't called for. It is amazing how these parents perform through these testing times..times that sometimes last their life time and sometimes the child's...
I salute the heroism of those who didn't dream of being heroes.

stepping into the patients shoes.

2008-05-07T19:10:00.000-07:00

Dehydration with food poisoning wasn't a pleasant experience, but it did give me a view of life from the hospital sickbed. I wasn't exactly the king who disguises and walks barefoot in his kingdom to know the plight of his people. I wasn't disguised at all... still wearing my scrubs, my white coat.and ya my face...which only looked like I was post call squared. Infact I was dressed appropriately to get priority treatment and I even used the backdoors to get to the registration desk.
So as I sat slumped in a chair filling out irrelevant stuff like consent to have phone calls, language fluency etc, a physician assistant in the ER came up to me, looked at my badge and said" You general surgery ! " I was waiting to hear something like.."Oh what happened to you" but instead he said..."Oh I was looking for orthopedic surgery " I thought..What was he thinking...do I look like a doctor to you ? So ya I wasn't dressed for the occasion. But then as if my prayers were answered, I was given a gown..the ones that are backless with strings. ( Oh when I have my own hospital its going to be velcro with appropriate approximation of edges ) So everytime I needed to get up, I had to put my white coat back on. So it was scrub pants..string gown..white coat..the IV pole in hand..now I looked so much better !
Inspite of my demanding self, I was of very non assertive disposition that night. So when the nurse asked me" doc where would you like me to place your IV?" , and the ER guy asked me whether I would agree to a CT scan..I mostly answered " whatever" though I felt like screaming "for once stop asking me questions, I dont want to think"..(and its not because this time I'm not the one getting paid for it)..You see when you are a patient, you can scream and yell and get away with it..in my case I didn't have that kinda liberty..I'd have to hear about that doctor -patient story for the next 4 years. And infact I wanted to be least noticed out there..infact I thought it was embarrasing to go to the ER for a non surgical condition.. I know dehydration can be serious, but I think its somehow humiliating for a surgeon.
This 6' x 4' feet ER space had housed a surgery resident's bed had become the VIP suite equivalent. I was given extra blankets right out of the warmer, the ER's cordless phone so that my chief resident could be updated about my condition (so the call schedule could be changed for the day) And infact the next morning when I was rehydrated and ready to leave I was also given a work excuse for 4 days! (seemed like a free spa session with the luxury suite package ) At that point I laughed.. I was back to life, I had the fluids that I needed on board, I had stopped vomiting..(my appendix was still in place)...and a 4 day work excuse? I was back to work next day.

free

2008-05-01T20:07:00.000-07:00

A goldfish in a bowl…. a dolphin in the sea
A canary in a cage… a dove in a tree
A girl that’s her.... and one that’s me.

I can write a book.

2008-04-24T22:45:00.001-07:00

After reading what Ellen Degeneres had to say in her second published book "the funny thing is".. I think one day I want to write a book..I realise you don't need grammar, vocabulary and infact not even matter! What you need is a sense of flow to whatever non- matter you are writing.But Ellen has an advantage..you read it with a bias assuming its going to be funny.. If I were to do it Ellen style (writing the book I mean), here's the preface:

Anybody can write a blog.. you believe you've delivered to the world, all the crap nobody sitting next to you would listen to. Writing a book though would be different.. elite, glorifying..bring a sense of accomplishment...the person sitting next to you would ask for an autographed copy. Wring a real book is awesome.. I mean a book is published, people are fooled into spending, thinking they'll buy wisdom...and the paper its written on can be recycled...thank God they don't need to cut trees everytime you use microsoft word.
The question is, what should I write about? I guess I could write about an amazing discovery related to the medical world..but for that I would have to make one. I could write about someone else's discovery but then I would be a writer , not a doctor..oh I forgot that was the whole point !
Discoveries in medicine should not be so hard. You take a known truth, prove it false, and there you go. Its a milestone in evidence based medicine...(atleast until someone else proves you wrong) I could discover that your 81 mg of baby Aspirin a day is actually bad..or lets say Horrible (thats how writers write) for your heart ..by the way, have you ever thought what is it about 81 mg that baby aspirin couldn't have been 80 mg? So coming back to the point..say I discovered that your baby aspirin is bad for your heart..wrote a book..sold a million copies (lets say 1 million and 27 to keep it realistic)..Can you imagine the number of people that would get heart attacks from just reading the book? That my friend, would not be consistent with my altruistic idea of writing a book....The real problem with medical literature though is that..if you write one small paper in medicine ..its followed by four pages of criticism for inadequate data, incomplete review of literature, a thousand kinds of biases (is that how you spell it)..and the worst thing is these critics unlike regular critics are doctors..so not only do they know the right road but they also know how to drive the car ! So I think writing a book anywhere related to medicine is a bad idea.
I could write an autobiography...Its funny how that will make everything in your life appear legitimate and well placed..just because its on paper. Unlike real life, you have a great deal of control over your written life... you can go great lengths to describe how shattered your neighbor was when her dog died...you don't even have to mention that it was You who killed the dog. Don't you think I could get paid more for this manipulation..if this were somebody else's biography..but I could never spend a precious lifetime researching into somebody else's life..especially not someone who is dead. (Its like you pronounce someone dead ..walk back to their room and start asking about their birthplace)
I'm well 4 paragraphs into this preface and I don't know what my book is going to be about. Didn't I say that's was what I was talking about? And you're still left with this uncomfortable incompleteness and want me to finish the book?

