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Behind the Mask – The (Socially) Distant Acute Care Surgeon

Social distancing has now become the norm across the land. This is a necessary effort to prevent the spread of the coronavirus and its potentially deadly consequences. The ‘COVID lockdown’ as I call it in my casual conversations has had a ripple effect across many lives and industries beyond the patients and families and day-to-day work of the US healthcare-industrial complex.

In these days of COVID, the new normal for me is covering myself for all encounters. Asymptomatic infection is high. In any given day, I will see multiple new patients in short order and even with the highest level of hygiene, I might be the greatest risk to a patient for whom a trip to the hospital is unavoidable. I do not shake hands. I do not begin with a warm smile to ease the anxiety. I do not hand out my card with a reassurance that my partners and I are available 24/7 – just call.

I am a surgeon. I am no stranger to donning a mask for sterility in the OR or for bedside ICU procedures. I am no stranger to donning a mask to protect a vulnerable cancer patient who nevertheless needs me to examine their abdomen. And when my hands will be touching a body part during an exam, I am no stranger to donning gloves.

My hands and cuticles are raw year round because they are no strangers to repeated contact with 70% alcohol-containing solutions.

I still perform the exam. I still explain the diagnosis and my rationale for the treatment options in a level of detail that would make residents roll their eyes (if they were still allowed to see patients by my side). But I don’t ask for permission to sit at the foot of the bed while I do so. I don’t gently lay a hand on a covered knee while having a very difficult conversation.

Often, family members will ask if it’s okay to hug me at the end of an encounter (even if the outcome was their loved one’s death). Currently, patients are not allowed visitors outside of very rare exceptions. There is no hugging in COVID lockdown.

Sometimes, I cry with my patients who never expected to need a surgeon until the day they met me. Tears are a body fluid. There is no crying in COVID lockdown.

But my patients are so very alone right now. Whatever they are stricken with – and luckily for me and for them so far it hasn’t been COVID-19 – these are dark and scary times in their lives and they are all alone. Completely, totally alone. And I can do nothing to ease that loneliness behind my mask.

The warmth and non-medical touch during these encounters matters as much as detailed explanations but I am trapped behind my mask, unable to be the kind of surgeon that I truly am on the inside. I feel inadequate even though my clinical acumen and technical skills are unchanged by the COVID lockdown.

I am compliant with the need to be distant and sterile during these encounters because it is how it must be. However, the heartbreak of every encounter is real for me and my patients. Some will survive; some will not. Will they or their families be grateful for the surgeon behind the mask who played a role in some way?

Who am I to say. 

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COVID and the Break in the Acute Care Surgery Coat of Armor

The thing about acute care surgeons is that we always show up with our invisible coat of armor. Over years of training and experience with grittiest and most tenacious role models and mentors guiding our way, we become resilient. We learn to provide timely and high-quality care to all those in need whether it’s 2 am or 2 pm, whether it is a weekend or a holiday when everyone we love has some respite, whether its a pedophile from the federal penitentiary or the sweet old lady who reminds us of grandma who needs us to help urgently, whether it is a slam dunk easy case or the risk of mortality is high in the best case scenario. We do this despite the momentary cost to our physical or emotional health because that coat of armor shields us.

Often we are where the buck stops when patients are complex. When our colleagues need help figuring out the culprit on their differential diagnosis or an extra set of hands they call us.  Can’t figure out if the nausea is from an intra-abdominal source, call acute care surgery. Can’t figure out if the source of florid sepsis is GI perforation, call acute care surgery. Can’t figure out if this skin exam is consistent with cellulitis or necrotizing soft tissue infection, call acute care surgery. Can’t figure out if the airway pressures are rising due to abdominal compartment syndrome, call acute care surgery. Urgent central venous access, call acute care surgery. Difficult airway, call acute care surgery.

Like every town’s fire brigade, we are there. We show up whether or not there is a fire to be put out because someone was concerned enough to ask for help. We have chosen our specialty because we are committed to helping not just our patients but our colleagues, in even the most inopportune circumstances. To do so, we truly function as a family. I may not have chosen to be friends with them outside of work but at four different jobs with a team based approach to emergency surgical care, I have alway loved and cherished my team members like family. It’s like wedding vows. We are in it together and would lay down across rail road tracks to help each other do right by our patients.

In these unprecedented times surrounding COVID-19, from preparations to actual care of extremely critically ill patients, this family’s invisible coat of armor has started to crumble.  Our ER, hospital medicine, and medical intensive care colleagues still need us for those vexing matters that are routinely part of our work responsibilities. However, we may or may not be able to offer these patients with the inflamed organs or perforations the same kind of care that we might have as recently as two weeks ago. We might have to offer something that is likely non-inferior. It may be non-operative or operative in the old fashioned way we did it long before fiberoptic cables and robots.  These alternative decisions might be because we have to be proactive about using supplies. They might be because asymptomatic carrier rate is high and we need to protect the surgical and anesthesia workforce. They might be because we simply don’t have the physical space to provide surgical care. Meanwhile, given our critical care expertise we are, of course, available for managing patients whose only known issue is COVID-19. We understand ventilator management, and ARDS, and reversing I:E ratios, and proning. We have put young previously healthy patients on ECMO before. We remain here – day and night – to help. We are searching for scarcer and scarcer PPE so we don’t miss a beat when you need us.

All of this is happening for each of us on the front lines including EM, IM, and MICU all day every day (even while others might be figuring out their new normal mostly at home) while our families are struggling from social isolation in general, from knowing we are in the direct line of fire, or seeing how preoccupied we are with being prepared given so much uncertainty. Like our other front line colleagues, there is no down time for acute care surgeon, even those who have been put in the “bullpen” at home in case we start losing faculty to COVID-19. Because being out of harms way means that someone else is in harms way, the moral distress of sitting out is paradoxically crippling. On top of this worry for work family, where ever we are stationed, there are a dozen relevant emails before the crack of dawn. Multiple remote conferences to stay up to speed. At best you a catatonic shadow in the lives of your real family when they truly need you – the medical person in their life – to have no breaks in the armor. Some of us, have gone to extreme measures of isolating in separate quarters within the home or in entirely separate locations from our loved ones – the ones’ whose snuggles and kisses are such a critical part of our day to day resiliency when things are at baseline.

