The Question We Cannot Ask

[Some might call this another rant. I call it a serious question we ALL should be asking.]


From an article about John McCain's entry into politics, in the New York Times:

"After five and a half years of listening to senators’ antiwar speeches over prison camp loudspeakers, Mr. McCain came home in 1973 contemptuous of America’s elected officials, convinced Congress had betrayed the country’s fighting men by hamstringing the war effort."

From innumerable McCain appearances:

I'll never surrender in Iraq... Obama wants to surrender... Democrats want to wave the white flag of surrender... If we leave, the terrorists win...

So let me ask a question that no one wants to ask: might five years of torture in a prison camp be expected to have an effect on one's (or some's) thinking about war? About challenging a war policy? Is it possible that one subjected to awful and inhuman and nearly unbearable conditions (for many, they were unbearable) could develop certain visceral reactions to the idea of war, positive or negative? To those who raise questions about a war? Might they affect the ability to distinguish between negotiating and collaborating? Could arguments be filtered through that personal horror in a way that makes one's reasoning different from one who never suffered in such a way? Faulty, even? Just theoretically: isn't it possible?

My experience in Vietnam compares to John McCain's as a bee-sting compares to a shark attack, but I have some memories, and things that trigger them. I hate the sound of a helicopter, of a fighter-jet taking off. (I live near an airport, and I hear both.) Sirens of a certain kind raise my pulse; distant explosions, as on the Forth of July, remind me of nights spent diving for cover. And no one beat me when these things happened; no one broke my arms. (Oh, I got a little broken in one rocket attack, but I healed fine.) I got up every morning and took a shower, ate a nice meal, went to the clinic and set up shop. In my room was a hotplate and a stereo. My wife sent me the fixings for chocolate pudding. Still, there are little things, and little reactions.

When John McCain equates talk of leaving Iraq to "surrender;" when he says those who question whether the war has done more harm than good are waving a white flag -- is it possible his judgment is clouded? Are those things that he survived (which many of us, myself included, probably wouldn't have had the grit to do) in any way affecting the thought process that connects skepticism to surrender? I'm just asking.

Given the stakes, and given the unprecedented situation of a presidential candidate who was a tortured prisoner for five years, in a war that split our nation asunder and which, in retrospect, accomplished nothing, isn't it an issue that ought to be considered? I don't have an answer. But I'd think, based on the fact that I'm a human and therefore have at least some knowledge of how humans behave, it is at least possible that this man's approach to war has been made, in part, irrational by what he went through. His is a voice to be listened to, a point of view worth knowing; but is it the one that ought to have the final say?

Believe it or not, this isn't the partisan me speaking; not the usual weekend ranter. It actually worries me, separate from my political opinions and views on the war. In these most cataclysmic of times, in the aftermath of questions not asked, I think this issue of which we dare not speak needs raising. Plenty of people believe, and are saying, that the time Barack Obama spent, as a young child, going to a Muslim-run but multi-denominational non-religious-based school makes him untrustworthy. What about being tortured for years, seething in a cell while anti-war propaganda played, and then being tortured again?

[The New York Times Magazine, in an article on McCain from May 18, quotes some fellow Vietnam Vet Senators from both sides of the aisle, all of whom have less jingoistic (and generally quite negative) views of the Iraq war: Kerry, Cleland, Hagel, Webb. Their take (and these are all guys who consider him a real friend) is slightly different from the question I raise. They imply that since he spent his time as a prisoner, he never faced the ambivalence of war that's seen by those on the ground, in combat, shooting and being shot at; they came to see it in shades of grey, as do most (I'd say) who've been in combat. McCain, they suggest, remained in a situation where right and wrong were entirely black and white. An interesting, and less dire, point of view compared to the question I raise. Either way, it takes a willingness not to give John McCain an automatic pass, just because of the horror of what he went through.]

Got Your Back

Where I trained, it was a very top-down place. At all levels, you were expected to inform the person next up the ladder before embarking on nearly anything. Which, as far as I'm concerned, is how it should be. Learn your limits: nothing is more important in being a safe surgeon. Ask for help, get advice, know the need. There were no mistakes as unforgivable as those of not following the chain of command.

In "Cutting Remarks," I told the story of a fellow resident who performed an emergency tracheostomy in the Emergency Room. That it turned out to have been unnecessary was not what got him in trouble. It was that when the nurse asked if she should call the Trauma Team, he said no, he could handle it, which he did, in terms of technique. But for his failure to communicate, he was called into the Chief's office and told this: "A cat has nine lives. A surgery resident has two. You've just used one. Now get out of my office."