How Doctors Think

2008-04-23T13:00:00.000-07:00

I had the opportunity interact with Jerome Groopman, author of "How doctors think" during a webinar arranged for the university students. He talks about mainly three pitfalls in the way we think, leading to missed diagnoses... citing them as the three As. These three A s work as shortcuts in a world of 15 minute clinic visits, overloaded emergency rooms, where doctors are pressed for time. He says they serve us well almost 85 % of the time, but a doctor's job demands a higher accuracy than that.
His 3 As:
Anchoring: holding onto and moving on from the first piece of significant information we find. We then make a presumptive diagnosis, registering the pieces that fit and discounting other findings that don't.
Availability: recent experiences leading us to pick most available of diagnoses. eg labeling every cough as flu during flu season
Attribution: labeling all findings to one known fact or diagnosis. eg attributing a disheveled appearance and abnormal gait to alcoholism.

It seems to me that learning the above thought mechanisms is vital to form a logical diagnosis, to avoid drowning in a sea of information. Looking at where a diagnosis may have been missed one can trace back to these processes, but I think they are the equivalent of "scene of crime" rather than the crime itself.
What's important though, is to look at what one might do to avoid these errors. Dr. Groopman says.."Listen to the patient" most doctors start with open ended questions like "how are you doing?" , but interrupt the patient within 18 sec of the patient having said anything. He says "as you formulate your diagnosis, ask yourself - what else may be wrong? Could there be two different things going wrong? -Is there anything in the exam , tests etc that doesn't fit? Agreed that these questions serve us all well, and we do use them all the time..however in situations like polytrauma, multisystemic failure or other surgical emergencies though, we're dealing with a different set of questions, more like "what could kill him in minutes" or "what can wait the hour?" sometimes the "what" stares at us..like an exsanguinating limb or intracranial hemorrhage on a CT scan" but sometimes the "what" that kills the patient sneaks by amidst the chaos, while we aren't watching...perhaps at the same 3 locales we mentioned..but the time we have to look at them seems only the time of retrospection.
We all hate the missed diagnoses.. we label them "the masqueraders". The angina that looked like heartburn...yes but to whom? to the patient? to the nurse ? to the doctor? to the umpteenth doctor? Is the masquerader wearing a mask..or is someone wearing blinders?

"frontage road driver"

2008-04-12T14:37:00.000-07:00

Frontage roads that parallel the freeway are peculiar to Texas, although they can be found in other states. Not only are they feeders to the freeway but they also enable U-turns or turnarounds over or under the freeway, making the drive quite convenient..not to mention forgiving.. to drivers who are headed in the wrong direction or those who missed their exit.
My habit of preferentially driving on the the frontage road started with the intimidation from highway speed limits,at a time when I was still getting over my left-right disorientation. Although I can now zoom away on the freeway, I peculiarly remain loyal to these frontage roads. Mornings when I go to work, evenings when I go shopping, as long as I'm not going too far.. I find myself taking the frontage road. There's a few more habits that complete this syndrome of the frontage road driver...when I make it past three consecutive green lights, I feel relieved when I have to stop on red at the fourth...and then I can drink my coffee. If one of my favorite songs is playing on the radio as I'm about to step out of the car, I wait in the car till the song ends, telling myself its ok..since I made it past the first three traffic lights on a green.
If people who break speed limits are aggressive, this behaviour qualifies to be called passive aggressive..you can't make me drive faster than I want to..you cant make me feel bad by putting a stop light. ..so seems like making an assertion of wielding control. Enjoying your coffee at a red light may seem like optimism, but not taking the highway when you can, is certainly not opportunistic. All in all, its being a "frontage road driver".

Women in surgery

2008-04-09T17:25:00.000-07:00

It was short but interesting discussion this afternoon. I was on a panel for "Women in Surgery" arranged by the medical school's surgical society for students. I was surprised to see that there was equal representation from the married and the single women. I thought most of women in surgery were either never married or divorced at least once.
The women shared their experiences on how their dating life was complicated: guys were often intimidated by the girls who had stronger educational qualifications and perhaps more earning potential ... soon enough, dating the smart girl wasn't the coolest idea. I think its not so much "the smart girl" than the "I dont need you" girl that any guy would stay away from.. My advice would be- You may perform a closed reduction of a dislocated hip when you are at work..but when you come home you can still ask him to open the jars!
I envy guys in our residency ..(the ones that aren't divorced, have kids and have wives at home taking care of the kids) When they are working, they can put their heart into their work, they know the kids are getting fed and don't have to worry about their homework. What do the married female surgeons do? Surprisingly the same ! Some women have have found a species of men called the "supportive husband". One who takes care of the home when she's away, occasionally brings her lunch when she's on call and when she throws a tantrum on a day post call says" Its ok dear ! you're in residency I understand" I was a little skeptical about this species when there was another revelation....the wives are pretty sure that this supportive husband species is also monogamous!
Anyways what did I have to say on a panel like that? Here's what...
When and why would women choose a career in surgery? Only if they can't see themselves do anything else. If you can see yourself do ENT or surgery, pick ENT. If you can do family practice or surgery, do family practice. If you cant get yourself to like anything else as much as you love surgery, then you're decision is made...because surgery gives you nothing other than surgery. And to someone who loves just that, its all that matters.
When you make that decision, make yourself another promise: And its not" I won't give up or I wont quit" ... Its " I won't be stuck" Work till the day you love what you do..if you find you got your priorities wrong, you're miserable, you hate this life.. stop ! If you'd rather be a singer, go for it..have a back up plan if you must. But when you work as a surgeon, work because you love your job..be professional ..be good..no one will discriminate against you if you are the best they have ! The next most important thing is..love yourself...love being a woman. You are in your scrubs most days, but If you want to dress up for Mondays conference, go shopping on Sunday ! if you want to get your manicure and perm on the weekend, go for it..dont worry that you have to cut your nails come Tuesday's OR, and your hair isn't going to be seen under the scrub cap !

