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I’m about to go to work.  During the course of my emergency department shift, I may see everything from an ankle sprain to a complex poisoning, a dying patient with cardiogenic shock to a corneal abrasion.

In the course of my career, at a mid-sized community emergency department, I have opened the chests of three individuals with stab wounds to the heart.  I have cared for paralysis, profound hypothermia, cardiac rhythm disturbances, SIDS deaths, assorted gun-shot wounds, metabolic derangements, venomous snake-bites, near-drownings and untold other complaints that have afflicted God’s creatures who came through my ER.

The fascinating turn of events in medicine is that, even as my colleagues and I push the limits of our knowledge and skills, medicine is filling up with doctors (and frankly with nurses) whose battle cry is ‘I’m not comfortable with that.’

In my residency (here we go with the old war stories), we flew on a medical helicopter called Lifeline.  On Lifeline shifts, you might fly to and enter a small rural emergency room and be met with utter and unimaginable chaos.  I saw a friend doing a thoracotamy once.  I did escharotamies on the charred skin of terribly burned adults and children.  I lay in the mud intubating a gunshot wound. But do you know the one common denominator?  None of it made me especially comfortable.

I think we’ve lost our way.  Medicine used to be a place where people went when they were willing to take risks to care for the sick and dying.  I mean, we knew everyone died, and most everyone became injured or ill.  So we figured, ‘I’ll give it a shot!’

Now, forgetting the universality of death, forgetting the near universality of error, and ignoring the great value of bold attempts to do good, our culture rejects all risk and our physicians have become soft and cowardly, hiding behind the fear of malpractice or worse…censure by regulatory bodies, loss of profit and inconvenience.

Where are the cowboys and cowgirls?

I won’t be comfortable with everything tonight.  But with God’s help, I’ll sure give it a whirl.

I hope physicians learn to rediscover the joy of risk.

Otherwise, we’ll be stuck with a profession full of insurance adjustors who sound like Bartelby the Scrivener…

‘I would prefer not.’

God help us!  And all our children, and theirs.

Edwin

My dear friend and partner Doug McGuff is a brilliant man.  He could teach at any medical university and be a much loved instructor.  He thinks of things, on a routine basis, that most of us forgot the day of the exam in medical school.  And he knows the Krebb’s Cycle…by heart.  I thought it was something on the dishwasher!
Doug’s great passion, after his lovely wife and children, is weight training.  He owns a high intensity weight training facility called Ultimate Exercise, in Seneca, SC.

Now, he has a new book on exercise called ‘Body By Science.’  I hope you’ll check it out.  Because the man knows whereof he speaks.

Here’s the link to his book at Amazon.com:  

http://www.amazon.com/Body-Science-Research-Program-Results/dp/0071597174/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1230930939&sr=8-1
The Krebb’s Cycle…is that on the dishwasher?

Edwin

Here’s my column in this month’s Emergency Medicine News.  Please remember to submit to grand rounds; our theme ‘Profit in Health-care!’  Send links or essays to edwinleap@gmail.com.

Happy New Year!

Edwin

Consider what you love

I love the skin of babies, because it is soft, and because it bears none of the scars that time, sickness, injury and heart-ache will leave.  It is a canvas waiting to be filled with kisses, touches and embraces   But I love the skin of the elderly because it is textured with time and stories, like imprints on a vinyl record.  Wrinkles simply represent long life, stored in the many hills and valleys of a body that has seen much, and endured much.  Touching the skin of our patients is such a rare delight.

I love, in an odd way, the sound of patients crying.  Not because I want anyone to suffer.  I love crying because I have cried.  Falling tears and heaving sobs are signs that we are all equally vulnerable.  They mean that we have in common our frustration with this life, and our desire for help, healing or simply comfort.  Sometimes, when a patient is crying, I want to hold them close.  I’m not there yet, but maybe I will be one day.

The sound of breath, smooth and clear or sonorous and rattling, is fascinating to me.  I think I love knowing the difference between good breaths and bad.  It is magnificent to have listened to that sound thousands upon thousands of times.  They say that with every breath, we inhale a molecule of air that Julius Caesar exhaled on the Ides of March.  By now, I can almost hear him say ‘Et tu, Brute?’  It is a gift, an amazing gift, to have heard life move in and out so many times.

Equally fantastic is the sound of the heart.  I am fascinated every time that I hear its amazing twisting movement and contraction, its mysterious expulsion and reception of blood that occurs over and over again until one day, with similar mystery, it ceases.  The heart is special because as I listen, I may put my hand on the wrist or neck of the patient, and feel the pulsations travel down the highway of arteries, feel it beat against my nerve endings and travel back up all the long distance to brain where I sense it.  And across infinity to my mind, where I perceive it.  The heart gets inside my head, you might say, and its beating can thrill as much as its cessation terrifies.