When you play so many key day to day safety net roles across a health system when things are acute care surgery “normal,” the extreme abnormality of COVID-19 is a serious hit. There are so many moving pieces that we must be totally on top of.  From where to enter the hospital, what to don where and when, where patients will be cohorted, whether surgeries can be performed, where overflow ICU beds will be, how to protect our trainees… the list goes on and on. Each bit of uncertainty, each disruption to our typical decision making or daily practices, each pang of guilt or worry regarding the work family or the home family, along with the constant use of brain power to keep us COVID-related issues is physically and mentally exhausting even before you’ve passed that soviet-era temperature checkpoint to start your day at work.  It chips away at the invisible shield of armor that usually shields us. So we have to figure our other ways to be resilient in these trying times because our usual mechanism is failing us.

But there is a fire somewhere and we are needed. I am sure that in sickness or in health we acute care surgeons will figure it out.

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An Open Letter to My Elected Officials on Firearms and the Deaths Trauma Surgeons See Daily

An Open Letter to My Elected Representatives

February 23, 2018

Dear Elected Official:

As a trauma surgeon and one of your constituents, I was heartened to hear that you are reconsidering your views on how to protect Americans from the ravages of our national gun violence epidemic. I am writing to share my first hand experiences along with known facts about widespread use of guns in the US today. In my line of work I am all too familiar with the lethal potential of firearms, especially when coupled with a cavalier attitude that many legal gun owners in America have that they or their families are somehow immune to the deadly power of guns. While every life I save is a privilege, my greatest success as a trauma surgeon would be to significantly reduce the number of people who need my care. Injury prevention is as fundamental to my work as is operating. In the case of firearms-related injury, there is much work to be done. I hope my perspective on the morbid consequences of Americans’ unfettered access to firearms will be helpful as you consider what should be done to protect each and every one of us from a death that is truly 100% preventable.

As a trauma surgeon, I have held countless ounces of brain matter in my hands while examining a self-inflicted gunshot wound. Occasionally, someone shoots themself in the chest, aiming at the heart. Most often, however, the suicide victim points a gun, legally purchased by themself or a family member, at the temple or roof of the mouth aiming at the brain. At such close range, despite my expert skill in trauma care, the damage is far too severe to reverse. It is a uniquely American reality that homes across the nation, occupied by residents experiencing deep depression, are also filled with firearms acquired for sport, hunting, or presumed personal protection. Of the nearly 96 Americans who die a firearms-related death in the US daily, nearly 59 die as the result of suicide. People with suicidal thoughts are three times more likely to succeed if they live in a home with a firearm. Furthermore, while 9 out of 10 suicide attempts with a gun are successful, only 1 out of 10 attempts by all other means succeed. To be sure, we as a society need to lift the stigma on psychiatric disease and enact policies that increase our nation’s mental health workforce and require both insurance companies and hospital systems to treat mental health conditions like any other illness. However, given that the leap from suicidal ideation to death by suicide is shortened by the presence of firearms, we must also take steps reduce access to firearms in US homes.

As a trauma surgeon, I have felt the anguish of too many parents who learned that their child was dead from me. Occasionally, the child was a teen who, in the absence of strong public education, housing security, and hope for an economically sound future, turned to a life of gang warfare in our urban centers. But more often, a child’s death has been deemed in our societal discourse an “accident.” Yet, the presence of the firearm used in the “accident” is in fact very intentional. Our fellow citizens routinely purchase these deadly weapons and keep them in their homes, thinking they are for defense, sport, or hobby. I wish I did not know the horror of a child killed “accidentally” by a sibling, a friend or even themself, but I do. The adult gun owners in each of these cases would swear to be well-versed in firearm safety. But, having seen that child lying cold and lifeless in my trauma bay, I know that they were overconfident in their ability to safely store their firearms. Nearly 1,300 American children die of gunshots every year. Worldwide, of all children who die this way, the US accounts for 91% of them. And, despite the characterization of our nation’s urban centers as the source of the majority of our dead American teenagers, it is important to note that only one in five teens who suffer a firearms-related death was involved in gangs; the vast majority of firearms-related deaths among teens in our nation are, in fact, due to suicides and these supposed “accidents.” Certainly, we should address the problem of urban violence among our youth and the illegal firearms trade that makes it so easy for them to kill each other (recalling that all illegal guns were at one point legally acquired). And, as the number of children lost in school shootings impossibly rises, we absolutely should address the pervasive issues affecting our boys today which might make any one of them turn against their classmates with lethal force. But these efforts would not be nearly enough given that the vast majority of children killed by firearms in the US die in settings with legally acquired guns one “accidental” death or suicide at a time. We must reduce the widespread presence of firearms in American homes and we must stop giving those who choose to keep deadly weapons near their children a pass when their carelessness results in a death.

As a trauma surgeon, I have also taken care of too many people, most often women, who have been shot dead in an act of domestic violence. When my patients have been beaten (by hands or weaponized object such as a bat or pipe) or stabbed (by weaponized knife or bottle) by their abuser, I have a realistic chance to heal them of their physical and mental wounds and get them to a safer place. However, firearms make it too easy for the abuser to become a murderer and I am robbed of the opportunity to end the cycle of domestic abuse in a positive way. Of all women murdered in this country, 45% are murdered by someone who supposedly loves them. This risk of intimate partner violence spans all sociodemographic groups but women residing in homes with firearms are 5 times more likely to be murdered by their abuser than those whose abusers do not have easy access to a gun. To be sure, we need as a society to address the root causes of domestic violence in the US and expand services nationally to help people in abusive relationships leave. However, it is clear that easy access to firearms is the major cause of domestic abuse fatalities; we must at the very least put a halt to how easy it is for abusers to acquire guns.

As a trauma surgeon, I have been fortunate not to have to care for victims from a mass shooting event; but I have trained repeatedly for mass casualty response. Years ago, we used to prepare for something like a bus crash or a building collapse; these days we prepare for shooters. Sadly, I have had to learn from the experiences of my fellow trauma surgeons in places like Newtown, Orlando, Las Vegas, and Fort Lauderdale. There is no glory in caring for victim after victim arriving with bullet holes, only grief; and then one must have the fortitude to bury the grief and move on to the next victim. Often, however, the grief is not from the patients coming into our trauma bays. Rather it is the eerie quiet in the empty bay picturing all the lifeless bodies that never needed to come to the trauma center. We have seen over and over in our country the highly lethal mix of angry people (some with true mental illness but most simply filled with rage) and easy access to firearms, typically legally acquired by self or family member. Surely, reducing overall access to firearms must be part of the equation in improving our collective right to life, liberty, and the pursuit of happiness while we are at school, the movies, and other public venues.