Make up !

2008-03-20T20:11:00.000-07:00

Its annoying or amusing..but no denying that there's something crazy about women and make-up.

I had a thirty something woman come to the ER with abdominal pain. As I interviewed and examined her I could tell she was in significant distress. I made arrangements for her to be admitted to the hospital and when I was back to tell her about the plan of care...... I see her open her purse, reapply her lipstick while her knees are still curled up to her belly from the pain !

Then we had a 50 something woman present to the OR for her elective scheduled surgery with bright pink freshly painted toes and lipstick to match..DId she not know that she was going to wear a breathing tube down her throat? I mean what all does the anesthesiologist have to watch out for..be careful not to smudge the lipstick ?

My favourite was this one lady who had tattoed eyeliner and eyebrow makeup...every morning 5 am you walked into her room..she looked all dressed up for the party..except that she'd been in a coma for the last 2 months !

Loving a broken heart.

2008-03-10T16:05:00.000-07:00

Like the door left ajar but not quite open,
You may read his thoughts, but his minds unspoken.

His smile’s a little short of what it might have been
His laughs so willful, his hurt’s unseen.

His glance lasts a moment, but feels like a stare,
Stolen away so fast, unwilling to share.

A heart that loves so easy, true and pure
A mind that warns again, don’t be so sure.

He’s imprisoned himself, so you can’t be let in.
If you found the key, is he truly within?

When she left, she took a part of him with her.
He doesn’t believe it, you cant make him either.

You can’t promise a tomorrow free of hurt and sorrow,
If you did, he doesn’t believe in promises or tomorrow.

One day you think the long yesterday would be over.
Or will it be forever for this heartbroken lover…

The Whirlwind

2008-03-10T15:51:00.000-07:00

Swept off the ground by a fine summer breeze
Two leaves off two different trees….
The whirling wind drove them closer
Together they rose higher and higher…

Ecstatic to reach the skies unseen…
The world was like it had never been
Would this journey go on forever?

The dust soon settled and the whirlwind died
Heard by none, the two leaves cried
Drifted down two different streams
What about those hundred dreams?
Would they meet again in a river..
Should forever unfold to be never?

Dangerous noodles !

2008-03-02T11:19:00.000-08:00

If you thought Noodles was a 2 minute deal, a child's play and a safe quick-fix , think again. The number of kids I've seen suffer extensive burns from boiling noodles, makes me think all the noodle packs must carry a safety instruction "prepare under adult supervision only"
It isn't hard to picture a 5 year old reaching for a heated "Cup O noodles" from the microwave a little over his head. Or a 2 year old spilling and spluttering boiling hot noodles from his bowl.
I love Maggi noodles and I can thrive on it forever...but if I have kids, they are not making their own noodles!

The Chaplain and I

2008-02-21T17:17:00.000-08:00

We were both in the pre-operative patient holding area, talking to two different patients ready to go to the operating room.
I: I'd like to go over your consent form with you..
Chaplain: Would you like to listen to some scriptures and pray before you go to your surgery?
I: the diagnosis is ..... the procedure we will perfrom is .....and the surgeons are...
Chaplain: May God give strength to you, the surgeons and all others on the team
I: Anytime you undergo a major procedure, there is risk of stroke, heart attacks and even death.
Chaplain: and He will save you and be with you...

One of us had facts..or did both of us?
and the other had faith...or did both of us?
As I elaborate on a possible complication, I invariably find myself adding on to say " It doesn't happen all the time, its a rare complication..but I don't want you to be surprised if you land up with a bigger incision or with tubes and drains" As I say all this, I am optimistic and confident that none of this will happen..in my mind I am perhaps praying too...and I want the patient to trust that everything will be alright..only I don't have the Chaplains words and Biblical evidence to say that, I have to make believe it has to do with a surgeons experience and skill.
The chaplain perhaps doesn't know what all can go wrong and he's still reassuring, praying that may all be well.

A surgeons skill and confidence, a patients vulnerability and faith , the chaplain's soothing reassurance were all intertwined to form a wreath of spiritual humility that is hard to witness in a hurried passing moment.

But the elephant got here first !