I am enamored of examining the abdomen, wherein lie so many organs, so many blood vessels, babies in the process of becoming, tumors in the process of destroying.  To examine the abdomen is to shake a Christmas package, wondering what might be inside.  I love the feel of appendicitis, though I am sorry for those who endure it.  There is such joy in seeing the wisdom of our teachers made manifest in our hands, and confirmed in the truth of our suspicions when the diagnosis is made.

The smooth symmetry of intact limbs is artistic, but equally wonderful is the way I can know, frequently without any test, that a limb is broken.  The many shades of blue and gray that surround fractures are testament to the underlying dysfunction.  There is an awful artistry to the jagged, disordered, fractal geometry of broken bones.

Wounds of all sorts are oddly amazing, and I have touched so many that I almost enjoy the reproducible warmth of blood, and its smell, as it pours across my gloved hand and I admire its lovely scarlet shades, my delight nearly vampiric.  Holes and slashes from weapons are unfortunate portals into the mysteries of the living, and sometimes the dead, human body.  I hate to see such suffering; but I am a voyeur of the flesh, having spent so many years hovering over it and touching it.

And death, death!  The lessons it has taught me over the years! It is sudden and slow, painful and painless.  It is tragedy and loss, hope and opportunity.  And it is a thing unlike any other.  I have seen life depart in young and old alike.  I know, through death, that there is something indescribably holy that enlivens us all before that moment and that leaves with breath and heartbeat.  I sense, in that fact, indescribable hope.

We humans are such pieces of wonder.  Every year that I have the privilege of practicing medicine, I realize that what I’m actually practicing is far more.  Medicine is the word for the study of the soul and flesh that dwell together in humans, and by which we physicians seek (in our limited ways) to put it right while it walks the earth; and before it is lain to rest in the earth.

Spend a day, now and then, in amazement.  Love the broken, touch the sick, caress the dying, shake hands with the scandalous and wicked, embrace the mad.  Learn the feel of their heartbeats and the sound of their breaths, the color of their eyes and the textures of their hair.  Each of them is a wonder no less than the stars.

Learn to see your career that way, and you’ll be able to keep going from body to body, wonder to wonder, without misery.  Let this be the year you fall back in love with your career by falling back in love with humanity, with the amazing structure and function of each human, and with the eternal worth of each and every life entrusted to your hands.

This was my column in the Greenville News on Christmas Eve.  I hope you find it relevant to your life, or the life of someone you care about!  Because my formatting isn’t working lately, here’s the link to the actual online column, as well.

http://www.greenvilleonline.com/article/20081224/OPINION/812240348/1016/OPINION

Against the serene backdrop of our theoretically peaceful Christmas season, I believe we are a nation of men and women, boys and girls completely overwhelmed by our schedules.  Do you doubt it?  Let’s look at the facts.

We work, belong to clubs, go to church, go to the gym, volunteer to ‘give back,’ and last of all, try to squeeze in time with our spouses and children.  Our children’s activities dwarf our own in scope and schedule.  One child may, in any given week, have school (with homework), soccer, swimming, dance, horse-back riding, parties, music lessons and tutoring.

For an eye-opening bit of truth, we should all ask ourselves one thunderous, salient question about our pace and our ‘busy-ness.’  The question is ‘why?’  Why do we do it?  Of course, we have to work.  And we enjoy social interaction to a degree.  But why do we do all the rest?  Is it because we believe we have to?  And if so, who said?

I suspect it was that universally powerful group known as ‘they.’  You may have heard of them.  ‘They’ are apparently a quasi-governmental organization based on human anxiety, loneliness and restlessness, funded by assorted membership fees and committed to the advancement of human misery and exhaustion.

‘They say everyone should volunteer.  They say you should work out three times a week.  They say that children need lots of activities and “socialization.”  They say that kids who do certain activities are more likely to get into good colleges and get good jobs.  They say that if you don’t get the right job you’ll be unhappy.  They say you won’t succeed in life without the right degree from the right school.  They say your children really don’t want time with their parents.  They say every kid needs a cell-phone, television and computer in order to be normal.’  I have to tell you, I can’t stand ‘them.’

The truth is that when we listen to ‘them,’ we push ourselves too hard for very little gain.  I know people who are literally slaves to activities; especially the activities of their kids.  They don’t rest and they don’t enjoy life.  They are worn, haggard and out of money.

Furthermore, it is my absolute conviction that most of the time, children actually enjoy staying home and simply playing…no team, no competition, no trophy, no uniform.  Children, far more than adults, understand what it means just to be.

Families that are indentured to activity don’t enjoy one another.  Parents and children seldom sit quietly at bedtime and just listen to one another breathe.  They’re frantic to finish homework, check e-mail, send text-messages and engage in all of the other propellants that serve to keep humans distracted from the terror of monsters like quiet, simplicity, peace and interpersonal communications.