As a trauma surgeon, I have also trained for active shooter events because sadly, in additional to training for years to become the highly skilled professional that I am, I must now also be prepared to get shot in the line of duty as a healthcare provider. From 2000 to 2015 in the US, there were 241 hospital-related shootings. This statistic really hit home when cardiac surgeon Michael Davidson was shot dead in his clinic by a disgruntled family member whose mother had died of a known complication of major heart surgery. He was around my age. His wife was a college classmate. He was killed by a volatile man who lived in my community just 40 miles away. Complications are a part of what we do as surgeons no matter how expert we are, or how much caution we exercise in doing our work. To live in fear that my own death might be the consequence of my professional efforts, because so many of my patients and their families are legal gun owners, is something that my years of training simply did not prepare me for. Here again, the lethal combination of rage and access to firearms is painfully apparent. To be sure, we must make efforts to understand why people come to hospitals prepared to kill – whether it is a critically ill loved one or a physician who they see as responsible for a complication; but, we cannot simply continue let the answer to rage be grabbing one’s readily available firearm.

As a trauma surgeon, I can also provide some insight into the “good guys with guns” concept that people sometimes put forth as a solution to our nation’s gun violence epidemic. As evidenced by the seasoned hunter who shot off his reproductive organs cleaning his rifle or the experienced officer who shot himself while moving firearms from one cruiser to another, I have seen that even the most highly trained “good guys” sometimes don’t understand the power of their guns. Furthermore, the few times that I have been the one to care for a fallen police officer has taught me that even the “best of guys,” armed, well-trained, and experienced, can be taken by the actions of an enraged person with a gun. I was not on call recently when an officer shot while responding to a domestic altercation was brought to our trauma bay; my partner’s efforts to save his life proved to be futile. I can hear the wails of the grown men in blue who lost their partner that night as if I had been present because, sadly, I have heard those wails before. They are somehow even more haunting than the cries of a parent who has a lost child. To be sure, criminals intent on killing will find a way; however, in the decade leading up to 2016, 537 US police officers were killed by a perpetrator wielding a firearm. In contrast, those attacking with a knife, a bomb, or fist/strangle caused just 26 officer deaths in the same time period.  It seems clear that even the “good guys” are not immune to rage-filled persons armed with guns. Therefore, seriously limiting access to firearms will necessarily make more of a dent in our nation’s firearms-related death epidemic than arming others who are unlikely to respond quickly enough to make a save or, worse, might accidentally shoot themselves or someone else.

As a trauma surgeon, I have also seen the impact of high-powered military style assault weapons. As an interested professional, I have deliberately read reports on the autopsies of so many killed with such weapons in our nation’s most recent mass shootings. While all firearms are manufactured with the purpose of maiming or killing, make no mistake about it: the destructiveness of high velocity missiles that can be fired multiple rounds at a time makes semi-automatic assault rifles like no other gun. These kinds of weapons cause tissue damage that is unfathomable, leaving unrecognizable parts that were once part of a living, breathing human. Regarding ownership of such deadly weapons for the sport of hunting, I would argue that if you are such a bad shot that a bow & arrow or a shotgun does not suffice, then you should buy your meat from the store and take up a new hobby. Having seen firsthand what these assault weapons do, I see no reason why any civilian should have access to them for any purpose.

I am grateful that you have taken the time to read about my experiences. Based on my vantage point as a trauma surgeon, and as a concerned citizen, I have several suggestions that I hope will protect all of us from dying from a gunshot(s).

  • Firearms buybacks for those who simply no longer want to live subject to the possibility of the kinds of death I see daily
  • Deny gun permits to those with any history of domestic abuse, restraining orders, anger management issues, school suspensions, animal torture, and the like which all point to tendency for moments of rage
  • Mandate biometric trigger locks so that only the one legal owner of any firearm could use it, and not a thief, or a child, or a suicidal family member
  • Regulate firearms use and liability as we do with automobiles through required firearms training and testing and insurance to cover death/injury/anguish should anyone else get struck by a bullet from your gun
  • Allow survivors and states to sue gun manufacturers for wrongful death as we do for other consumer products (e.g., swimming pool drains, fertilizer, toys, airbags)
  • Prosecute adults whose negligent storage of a firearm leads to “accidental” death at that hands of a child
  • Ban the manufacture and sale of high velocity semi-automatic weapons and multiple rounds of ammunition along with a mandatory buyback of all such weapons followed by fines or jail time for those later found to be in violation of such laws

Again, I am heartened to know that reducing the burden of firearms related death in our society is among your legislative priorities. While I am not an expert in any such policy issues, as you have read, I am sadly an expert in people who die with bullet holes and buckshot wounds. Please do what you can to rid me and my colleagues of these horrific images and make all of us safer.

Sincerely,

 

Heena P. Santry, MD MS

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Hero

A colleague of mine was recently questioning her capabilities having lost yet another patient who had arrived nearly lifeless after being shot.  She was despondent over the nation’s overall complacency about our gun violence epidemic giving her far too many opportunities to fail or succeed as a trauma surgeon. Truthfully, neither quick decisive action nor expert surgical skill was enough to repair that much damage. Not in the hands of any trauma surgeon.

As trauma surgeons we bring everything we have–every ounce of energy and drive, countless years of specialized training, and an ever expanding armamentarium of medical technology to fix broken bodies–to our work but sometimes we simply feel like failures, both unable to save our patients and unable to move the dial on policies that might ameliorate gun violence.

Here are the words of support that I offered to my friend: a compassionate, highly skilled trauma surgeon who without hesitation took a hemorrhaging gun shot wound victim to the OR to try to save his life:

“The grief is understandable. For your patients. For your community. For our society. You have a skill set that makes you brave enough to even try, my friend. As a trauma surgeon when you hear audible hemorrhage you run toward it, just like the police run into the gunfire or the firefighters run into the flames. Each and every patient is lucky to have you and your strength; their families will be grateful for your efforts and empathy no matter the outcome. Don’t be too hard on your self.”

Having been raised in a culture of morbidity & mortality conferences where we scrutinize every decision and every action preceding a death or complication, having a chosen specialty whose goal is to salvage badly damaged bodies, and living in a world where these patients keep appearing in our trauma bays even when we speak up about gun violence, this self-doubt is common among us.