2008-02-13T17:27:00.000-08:00

When the serving sizes of the sodas and burgers increased, plus sizes became available in branded clothings. Lean diets, weight loss programs, bariatric surgeons to help loose weight, plastic surgeons for body recontouring...when all these adaptations were coming into effect, why did nobody make CT scanners that could scan the superXL size?
On several occasions I have run into patients that cannot get an emergent abdominal CT scan...its not because the scanner table cant hold 500 lbs, they just cant go through the scanner without getting stuck in the donut !
On more than one occasion I've heard disturbing rumors that these patients can be sent to Sea- World or the San Antonio zoo to get scanned on the animal CT scanners. One of the radiology techs innocently called the zoo the other day. She was told they didn't have any CT scanners for the animals. I dont know what to believe...if they have them there ie if such scanner exist, ..we would have one in our hopital by now. "What do they do when the whale has vertigo? or the Grizly has mental status changes?"
The truth still evades me..but somebody please make a CT scanner for humans ..one with a bigger donut.

The trauma of trauma

2008-01-31T19:21:00.000-08:00

There lived a princess in a castle. When she opened her window, she'd see children playing in the park, birds chirping in the trees and squirrels running in the grass. Then one day a window on the other side of the castle flung open. Now she could see a much darker side of life, which she knew always existed but never knew as close.
Seeing stab wounds, gunshot injuries, stories of hurt, abuse, gruesome accidents on the trauma rotation, wants me to shut that window. Then I realize I'm no longer indoors. In a world parallel to that of doctors, paramedics, police and military are people with more choices. They watch the news, remark that the world can be a harsh place .. then switch to the entertainment channel, have dinner and go to bed. They have a window to the dark side that they can shut. When they shut that window though, they know that there is someone in the field dousing the flames, fighting the enemy , stopping the bleeding and relieving the pain. Someone is awake so that someone can sleep.

The gut feeling

2008-01-16T16:13:00.000-08:00

Its happened to all of us.. in the last few minutes of the exam session.. we scratch out the right answer and mark the wrong one. The first answer that surfaces to your mind is often the right one...and as you think and reason with logical steps..you land up somewhere else.
Debates conducted during inter-school competitions baffled me..the ones that ask you to speak "for" or "against" a proposition without considering your opinion...which implies that logic presented in a direction can be leading or misleading...so you can reason to defend all those wrong answers ..one way or the other.
The right answer however "surfaces" from a place where all knowledge exists..I feel that somewhere at a subconscious level..there is all knowing...knowledge unadulterated by thought. The right answer comes from a synaptic web that has the complete resource..the active conscious mind though only processes one chain of thought..or perhaps multiple chains in sequence ..but never can you "think" using all you "know"

Don't forget -you are a princess !

2007-12-10T14:40:00.000-08:00

" You work hard doc.. you are smart and strong..are you married?
This wasn't one of those delirious guys emerging from anesthesia. Neither was this yesterday's holiday party where all it took was a glass of wine, and my life was suddenly everyone else's business.."just how keen are you then on meeting someone?"

She was 50 something had just had a liver transplant..from the high levels of cardiac enzymes in her blood, I thought she was in the midst of having a heart attack...She was oozing from a line that was pulled earlier..I was attempting to get control of the bleeding with pressure..and she was worried about me?
"Be careful" she said.. I was..her blood pressure was fine, so was her heart rate. She had no known coronary disease, the cardiologists called it a non STEMI..and weren't too concerned.
"If he asks you what's for dinner when you walk in with sore legs ..don't marry him"
That had to be coming from some past insult to her heart. I can imagine cardiac enzymes leaking into circulation..but this heart was leaking more information than I needed.

"You don't deserve dark circles around your eyes" If I wasn't thinking of something else, I would have given her my mascara excuse..Was she really still talking about me? If I didn't believe a percentage of what she was saying, I would have called this "elevated cardiac enzymes with mental status changes".

Normally this ICU conversation would be "Don't worry, relax. Since you don't have any chest pain, shortness of breath, your numbers on the monitor, and your EKG looks ok..you will be fine. Just relax, get some rest ..we'll watch you closely.."
But some how the conversation went "You are really intelligent , you can take control of a tough situation, you are a surgeon..but don't forget you are also a princess...don't let a guy take any of that away from you. I was just about to say something in protest..
"get yourself something to eat and get some sleep..remember you are a princess ..no dark circles"

My note that night ended. " Hemodynamically stable. Alert, oriented. Judgement and insight intact"

The goals of death.

2007-12-02T07:57:00.000-08:00

In life we have goals of beauty..that car ..that house...maybe that island.
Close to death however there's a different set of goals..and most often some one else is setting them for you..

I was given instructions that said:
Keep everything going till the family gets here..they'll be here in the hour.. stop the blood transfusions..keep the fluids and medications..we're certain they'll agree to withdrawal of support when they get here.
We've lost the blood pressure tracing.. the wife called.. she's 3 minutes away..keep him alive till then.
The wife's seen him..wants him to be comfortable. Turn off the beeping monitors..all medications..go up on the narcotic...just keep him comfortable.
Oh and you know what to do right? ..when you see no EKG tracing..listen to the heart..if there's no heart beat..turn off the ventilator..look for spontaneous respirations..if there isn't any..pronounce him.

It makes me think sometimes death really starts long before a person is dead. That for a long time life and death actually co-exist. Death tells life to give up her goals and life agrees for the sake that the remainder of life is comfortable..where the goals of death must take over. Although we perceive that we fight against death for sake of life..I think somewhere they must have understanding with eachother.