I wish that we could stop listening to ‘them’ and so learn, in part, to defeat our own motion.  If we did, we might eventually overcome our endless desire to please, our need for constant distraction and learn to love just being together.

I mean, what are the dangers of staying home and slowing down?  Fewer friendships?  Many of them were superficial anyway.  Less resume material?  Sanity and calm might make for better interviews and more thorough work.  It would be a wash, at least.  The greatest danger might be the reality of facing our families, day after day, evening after evening, without a reason to walk away, drive away or click away.  (Ghastly, isn’t it?)

But what about the benefits?  Well, if you want practical ones, we might drive less and spend less.  Good for the environment, good for the pocketbook.  When we stay home, when we resist the inner and external urge for constant motion and stimulation, we will find our joys simpler but more wonderful.  We can actually talk, in person! We may play games, work on projects, share meals we cook together or enjoy a movie without the press of the crowd and cost of the ticket.  The proximity and commitment of time together will teach us deep things about those we love.  And perhaps teach us to love ourselves without anyone else’s approval.

This Christmas, this New Year, give yourself the gift of less and the gift of no.  Engage in fewer activities and say no to people who won’t let you slow down.  In the process, I promise that you and your children will end up with ‘more.’  And will more often want to say ‘yes’ to spending time together.

I want to be Santa Claus. It seems an appealing career. I’m not terribly overweight, but I do love cookies. I could fill out that red suit in no time fat…I mean no time flat. I like snow, and have always wanted to visit the North Pole. I enjoy Christmas music and with the right icy castle, the right reindeer, the right staff of busy elves and my wife by my side as Mrs. Claus, I think I could give it a go. I don’t think she would be very excited about being plump and white haired, so we could probably make an exception. (Besides, I’ve seen some ‘Mrs. Claus’ costumes in catalogs that I’d much prefer to see her wear). The children, all avid toy lovers, would most certainly want to be in the business. Forget medicine! Fetch me my sleigh! The main reason I’d like to be Santa is that I like to give gifts. My wife says that for this reason alone, I would make a good Kris Kringle. I love is knowing what a few people desire, knowing what moves them or makes them smile, then providing that thing. If I had Santa’s budget, Santa’s magic, Santa’s apparent time travel capabilities and Santa’s obvious omniscience, I could really have a good time. I’m always sad when I know that people receive gifts from the ones who should known them best, but the gifts have no meaning. Gifts are sometimes limited by finances, of course, but that’s not what I mean. I’m talking about times when gifts that should be meaningful are meaningless because the giver didn’t take the time to know the heart of the recipient. I hate knowing that children are ignored by parents who are too busy, or too drunk, too self-occupied or too stoned to care. I hate knowing that mothers get sweeper attachments and fathers receive socks, when what they wanted were violin lessons and a Golden Retriever puppy for duck hunting. But when it comes to giving gifts, it seems that the best things are seldom things at all. If I were Santa, I would want the power to give those gifts that resonate in the halls of the heart. Because people are desperate for their hearts’ desires to be known and filled. We are seldom honest with our loved ones about what we truly want. Of course, we are seldom honest with ourselves. Perhaps we don’t tell the truth because have spent our lives so occupied with busy-ness and entertainment that we’ve never bothered to look inside our own wonderful, broken hearts. Having spent some time around people, a lot of people, I think I know what I would be dispensing if I were Santa. I would muster all of my magic and give things elemental. I would give freedom to people enslaved by drugs, by food and by the cruel words of others that hold them down. I would give them liberation from the terror of self, by showing them that all of the bad things they think inside their own minds about themselves are false. I would let them wake up, check their stockings by the fire, and suddenly see themselves beautiful and capable, strong and good. I would lift depression like a cloud blown on a winter wind. I would give children the attention and genuine affection of their parents. I would give relief and hope to those suffering with the pain of diseases, so that on Christmas morning they felt not an ounce of discomfort. I would give back the missing children, and restore the relationships of estranged families. I would renew the passion of marriages that have been mere rote, elevate them from misery to delight and let Christmas morning be like a reunion of lost lovers. If I were Santa, I would visit the dying with visions of heaven so wonderful that their fear was banished like darkness before the rising dawn of Christmas morning. I would let men and women wake to see their dreams as possibilities, and give them some thing, some opportunity, some chance meeting that would send them laughing into the rest of their lives, doing what God made them to do with absolute abandon. If I were Santa, I would even comfort the arthritic bones of old dogs, so they could chase one another once more. If I were Santa, I would do so much. But I’m not. I guess the best gifts are still up to all of us for now. Trust me, when I get the job, you’ll know.