But sometimes we just needed to be reminded we are heroes who have chosen to run toward the audible bleeding so we can get up and go back to work the next day.

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The Dignity of Pants

“Please don’t cut off my pants,” he pleaded. “I am homeless and they are my only pants. Please.”

He could say these words as we were conducting our initial assessment in the trauma bay so at least he was hemodynamically stable with an intact airway at that moment in time. However, he had arrived seconds earlier with potentially life threatening injuries as a level 1 trauma activation. Based on the location of wounds that were visible on his torso this was a real possibility so we needed to quickly conduct our secondary assessment. That meant rapid exposure by taking the trauma shears, one on each pant leg from my assistants, as we examined him from head to toe, front to back, in every crevice or crease that might hide a wound.

I looked him straight in the eye and said “Don’t worry. We will get you a pair of pants but right now we have to take care of you.”

Straight in the eye.

He relented. How could he not? The pants were already cut off even as I made eye contact. The process takes just seconds in the hands of a coordinated trauma team.

He was a very polite young man. He didn’t yell or kick or scream. He followed all of our instructions. He quietly told us his health, social, and family history. He told us he was scared. His life story mirrored that of many of our trauma patients: food insecurity, lack of affordable housing, few resources for education and job training, addiction, interpersonal violence, an endless vicious cycle. He was caught in that cycle and it was obvious that he was heartbroken to be there. He wanted a better life and tonight in the trauma bay, without his pants, he had failed once again to break it.

I always say that I was attracted to a career in trauma surgery because I am part surgeon and part social worker. In reality neither I nor the social worker employed by my hospital to help patients in need of socioeconomic support have much to offer our patients with these very real struggles. The policy level changes and investments that would bring grocery options, better schools, safe and affordable housing to our most underserved areas are not in our control. Even for those patients who want to make a change there are too few addiction treatment beds and job training programs. While these issues are clearly predictors of health, they are managed partly (addiction services) or entirely (basically everything else) outside of the healthcare system.

Yet every day we see the ravaging effects of socioeconomic insecurity on our population’s safety and well-being when they become our patients. We open the trauma bay doors and provide the full armamentarium of modern medicine to save a life acutely while feeling powerless to save lives at the societal level*.

We finished examining and working up our patient. He was not going to die that night and could be discharged. Discharged where? It was 3 in the morning. The social worker could give him the address of a shelter in town. There might be a bunk free. She could refer him to addiction treatment. There might be an available bed. A local non-profit might intervene in the light of day if we could make the connection.  But we had no way to guarantee that this man, who was lucky to be alive, would not simply just slip back into his otherwise unlucky life after discharge.

Oh, and there weren’t even any pants to give him. The social worker’s closet of donation was empty of men’s pants it turns out**.

This was not something the trauma team to could bear. We might not be able to provide our patient with better groceries, housing, or addiction treatment to this man who in all of his words and actions as our trauma patient showed us a deep hope to be in a better place in life; but the least we could do is provide him the dignity of a pair of pants to head back into his unfair reality.

So we pooled our cash on hand, asked him what size he wore, and waited until the local Target and Kohl’s opened***. The next morning the light in his face and the sincere words of gratitude when he saw his new jeans and a back up pair of track pants and shorts felt like as much of an accomplishment as stabilizing the unstable patients who had entered the trauma bay earlier or the exploratory laparatomy we had done.

“Thank you. Thank you. Thank you,” he said. “I really need these. Thank you.”

He needs so much more. But this was the least we could do.


*NB: Most trauma centers do provide targeted injury prevention like helmet, seat belt, or firearms safety education through small investments or grant funding but these typically address to specific injury mechanisms rather than social policy.
**Men be like the ladies and cull your closets seasonally; donate to your local trauma center.
***If any Kohl’s or Target folks are reading this consider donating items or gift cards to your local trauma center.
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The trouble with discourse that drives us apart in response to a death in the line of duty

My heart sank when I heard the news that a local police officer had been killed in the line of duty. I was not on call that day but I knew exactly what the words “he was taken to a local hospital where he was later pronounced dead” meant. As trauma surgeons we provide care for those injured in senseless, often preventable ways daily. But when an officer is stricken it hurts so deeply because we share a position with them at the forefront of the worst that happens in our society.

So when I heard the news I mourned for the officer, for his family, for his colleagues, for all of law enforcement, and for the people who tried so valiantly to save his life and would forever be asking themselves “was there something else we could have done?”

Let me assure you, there was not.

As with all trauma centers, we have a comprehensive morning report where we discuss all of our new patients: what was the mechanism, how did they present, what was done for the work-up and subsequent treatment? So it was clear that the trauma team did everything they scientifically or physiologically could in this case. In morbidity and mortality* terms, this would be a ‘non-preventable’ death.

Here’s the thing though, of course it was preventable. And we are all (as members of the community, as his brothers and sisters in law enforcement, as representatives of both sides of the criminal justice system, as providers in the healthcare system) asking this same question “why, why did a good man—a good cop, a good husband, a good father, a good son, a good citizen—die this way?”

In a statement to the press less soon after losing her son, the officer’s grief-stricken mother was quoted as saying there is “no respect for police anymore” suggesting perhaps that a pervasive devaluing of law enforcement by society might be at the root of her son’s preventable death. She was no doubt alluding to the national discourse evolving in recent years due to some high profile episodes where the actions of responding officers have been questioned. Some actions have been proven to be criminal by our justice system, as in the case of an Oklahoma City Police Officer who serially raped women he had pulled over, in other cases, however, the facts in support of criminal behavior beyond a reasonable doubt are less clear (e.g., Officer Parker of Madison, AL and Mr. Sureshbhai Patel; or Officer Wilson of Ferguson, MO and Mr. Michael Brown; or Officer Pantaleo of New York, NY and Mr. Eric Garner).

Clarity notwithstanding, there has seemingly been a shift in public rhetoric questioning of infallibility of those on the front lines of law enforcement. Sadly, in some cases the rhetoric has escalated to vitriol, rioting, and even directed acts of violence against law enforcement.  It truly is maddening that a man, fueled by the overarching discourse questioning police intentions and behavior, would then seek an opportunity to kill the police as in the case of Mr. Ismaaiyl Brinsley who gunned down Officers Wenjian Liu and Rafael Ramos of the NYPD, not during the act of apprehension or while committing another crime, but just because.