Gift wrapped in pain

2007-11-22T19:56:00.000-08:00

Almost everything surgeons do to serve their patients is associated with pain..
Good morning I'm sorry to wake you up..kind of early ( 5 am)..watch your eyes..I'm turning on the light.."Aah!"..sharp pain in the eye.
Can I take a quick look at your belly?.. lets take the dressing off.. I'm sorry..I know the tape ripping off your hair is the worse part...doesn't it make you wonder why women wax their legs?..Perfect..the incision looks perfect.. (oh yeah? can it ever? )
Any more belly pain this morning? Oh ok..down and to the left...let me take a quick feel..starting up and to the right ..moving cautiously and slyly to the point of maximal tenderness (did nobody ever mention eliciting tenderness is barbaric?)
This is just a small cut..I'm going to put in a couple of sutures..I'm going to numb the skin around it first ..you'll just feel a small poke and a burn of the numbing medication (there's got to be a smarter way of delivering numbing medication you'd think)
Ok we need to pull this tube from your chest..your lung is well expanded and you don't need the drain anymore. Don't worry, shouldn't hurt much..this tube is small and hasn't been in place too long (but what if you have a big fat one sitting for 4 weeks? ) "don't worry..this will feel weird..because the brain doesn't know what to make of a tube or pipe wriggling out of the body".. that hypnosis works..by time the patient is out of the hypnosis..the tube is out too..then you say " Good job you did great"..because he wont say it to you ..he hasn't had this before...and hope doesn't ever again.
Your surgery went well ..we think we got the whole tumor out.Any problems this morning? " Just the pain..lots of it" " I told you..for a day or 2 you'll feel like a truck ran over you" What kind of mental preparation is that ? Neither the patient nor surgeon has ever been hit by a truck !! why don't we just say.." we're going to use a power saw to cut through your breast bone"..or "we're using a knife and a hot tip cautery to cut and burn one after another, through several layers (and sometimes several inches) of abdominal wall..there are crossing nerve fibres..that are pain sensitive and.. ok maybe the truck was easier !
Moral : surgery is painful..and you are not anesthetized through the recovery period..thats not to say avoid surgery... nobody's going to offer surgery unless absolutely needed..the result of health and survival counts..thats the prize ..both yours and mine..thats the prize gift wrapped in pain.

learning to forgive yourself

2007-10-26T09:02:00.000-07:00

"Forgive and remember" by Charles Bosk the last book I read, talked about accountability of errors in the world of surgery...here's a little of what I learnt from it. When a patient dies, the internist is asked "what happened? " The surgeon is asked "What did you do?"
As young surgeons earning more responsibility, one of the hardest tasks to perform is handling a surgical complication.
You continue to do your best to correct the problem...explain yourself to the patient and his family and then present your case at morbidity and mortality conference. Handling complications objectively is perhaps a skill I may learn with experience..but will be able to justify and explain my errors to myself ?

As a trainee you always have a superior..your attending ...and so to a certain degree you are protected from legal responsibility. Decisions like to "operate or not" are already made for you..but some day it will be my judgement that will prove to be wrong. Surgery is a field fraught with imperfections..in a situation that is imperfect in itself ... the best course of action may in retrospect be labelled as an " error of judgement" ....you may wish you'd taken the other path..but if you were to do it again you probably would still do what you did. ..It is said "you can have a happy and perfect life with no complications..but then you would have to give up your career in surgery" So some of these errors are part and parcel of your job...its part of choosing what you think is the "lesser bad"

What is not forgiven is laziness to get up in the middle of the night to see a patient in need.... concealing facts from the patient or the surgical team.. the so called " normative errors" that someone expecting success in a surgical career had better stay away from...it may still be "human" to make these mistakes..but its not "surgeon"

" Errors in technique" are the ones in which you really cant separate the doer from the result. If an anastomosis leaks..sutures don't hold..it may have been the patient's friable tissues..but its still you who put the stitches in there.. A procedure may have a complication rate of 3 %..and if you do a 100 of these..having to deal with 3 cases is within reasonable expectation..but its still hard..you still pray the 3 go to someone else's share. When you see your patient going through prolonged hospitalisation..the morbidity.. added expenses.and sometimes death....how should you not feel responsible? You may talk your way out ..but in a solemn moment you still know " you did it " How you deal with this feeling, may affect the rest of your day..your other patients to be seen...and as much as your self esteem and career.

By all means then, forgiving yourself is an art you should learn..that is not to say that to avoid guilt, you absolve yourself from all responsibility..that's fooling yourself. Its about dealing with all the anger, guilt, sadness in a reasonable time and manner and finally coming to the acceptance to move on..forgive yourself..but learn from your mistakes..
"Forgive and remember"

Stranger dependence..the price of independence?

2007-10-12T12:14:00.000-07:00

As it nears time to discharge a patient from the hospital..we need to look into their availability of support at home. Often the solution to the missing element of family support is a nursing home, rehab facility or home nursing..but all too often it isn't. Sometimes the patient has no real nursing needs, no potential for rehabilitation yet needs some help at home..and there isn't. As societies develop, every person in a job has a defined role in this defined social organization that has replaced what used to be a taken for granted, free and functional arrangement...the family. It is difcicult to make time for family comittments ..to keep your job. And when you need help..you get it..from someone who's paid than from someone who cares.