However, no matter what the headlines are, the overwhelming majority of our men and women in blue are good men and women who take on their duties with the best of intentions and model professional behavior. And so, when this good man’s mother cites this volatile discourse as a possible cause of his death—as much as my heart breaks for her—it hurts our community by suggesting a local conflict where there was none.

By all accounts, the cop killer in this case was a sociopath lacking any respect for human life or the laws of our society in general as evident by a lengthy record replete with charges ranging from cocaine trafficking, to assault & battery, to weapons possession. Those of us who are not career criminals might get tachycardic or diaphoretic during traffic stops but our natural instinct is to reach for our license & registration, not for our gun. A man with no moral compass felt cornered and so he fired; but, this was no more because he was cornered by an officer than if I had made some gesture to this armed and dangerous criminal during my nightly dog walk.

So, while a family, a profession, and a community mourn, I urge each of us to contemplate how the criminal justice system might have functioned differently to prevent this senseless tragedy but to avoid stoking fired up rhetoric that pits people against the police and police against the people. Discourse that drives us apart stands in the way of viable solutions to combat the socioeconomic and psychological factors that may drive one to a lifetime of crime in the first place and to take those who cannot be rehabilitated off the streets before another preventable death, be it of an ordinary citizen or a man/woman in blue.

___________________________________________________________________

*Morbidity & Mortality, or M&M as it is called is a weekly conference held by surgical teams to review all deaths and complications in an effort to learn more about the systems-based and disease-based processes that led to the adverse outcome.

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Grief

I have been waiting for a moment of joy in the profession that did not involve death to write again. It turns out that those moments are few and far between and I feel compelled to write a few words today. Writing, sharing, letting out the feelings I must keep at bay when I am with my patients and their families is therapeutic. 

Bearing witness to physical pain and emotional suffering is part of the job. The opportunity to ameliorate the body’s failure and to transcend the soul’s response are part of the allure of the work of surgeons, in particular trauma surgeons like myself. A good day at work for me–a day when I get to flex my life saving muscle and bask in the glory of my critical care prowess–is a bad day for anyone on the receiving end of my clinical skills and empathy, no matter what the outcome.

No one wakes up expecting to be at the center of a human tragedy. Yet, as trauma surgeons we are thrust into a peripheral role in such tragedies daily. In my typical week on service (a few nights on call, 7 days of rounding, two clinics, and reams of accumulating paperwork) the balance of patients with minor injuries, good outcomes, or major life saves typically outweigh those with severe life-threatening injuries at risk of high morbidity and mortality.  But this has been an atypical week.

These last 6 days have been filled with inexplicable events and unimaginable losses for my patients and their families. Car crashes, suicide, house fires, occupational hazards, animal attacks, physical abuse, interpersonal violence. The causes have been varied. The effects have been a river of tears flowing through a mountain of grief. The landscape of sorrow created by these tragedies has exhausted me far more than the overnights and the ~110 hours logged in the effort to provide round the clock trauma care.

As surgeons, we hope not to grow too used to it, not to become cold and unfeeling in the face of human tragedy. But we need some way to move on. This week, I feel buoyed by gratitude of surviving family members and the supportive words from fellow providers. The warm embrace and patience of those who love me and care for me during those few hours away from work have also helped. But with one more day to go, I am simply wishing for a quiet last day on service devoid of human tragedy. No more bravado in the trauma bay. No more delivering bad news. No more grief for the people in my catchment area. We all need a break.

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The Miracle Worker Gets a Hug

The tension between the desire to provide the best care and the system putting up road blocks was building the entire day. As the surgeon advocating for my patient, it felt like the smoldering rapidly progressed to full on conflagration. And, yet the patient and his family were calm and filled with grace.

On morning rounds, I told my patient that his hernia remained reduced but there was an area along the bowel that had been stuck the prior evening that looked worrisome on CT scan. His vitals, exam, and blood work were reassuring, I explained. There was no imminent rush, no immediate threat to bowel or life. But, it made sense to get this done as soon as possible. The patient, and his wife at the bedside, understood. I had explained a clear set of options for what to do about the hernia depending on a) how the bowel looked when we put the cameras in and b) based on my understanding of his baseline co-morbidities. He was a smoker with a chronic cough that exacerbated his hernia. I spent a little bit of time counseling him that this might be an ideal time to quit. Anything to ameliorate the cough during the recovery process and beyond would reduce the chance of recurrence.

Those words “as soon as possible” resonated in my head as the wait for OR time dragged on all day.  Circumstances were at a systems level well beyond my control; the absence of an immediate life threat meant I had no real leverage other than rants about patient satisfaction and costs of prolonged length of stay. This meant nothing given that there were patients who truly needed life or limb saving interventions, including one of my own who arrived at 5pm with free air.

This patient was too stable.

I had run up to his bedside a few times during the day with updates to the effect of “not sure yet…but you continue to look good…as soon as possible” He and his family–thankfully–were remarkably affable while I was becoming more and more agitated at the OR inefficiency in between urgent cases.

[I could write a dissertation on OR efficiency, or lack of it. And, certainly this is not a problem limited to my workplace. But that’s not what this blog is about.]

I was not on call that night. The OR could finally accommodate the case in the late evening. It went as well as could have been expected. The bowel looked great. The patient got the best case scenario of the options I had presented to him some 16 hours previously.

When I went to talk to the patient’s wife afterward in the waiting area it was almost midnight. She was exhausted from a day of anticipation. From two hours of anxiously waiting while her husband was in the OR. She gave me a giant hug and thanked me so profusely for sticking by him. “I know you have been here since so early this morning,” she said. In the moment of that most genuine embrace, the fire went out and the frustration of the day slipped away.

The next day, in preparation for discharge, the patient was exuberant. “You’re a miracle worker doc!” he exclaimed. “I’m done with the butts now. Forever. Thanks to you. And you fixed my hernia. You’re a miracle worker.”

It took me a while to figure it out since it’s been forever since someone referred to cigarettes as butts to me. The miracle was not that I fixed the hernia. It was that for the first time in 50 years he was motivated to quit smoking. His wife would stop too, she told me that day.

It was a tough day at work but this lovely couple thought I was a miracle worker deserving of a hug despite it all. No anger. No bitterness. Just genuine gratitude, a case that went textbook well, and some preventative medicine to boot. What more could a beleaguered surgeon ask for?

[Posted with patient’s permission.]

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The Final Chapter

He had loved her with all his being for more than 6 decades. In the last 2 years of their 61 year marriage, he had watched helplessly as dementia wrapped its noose around her, slowly tightening its grip on her mind and pulling her away from him.

When I met him I knew the injury was irrecoverable. Her brain was consumed by hemorrhage that had filled the space (cerebral atrophy) left behind by progressive dementia and then some, deflecting the midline between the two hemispheres nearly 12mm.

I asked him what had happened. She had tripped and fallen. For all her mind’s frailty, her body was still strong and agile for her 83 years; how she stumbled in the small living room they had shared for more than 50 years remained a mystery.

She was still breathing on her own but her brainstem’s ability to preserve this vital function was succumbing quickly to the pressure building from above. She appeared to be peacefully sleeping. He had not yet grasped that she would not be waking up.

I asked him what life was like at home before today. She was no longer aware of who, what, when, where, and how. A nurse would came daily to help her bathe and dress. She would then spend most of her day in a trusty old recliner. He would cook and feed her, then put her to bed every evening. They had no children. They had outlived their siblings.

Theirs was a story of two lifelong friends and lovers. Every Sunday he would take her for a drive. He wanted her to see the sun and the trees and the world outside their home. This was romance in the denouement of life. And here I was, suddenly a supporting character in the final chapter of their love story.

He cried quietly as I explained the magnitude of the injury. Like too many of my octogenarian patients, she had no advanced directives. None of the providers who knew her far better than I had thought a discussion of code status was worthy it seems. So this was my role.

We talked for a long while. After reviewing what all the technology in my critical care armamentarium might do and not do for the love of his life he said to me, “I don’t know I what will do without her. I don’t know any other life. I don’t have anyone else.”

His heartache was palpable.

There was surprise and some expression of dismay at the administrative hassle I caused when I planned to send her home with hospice services directly from the ER that day. I am grateful for the ER physicians, nurses, and social workers who helped me execute that plan even though itt would have been far more convenient for us to simply admit her to the floor.

That she would die peacefully in her home of five decades with her partner of six by her side is the kind of medical outcome that looks poor on paper but feels good to the surgeon’s soul.

 

 

 

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Hey Doc!

“Hey Doc!” I heard the patient say as I blazed by Bed A.

Bed A is the ‘door’ bed. My patient was in Bed B, the ‘window’ bed. I had just met him; it was a new inpatient consult. For all the rules and regulations surrounding patient confidentiality, the curtains between beds do little to protect privacy since inevitably there will be audible conversations about symptoms, diagnosis, and management between patients and the doctors, nurses, or family who visit them.

The residents had already seen the patient in Bed B and were reviewing his case in detail with me between OR cases. I looked at my watch, contemplated typical OR turnover time for a moment, and decided we had enough time to get the consult done.

When I got to Bed B, I introduced myself to the patient and sat at the edge of his bed. I explained that I had already reviewed his story, lab data, and imaging and confirmed these facts. I stood briefly to perform my physical exam before beginning to scrawl on an index card. I simplistically portrayed the complex anatomic relationships between the liver, the gallbladder, and the pancreas and the series of tubes (the biliary tree) that connect these organs. I described how stones form when the balance of three ingredients (bile salts, lecithin, and cholesterol) in the viscous fluid (bile) made by the liver, and stored in the gallbladder, gets off kilter and how those stones can then cause blockages at various points along that biliary tree. I showed the patient where his problem was and used hash marks to explain the operation and what would be removed.

Before getting my patient’s signature on the consent form, I made sure any questions were answered and asked if he wanted me to call a family member to summarize the details. He said no and signed.

Conversations like this take time. Whether it is the 4 patients per 15 minute block in clinic or the patient who I am rushing to see between OR cases, I invariably feel pressed for time when talking to patients. But I do what I have to do, often skipping meals or holding in bodily functions while incorporating a brisk walking speed to keep up with competing demands, none of which seem to incentivize having thoughtful and thorough conversations with patients and/or their families.

After telling the patient in Bed B that I would see him in the pre-op holding area the following day, I upped my walking pace so I could run back down to the OR to my next patient. I had already taken too long and was anticipating the reprimand of the OR board. And that’s when I heard the patient in Bed A.

“Hey Doc!”

“Ugh” I thought to myself, “I really don’t have the time to find this guy’s nurse for his pain meds or to figure out how to keep his IV from beeping…”

But how could I not stop? He was addressing me directly so I paused and turned to him from the threshold to the room.

“Hey Doc! It ain’t none of my business or anything but I just wanted to say that there would be a lot less fear in healthcare if all doctors explained things the way you do.”

I was humbled by this man’s feedback. I hoped my residents were listening, both to the man in Bed A and to what had just transpired before Bed B.

I find it very irritating when students or residents peel away or talk among themselves, as if they are sick of hearing what I have to say, while I am having conversations with our patients. To me, modeling doctor-patient communication is my greatest gift to them as a teacher and a mentor. I want them to listen, to observe, to understand that every encounter is a chance to learn.

As we hustled back to the OR, I turned to the residents and proudly said “For as much pride as we surgeons take in doing the perfect operation or nailing a difficult diagnosis, what happened back there might have been the highlight of my career.”

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Ski Practice

To her it was like any other day. She had dropped him off, as was their usual routine, and gone into the city to see a friend.

He was an experienced member of the ski team. Practice was familiar. Take the lift up, ski down. Take the life up, slalom down. Take the life up…

It all happened quickly. He slipped through rail of the lift. The impact on the cold, hard packed snow was devastatingly complete. Perhaps it was his head, or maybe his spine, but vital functions were cut off immediately; he went into cardiac arrest. The ski patrol started CPR. Someone alerted dad. He arrived almost as quickly as the paramedics. They intubated him with efficiency and continues advanced cardiac life support.

He arrived as my patient immobilized with a long spine board and a cervical collar. He was intubated and CPR was ongoing. He had lost vitals signs at least 20 minutes ago. Dad was by his side as he rolled into the trauma bay. We kept coding him for the next 45 minutes. His pupils were blown. His skull base was boggy. We knew it was futile but he was someone’s child. It was hard to let go. But we did.

When I told dad, he was alone. He had not grasped the magnitude of on-going CPR and was utterly shocked when I told him his son was dead. My lip was quivering as I delivered the crushing news; my tears followed soon after he began to sob.