Role play

2007-10-01T17:37:00.000-07:00

Which of these individuals was more successful?
1) One businessman who brought up 2 sons to be the worlds most successful industrialists.
2) One farmer who brought up 6 sons on a farm and had them all graduate from good universities.
3) One single mother who brought up 3 sons and raised them to be lawful citizens.
4) One couple who adopted and raised 3 kids when they could have had their own.
5) One mother who raised a child who she knew wouldn't live past age 12.

In everyday work..we spend half our life in finding our goal and the rest in struggling to achieve it . Sometimes I wonder if success is about achieving your goal....maybe its just about playing your role.

Pathophysiology of abuse

2007-09-10T16:42:00.000-07:00

For years I associated spousal abuse with poverty illiteracy and alcoholism. During my recent years in medicine, I met women of my age and educational staus being victims of abuse.. I often wondered...how do they allow this to happen to themselves? Why did she not leave him earlier? how did a smart and educated girl become the battered wife?
Although most of us are familiar with some risk factors for abuse such as illiteracy unemployment alcohol, drug abuse.. few women diagnose abuse in their lives early enough to rescue themselves
Our first vulnerability comes with our choice of a partner: For whatever basic instinct is worth, females are looking for the strong macho male..who is not only strong but also the "aggressive protector". Although the properties of such a mate are appealing, do we think about how often.. this far from stone age.. is the aggresiveness vented in fighting an adversary? If his temper or fist are difficult to control, is it more likely they'll fly at you?
We know that women are more powerful verbal communicators than men. If all fights were verbal, we've won all the world wars and more. When you've made a winning point you leave him little choice than to leave or throw a temper tantrum...coz men wont cry. So his retaliation is disproportionately severe or stronger..(thats probably why the man is almost always the one who needs to apologize :)
We are naturally caring and understanding and cant leave a needy partner...most abused women I spoke to describe a pattern which sounds like "he throws me into the wall..he apologizes ..coz he really needs me... he chokes me..and apologises again..and this escalates....the final battering episode that has the woman hospitalized is usually preceded by a real threat by the woman to leave her husband.. coz that makes the abuser suddenly powerless.. he doesn't hate her..infact he actually believes he loves her and she believes it too...and most often after the episode of battering too...so its not as much a lack of love..for if it were so..the end result would be separation..not abuse.
I would think in any relationship no matter how close you feel to your partner..there need to be defined boundaries ..not to create distances..but to protect and preserve the closeness. There are certain rules "XYZ cannot be said" "XYZ cannot be done" These are rules that in most normal relationships are unsaid and mutually taken for granted. In those relationships where abuse goes unrecognized ..the boundaries are being recurrently breached..and partners have forgotten to recognize acceptable vs unacceptable behavior..if you tolerated it once ..you have no excuse against it the second time...and once you have recognized it you shouldn't feel guilty when you walk out.
And to save yourself from assault..Leave...don't threaten to leave..you may get shot at the door.

who's life is it anyway

2007-09-03T18:37:00.000-07:00

He was a 40 something male...who had been our patient in the hospital for several months..having sustained a major traumatic brain inury, was comatose for a long time....breathing through a hole in the windpipe , being fed through a tube placed into the stomach...being treated for hospital acquired infections from time to time. The morning report on him for most days had been "no change"
Over the last few weeks however he had made significant progress..one day he was opening one eye, next day both..the following week he would track your movemets with his eyes. then gradually showed change in facial expression as you spoke..One day he started to follow some commands..we were excited with every small progress he was making.
Then finally one day he spoke ..he uttered to his wife his first word in several months..we were excited once again till we learnt what it was .......he'd said in Spanish what traslated as "ENOUGH"
It was the first time I felt struck with victory and defeat all at once.

The female brain

2007-08-27T17:15:00.000-07:00

The book was published last year..but I didn't venture into that section of books, until recently. It may be the defence mechanism of "intellectualization" that brought me to pick up this particular book. Louann Brizendine, a neuropsychiatrist from UCSF has done a marvellous job, of explaining that we aren't crazy, we're just women.... processing and interpreting information along synaptic pathways disctinct from the male, spared the attack of an intrauterine testosterone surge. That's why a 3 year old little girl given a truck for a toy cuddles it and says" Dont worry little truckie, everything will be alright" The book also explains how sisters can be as different from one-another, why the teenage daughter can't put her phone away and perhaps why a woman loves two different kinds of men at different phases of life.
It is a must read for all mothers, daughters and couples in new or changing relationships. Although it would be a great read for all guys in general, I dont expect them to have a great appetite for "science of emotion served on a platter" Stongly recommended for all.

do you wanna?

2007-08-21T18:24:00.000-07:00

I dont know where the Americans have picked up these bizarre expressions: Do you wanna fill out this form ? Do you wanna pass me that pen? Do you wanna look this up for me?
Did I say I want to? Ofcourse I dont want to..dont make me believe "I want to" do the things I " have to "
Dont save yourself the effort of asking me to do something for you.."Would you please take care of this" ..
"Please do this "..or even "do this" is better..just take responsibility.

The treadmill and the walk

2007-08-15T17:51:00.000-07:00

On a treadmil: Its a set pace, You walk, but not to any destination. You keep walking but all you do is keep up. Its man-made.
On a walk outdoors: The kids in the park , the birds and squirrels in the trees make your mind wander. An occasional fragrance makes you smile without reason, and a breeze brings along memory that makes you want to cry. It's God-made.