He asked me to call his wife. I told her it was serious and to arrive quickly but safely. Her grief is something that I will forever hold with me. I cried with her too. And, though it was not the first, nor would it be the last, time, that I would cry with a family experiencing sudden loss, my ability to be with these parents–REALLY BE WITH THEM–at the darkest moment of their lives reminded me, somewhat paradoxically, of the joys of my profession.

RBG is everything!

Originally posted on heelskicksscalpel.com

I finally made it to a showing of the Ruth Bader Ginsburg documentary This week. Despite my long absence from the blog, RBG so resonated with me that I felt compelled to tell you why.

Ruth Bader Ginsburg the woman and RBG the documentary is everything.

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(source: https://www.americanprogress.org/issues/race/news/2016/10/14/146171/say-it-aint-so-ruth-bader-ginsburg/)

I expected a thorough retelling of the life a remarkable woman. A quiet but fierce jurist and principled judge. A trailblazer among women and the strongest of advocates for equal rights. But I got so much more.

I didn’t anticipate that this was the kind of documentary that would make me cry. But I did. More than once. In fact, I cried several times.  I shed tears of sorrow as the documentary follows the Ruth Bader through the grief of losing the bookends of her life, her stern but loving mother at age 17 and her soulmate since age 18 Marty Ginsburg.  I welled up with tears of pride seeing her, just one of seven women in her law school class, making the Law Review,  successfully arguing before the nation’s highest court for equality across genders in all domains of personal and professional life, and then telling of her struggles, of her sex’s struggles, including the struggle to exercise control over our own bodies before the Senate Judiciary Committee when she was under consideration for a seat on that same court. I cried the happy tears inspired by true love and affection. First, there was the adoration in Joe Biden’s eyes as he listened to Ginsburg’s testimony during her nomination hearings. Then there was the remarkable, heartfelt, and genuine friendship between Ginsburg and her ideologic foe Antonin Scalia. I mean to watch them have fun together and share in their love of opera was truly such a wonderful and tear worthy thing. And, woven throughout the documentary was the once in a lifetime, made for each other that the Ginsberg shared. Every word that Marty said about his dear wife as a wife, a mother, or a professional made me squeeze my own husband’s hand a little tighter as I dabbed my eyes. It’s the kind of love, mutual respect, and balancing of inherent traits through open dialogue that leads to lasting marriages. The Ginsburgs had that.

I also did not imagine that I was going to a comedy but laughed plenty during RBG. I giggled at the site of a rather serious pint sized woman occasionally not taking herself so seriously. There are multiple cuts of Ginsburg working out her burly trainer wearing her ‘Super Diva’ sweatshirt. It’s just the cutest/most badass thing to see her bust out real push-ups (“not the girl kind” which is the only sexist moment I caught in the whole film). There a multiple different times when Ginsburg’s prowess, or rather lack thereof, in the kitchen comes up. She is able to heartily accept her failings as a cook as others in her family mock her for it. While the sharing of memes and addition of music to video of Ginsburg in relation to her being dubbed the “Notorius RBG” are humorous, the really hysterical moment is when Ginsburg details who she and the Notorius BIG have a lot in common. It should surprise no one that Ginsburg is not an avid television connoisseur. Thus, watching her laugh at impressions of herself that are wholly unlike her in real life are ridiculously funny. Seeing Ginsburg in costume to do bit parts in real operas, sometimes even composing some of the speaking parts, is funny as well. And, who wouldn’t crack up learning how Ginsburg accessorizes her robes with collars based on the content of the judgment to be rendered.

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(source: https://www.vanityfair.com/hollywood/2018/05/rgb-documentary-about-ruth-bader-ginsburg-is-surprise-box-office-hit)

I did expect, however, to feel anger and to be sure the RBG delivered. I was angry that Ginsburg had to fight so many battles on behalf of others who simply did not stand a chance in a system rigged to favor white men. I was angry that Ginsburg had to battle so many double standards to rise to her current position. I was angry that she has had to dissent on a number of key SCOTUS decisions, such as reversing voting rights protections or guaranteeing equal pay for equal work, that are taking our nation back to place resembling more the America of her childhood than the America in which I should feel that there is nothing to hold me back from being as accomplished as my male counterparts. There’s not much more to say. Anyone who is a thoughtful human would feel anger at this. In this regard, the documentary is pretty straight forward. Ginsburg has spent a lifetime fighting to make our nation a more fair and just place for everyone and she’s currently not on the winning side of the battle. It’s sucks. And it makes me really angry.

In the end, RBG was not just about anger, laughter, and tears. It was a playbook on succeeding as a woman in a man’s world. It was about grit, tenacity, and hunger to do good paired with a great mind. It was about giving permission to a generation of ambitious women to have a home life distinctly unlike that which has historically been most valued and expected in our society. It was about enduring love between two opposites driven by mutual respect and admiration. It was about the legacy of a principled woman of profound intellect who was not afraid to stand up and speak. We should be like RBG. We should be everything. The battle wages on and we need to be everything.

Memories (In a pile of old receipts)

Originally posted in heelskicksscalpel.com

In college, soon after I got my first bank account and a credit card with a $300 credit limit, I started keeping every receipt for every purchase I ever made. At the end of every calendar year, I would box up an annual pile of receipts. This continued until a few years ago when my husband decided he could no longer tolerate me forcing us as a family to save every receipt filed away into individual envelopes for necessities, frivolities, groceries, gifts, etc. He was right, outside of certain big ticket items and shoes from Nordstrom, there really was not any reason to “hoard” receipts (his words, not mine).

It’s been a tough habit to break. Now, when I empty out my wallet after a few days I scan the receipt for what I purchased and then cringe as a toss it. Every. Single. Time. Not sure if it’s just me still trying to break the habit or some weird paranoia that I will truly someday miss having proof of purchase for that t-shirt from target or that gallon of milk.

In any case, during some spring cleaning yesterday I came across all of my receipts from those college years. It was a fascinating lens into my past habits and routines. He’s what I remembered/learned about myself all these years later.

  1. I bought a lot of feminine hygiene products. A lot.
  2. I spent a lot of money on photocopies and laser printing.
  3. I ate out. Often. And, surprisingly I can remember who I ate with for each of those meals away from our usual two or three go-to restaurants. Making the effort to go somewhere more expensive or (gasp) leave the general vicinity of campus = a special occasion and I found myself imagining everyone who I thought was special to me all those years ago.
  4. I didn’t, however, indulge in snacks at convenience stores or similar. This is notable only because I am married to someone who definitely did.
  5. I always love to shop, it seems.
  6. I never paid more than $19.99 for any of my shoes or clothes back then. Typically, my stuff came in well under ten bucks.
  7. I owe a special thank you to the Wexner family of Columbus, OH. Were it not for their Limited/Express stores back in the day I might have had to go through college naked.
  8. I even once purchased something at an Abercrombie & Fitch store. This must have been before I developed migraines in response to strong perfumes or colognes. I won’t allow my daughter to shop there (at least when I am with her) because it’s some sort of moral stand I decided to take for reasons related to the forced inhalation of strong smells as I walk by their stores in the modern American mall.   I have always denied ever shopping there; evidently, I am a big liar.
  9. I never bought anything that would be considered athletic. Nope. Not a thing in which one could workout. This is regrettable, not only for the fact that it is evidence of my complete lack of physical self-care back then but also because it likely led to the backlash known as my current Athleta problem.
  10. I got just a bit nostalgic that Caldor, Lechmere, and Filene’s no longer exist.
  11. I evidently was also the kiss of death for any bank I decided to do my saving with. None of the three banks I used during those years exist today.
  12. I used to listen to a lot more music than I do now. Today I could stream constantly if I wanted to but honesty I don’t ever listen to music outside of my car or on workouts. Back then between mail order and the local Tower Records, I bought a lot of CDs.
  13. I enjoyed live music far more often than the concert every couple of years I enjoy today. But, there was no genre in particular that called my name as was evident from my ticket stubs for House of Pain, Duran Duran, James Taylor, and They Might Be Giants. And, as with those special dinners, I remember exactly who I saw each of those shows with.
  14. If there wasn’t live music to be enjoyed, I went to the movies. I saw some great films and some mediocre ones. I often sought out art house cinemas for limit release films. I didn’t just seek out the big screen for films whose effects would warrant the time, effort, and cost of going to the movies [read: the only movies I have seen in the theatre in the last 3 years are the 2 Star Wars movies.] I simply enjoyed going to the movies back then unfettered by the logistics of sitters and evening little league games or by the gravitational pull of my pajamas at 7:30pm.
  15. Occasionally, I went to a play but I was not so much a theater person. Rather I was an ardent supporter of my friends who ran the set, played in the pit, or were making their acting debut on their way to become ophthalmologists, lawyers, and Drosophila experts.
  16. I clearly went out a lot. But when I was in, I spent a lot of time on the phone at substantial cost. If I had invested the money I spent on hours of late night calls with my best friend from home, she and I would be enjoying some really tricked out girls’ weekends now. Calling friends came at a premium back then. Now, we have unlimited minutes to talk yet we rarely do; and, if we do it’s for minutes, not hours.
  17. I was proud of the fact that I worked to finance all of these “frivolities” that lightened my college years. I made $65/week at my work study and always deposited $40, spending about $25 on the typical weekend (Thursday night through Sunday brunch back in those days — never paying for a brunch until years later because, well, dining waffled were just that good) and putting away the rest for my phone bill and summer adventures.
  18. I didn’t really have any real adventures, though. I visited my sister and my best friend in New York a lot. I had a great trip to visit my roommate on the west coast our first summer after college. And, yes I saved every boarding pass and bus ticket. Greyhound and Peter Pan still exist but wow my TWA ticket for the *non-smoking* section was a real blast from the past. As was that boarding pass for my first every Southwest flight in 1993 — an experience that kept me from using this airline for the ensuing nearly a quarter of a century until driven by desperation about 2 years ago.
  19. I wonder what has happened to the carbon paper industry. I miss the satisfying mechanical sound of the credit card impression maker thingy. The screeching feedback that it’s time to remove my chip is not the same.
  20. I also miss my original signature with first, middle, and last name fully legible. receipts

 

A Belated Thank You

It was late. I had just finished a straight-forward appendectomy. I explained the findings and expectations for recovery to the family gathered in the waiting area. There were a lot more people there than in the emergency room just a few hours earlier.

“Yes, he will most likely be going home tomorrow morning,” I answered in response to a final question from a family member. I shook the mother’s hand and turned to walk away. Everyone’s expression was one of relief. It’s an every day diagnosis and procedure for us; for them, it’s quite possibly the scariest thing to have happen to a love one.

Except it wasn’t.

“I think I know you,” I heard when my back was already turned. “Do you take care of people in car crashes?” It was a timid inquiry.

“Yes, I am an acute care surgeon. I do trauma and emergency general surgery.”

“You think you took care of my daughter. Years ago. She died in a car crash. She…”

I cannot imagine how difficult it must have been for that mother to be back in that hospital, back in a bland waiting room with fluorescent lights illuminating my face again. I simply can’t. But, I had a crystal clear memory of that morning. Nothing was left to the imagination that day. Nothing needed to be discerned by the powers of radiation vectors.

It was a long time ago. Still, the image of that poor girl, a life I could not save, a body badly mangled by someone going the wrong way at highway speeds, was seared in my brain. It was truly horrific. The bodily damage was unlike I had ever seen before. My boss with more than 30 years more experience was there too. Neither had he.

“…Thank you for everything you did. You were so kind to us. You told us she didn’t suffer. You let us wail and you held us. We never said thank you.”

“Yes, I remember,” I gulped. I felt a lump in my throat, a tear in my eye.

CPR was in progress upon arrival. There was nothing to do but be kind. Words of gratitude were neither needed nor expected. It’s what we do. However, the reminder that families are grateful when we tell them we removed a vestigial organ without incident or when we deliver the soul-crushing news that their child is dead was deeply appreciated. For the lives we cannot save, with kindness and empathy we can at least spare those left behind from just a little bit of suffering in the midst of so much agony.

A Leading Woman Surgeon Speaks the Truth about Women in the Profession 

Originally published on heelskicksscalpel.com

Any one who follows this blog on the nuanced life and career of a woman surgeon  should watch this. In its entirety.

http://academicsurgicalcongress.org/aas-2017-president-address-caprice-greenberg-md-mph/

It is the Presidential address delivered recently by Dr Caprice Greenberg to end her term as President of the Association of Academic Surgery. She speaks with clarity and conviction on a topic of importance to both men and women across generations of surgeons. She provides data, vivid examples, and eye opening analyses about how and why women are professionally held back, not just in surgery but across specialties and other professional roles.