Delivering a fatal diagnosis

2007-07-22T18:37:00.000-07:00

I knew my patient's diagnosis and he didn't. We were waiting on final pathology results to discuss anything with the patient. Everyone in his family had died in their 60's and at hence at 66 he had a premonition that this hospitalisation was going to bring him his death. He was otherwise prettly illiterate with issues of health and disease and believed in his doctors with all faith..overall a very sweet chap.
As I was on rounds in the afternoon he just went about summarising his life.....he'd been a contrtactor with painting and roofing jobs, he had bred and trained roosters to sell them for fights ..gone to jail for a few months...had married atleast twice...had two golden teeth...but he was still afraid of death.
I asked that he should write an autobiography..his life events seemed pretty interesting to me..I asked him what he would like to do further on in life. He said" With all these health issues I really can't do much..and I really cant think of much more to do" " But I dont want to go..I dont want to die"
Its awkward for a doctor to deliver a diagnosis of an inoperable cancer..most of us want someone else to do it for us. We are trained to elucidate disease.. but not life and death. One of the members of our team completed the task. My patient was a little low the next two days and the evening of day 3 we had a chat again. He said that if we couldn't cure him, he wanted to donate his body for the study of science so that one day, those with his disease ..perhaps in the generation of his grandchildren ..might be cured...I didn't know what to say.
"And eitherway "he said.."I'm going to write my book"

Smiles: plastic and elastic

2007-07-14T20:51:00.000-07:00

Whether its the grocery store or the clinic, theres a compulsion in the work environment to smile when you greet your customer, your colleague or your patient. This is exemplified in sales surveys which have questions like "did your cashier greet you with a smile today?"
The salesgirls walking around the store usually find it convenient to adopt the "plastic smiles" where the smile is forever plastered on their faces whether they are being spoken to or not! In jobs which involve moving back and forth from focused paperwork to manadatory conversations..we've adopted the "elastic smiles" These have an unbelievable rate of recoil to a straight face. If you want to know what I'm talking about, just continue to observe a persons face after he or she has looked away from you. Was that face really smilling a second ago? Next time you smile, keep it lingering for an extra 2 seconds...atleast to make it believable!

There's only so much I can gather

2007-06-27T18:47:00.000-07:00

As I sat at the airport to leave Rochester..I knew I was leaving forever..my first home away from home. I yearned for one last glimpse of the goslings on Silver lake, one bite of an apple Pannekoeken and another goodbye hug from my best friend.
All I was left with were pictures and memories but most importantly a new me.

On vascular surgery rotation..

2007-06-01T13:15:00.000-07:00

Cold coffee should be the preferred drink. Coffee coz it's coffee. Cold for two reasons: 1. You can gulp it downbefore you run. 2. You can get back to it and it hasn't gone cold.

If you loose your watch, dont bother to look for it..the loss is a blessing in disguise..and if you find it ..it won't be as useful a thing anyway.

You shouldn't complain about getting paged with silly issues in the middle of the night. You owe your patients a lot... for not dying on you.

Hope within a brazilnut

2007-05-19T06:35:00.000-07:00

He was a paraplegic in his 50s who had spent several months in the hospital. He was attempting to heal a sacral pressure sore. Once a week as I would change his dressings, we would discuss the progress he was making.
"How big is it today?" was his question as he couldn't see the ulcer on his lower back for himself. We went from calling it a tennis ball..then golf ball..and then walnut size. After walnut size, one week I didn't notice much of a difference except that the wound was a little smaller from side to side. I didn't want to disappoint him but he was still enthusiastic.
" Dont worry" he said, "It's now a brazilnut."

The Post-it certificate

2007-05-01T16:05:00.000-07:00

The weather is changing to summer in Rochester. Its easy to go out to work wearing a light jacket and then forget all about it on the way back home. (Thats just to say I'm not really forgetful). Ok ! so thats what I did when I was called in by the internal medicine team the other night for "a stat surgery consult"
The next morning I asked my friend who is posted at that campus to pick up my jacket for me. She had to look around for it a bit, but once she did find it she burst out. On the back of my jacket was stuck a yellow Post-it that read :
" This Jacket belongs to a surgeon-(Female)-who came in at 1 am last night to see our patient in room 280." My friend handed the jacket to me the next day with the note still stuck on it. That 2"x 2" paper scribbled in runny blue ink was the prettiest little certificate I had ever seen"

To the woman surgeon.

2007-04-23T12:33:00.000-07:00

As a young woman in my first year of surgery residency, I am puzzled and worried about the fate of women in surgery. It is strange how easy it is to believe that a woman must almost give up her ‘womanhood’ to be successful in a surgical career. I observe an unfortunate division of women surgeons into two groups: one that has for prototype the strong, successful but single woman and the other has the wife and mother, easily labeled “laid back” woman. What is worse I think is the lack of empathy between these groups of women themselves and an unsaid but evident bitterness. The former group secretly envies the latter and the latter runs the risk of being “run over” by the stronger colleagues.
I think a big part of the responsibility of bringing about change to this attitude lies on our own shoulders. Offer to pick up your woman colleague’s daughter from school on your day off. It will make a difference.

Its not the best time to talk..I'm in shock

2007-04-08T18:31:00.000-07:00

It had been a tiring day, not very long but still more tiring than longer days. One of my patients had sustained a major intraabdominal bleed during her postoperative period. She had to be taken to the operating room emergently to stop the hemorrhage. While we were trying to pump blood into her system of hemoglobin 5 in the pre-op area, I was trying to talk to her every couple of minutes to make sure she was arousable and to reassure her. When the anesthesiologist was happy with the resuscitation, we took her to surgery, took care of the problem and tucked her into the ICU for the night.
The next day it was nice to see her awake, comfortable and a smile on her now pink face. I did not expect her to remember much of our interaction the previous night. But when she saw me she said "I'm sorry I didn't talk to you last night.. I really didn't feel like talking to you."... I didn't know what to reply to her" I was making sure you weren't losing it" would be scary.. "its ok.. we'll catch up later" would seem like I hadn't considered the best time, the first time. "I was reassuring you" would seem like "thank me now"...so I said ......." I'm just stubborn.. I keep talking"..and the nurse in the room winked a smile.

Grey

2007-04-08T16:06:00.000-07:00

We had a group discussion on "what makes a great presentation." We made comments on slide presentations over the last few years. "the border of the image is too thick" " the slide is very crowded" "dont like the textured background"..and so on. We then came upon a slide that used coloured arrows and colour key by the side. A medical student in the group volunteered a " I'm color-blind". For a moment we were all quiet, felt ignorant and dumb all at the same time. After all there must be some amongst us who see "all grey." The med student still volunteered that one of the colors looked like "what we call yellow" and the othe "r looked like what we call green" .So to him, grey had shades that meant much more. I realised how little we understand "grey" in our day to day lives. Its easy to see the black as black, and the white as white, but who knows what lies in the mundane grey. How happy is someone who "grey"ly says I'm OK..or how sad?

2007-03-27T17:48:00.000-07:00

Can't buy flowers!

2007-03-27T16:41:00.000-07:00

While chatting with one of my patients Mrs. Carlson one afternoon, I remarked that her hair looked different from usual. She said that her nurse had combed it differently.The conversation then lead on to young girls who perm and straighten their hair ever so often. She thought it was crazy and I thought it was crazy...only that I was 25 and she was 90.
So having struck a common note, we delved into the subject of fashion and trends a little further...people who change to smarter phones every couple of weeks and cooler cars every now and then. Neither Mrs. Carlson nor I could afford such a thing, but then neither of us Would if even if we could! She said it was a futile chase... "some of them dont realise they're barking up the wrong tree"
But then I suggested that there had to be something perhaps that WE were missing.. maybe we hadn't trained ourselves to enjoy these short-term joys, always looking for the quality that lasts. The phone is to communicate (its the one feature my decade old sturdy model shares with delicate contemporaries) The car is to drive you from one point to another ..ofcourse thats right ! But would I exchange for a better model if it wouldn't cost me ? Yes ofcourse ! Then it isn't about not Wanting the new one..its about not willing to pay the Price..Right its not worth it..but thats for me...may be I'm stingy. Mrs Carlson however said "No..you're practical"...for a moment I liked that.
I remarked that its a lot of fun however to receive these "not worth it" things as gifts ..for we''d never spend our own money on them. Then I went on to say what a I truly regret .I said.. "LIKE FLOWERS". It made us both realise that I was worse than practical or stingy ! I was obsessed with wanting everything to last forever ! I had never bought myself flowers because on day 4 they wither and go to the trash ! I was missing something...I was missing the fact that flowers are meant to live a few days and what you pay for IS infact the shortlived scent and beauty !
I drew a conclusion to the discussion "People who curl and straighten their hair all too often are crazy..and so are those who can't buy flowers" Mrs Carlson agreed, " That is nutty!"

Whiteboard art

2007-03-25T10:15:00.000-07:00

On afternoon rounds, I often have enough time to talk to my patients for as long as I want. As a surgery intern I am pretty much qualified to talk about everything except the diagnosis and prognosis of the patient. I also get to show off my talent to an audience that has no escaping. One such talent is scribbling and sketching on the whiteboard across the patient's bed. These beds often have the name of the Doctor, nurse, diet regimen, activity recommended for the patient etc..sometimes there is room for a an illustration or two. I think illustrations are an excellent aid when you dont have the luxury of a common language to speak to your patient..they dont much follow the language of medicine. Oh but it isn't everyday that I can demonstrate a gastro-intestinal anastomosis or a rotational flap ...so I've picked a simple but fun tradition from the nurses on the surgery floor. After every prescribed walk of the day, the nurse draws a small smiley face on the whiteboard..so as to replace a checkbox. On evening rounds, we often look at these earned smileys on the whiteboard to discuss how the day has been for the patient. If you see to just one or two smileys..you discuss adequacy of pain control, risks of declining lung function, deep vein thrombosis associated with lying too long in bed. If you see 8 smileys you say "looks like someone has been doing more rounds on the floor than I have..well done!" Occasionally a patient will protest that the most recent walk has not been charted on the board yet..and thats the opprtunity I'm always looking for! I pick up the marker..draw the last smiley and then unable to resist myself, start decorating all the other smileys on the board...give a cap to one, a bow to the other and with a surge of feminism..always make one smiley wear two plaits !