That Chief was F. William Blaisdell, or, as we referred to him, the Blazer. A leader in the formalizing of trauma care, Blazer ran the Department of Surgery at San Francisco General Hospital while I was there, and he was one of my two most influential teachers. Some of his demands were a little annoying: no facial hair, no scrub clothes out of the operating room, wear a necktie at all times. But it was about respect. Respect for our patients, most of whom were derelicts and drunks and down on their luck. No matter. We handed every one of them a personal business card that Blazer had seen to for us, including the number of the surgery department and of the paging system.

What Blazer expected of his Chief Residents, of which, eventually, I became one, was not that we be right all the time. His expectation was that every decision we made was well thought-out, that it took full account of the situation, of all the possibilities, that the proper data had been collected and evaluated. Short-cuts, sloppiness were indefensible offenses. When I called him in the middle of the night to describe a patient and tell him of my plan, he might or might not choose to come in to assist. (I appreciated his confidence in me when he stayed away, but I always liked having him there. It'd be soon enough, I figured, that I'd be on my own. Now was the time to pick as many pearls of wisdom as I could.)

And here's the thing: if he felt you'd properly reasoned he'd never second-guess or fail to support your decision, even if it didn't work out. He'd talk it over, dissect it; teach back from the problems. But he'd stand up for you. Unlike some of the other staff.

Like most training programs, we had a weekly conference in which every imperfect outcome was discussed. "M and M" is the most common designation, for Morbidity and Mortality; ours was "D and C," for Death and Complications. The conference took up several hours of every Saturday morning, delaying the beginning of the infrequent weekend off, if such it was. But it was the best conference we had, probably the source of the most learning outside the OR. Chief Residents of each service presented the cases, but the grilling might be directed at anyone, even the loftiest of professors.

When I was on Blazer's service, the one thing I could count on, though, was that he'd be there for me. If there was a bad outcome, as long as he believed I'd done the right thing at every step of the way, he'd defend me against whatever onslaught, from whatever lofty source. Some of his junior professors were not so solid. "I told him he shouldn't do that," they'd lie. One guy in particular, whom I won't name. A tough case with a great result, he was there to take the credit, as if he'd done it and not me. But if something was imperfect, he sidled away like a crab catching the tide, wagging his tiniest claw behind him: not me, not me, not me.

Music of the Gods

This article is so dense with intriguing stuff that I hardly know where to start. Let's begin by ignoring the guy's extraordinary brilliance, with PhDs in stem cell biology and in music, before getting his MD. Ignore it, because it puts him so much in a class by himself that it must make the rest of us feel like tiny-brained sub-species. If he's superhuman, we'd be kidding ourselves to apply it to ourselves. So let's just consider the mind-music-medicine-surgery implications, starting with this:

“If I don’t play [the piano, if you didn't bother to read the article!] for a couple of days ... I cannot feel things as well in surgery. My hands are not as tender with the tissue. They are not as sensitive to the feedback that the tissue gives you.”

Fascinating. Is that an effect that translates to the rest of us? Or is it related to his special brain-wiring for music? If the latter, does music raise him above the level of other surgeons, or is it that it's necessary to keep him from falling below ours? Is it, in other words, a gift or a handicap? In my book, and here, as well as other places in this blog, I've likened surgery to music, and to ballet. At its best, it's apt: when the process of operating comes together in all its parts, with surgeon, assistant, scrub nurse, anesthesia in a kind of flow of understanding and anticipation, the result is symphonic and thrilling. Allowed to do so, freed from distractions and stops and starts arising from unfamiliar team-members, I can get into a rhythm of operating that seems to play like music, both carried along by it, and carrying it along. Does Dr. Conrad exemplify the phenomenon at its highest? Do musicians make better surgeons, do surgeons make better musicians? Without doubt (to my observation, anyway) there are some surgeons much more gifted in the art, in the technical process of surgery, in anticipating how a given situation will unfold. Do we have "musical wiring" (by which I mean something in common with musicians, as opposed to being necessarily gifted in music)? (And, yeah, I said "we," and I know it's braggadocio.)

The article also addresses the physiological responses to music, both in terms of its potential soothing and healing effects, as well as an implication that it might raise the performance of surgeons in the OR. I've written about music in the OR: contrary to the belief on which I was raised that it's a distraction, it's generally been found to be of psychological benefit, and I like it, mostly (sometimes, when fans became fecal, I'd ask that it be turned off while I concentrated intently). That some music might raise levels of growth hormone is quite amazing. The possible specificity of Mozart, even more so! Dr. Conrad's point about Mozart intentionally or subconsciously writing to ease his own maladies is provocative. I love the idea that he's trying to flesh it out: music vs no music; types of music compared to each other. (Maybe athletes can get their growth hormone through headphones. Headline: "Baseball Bans Beethoven!")

To me, music is among the highest of human endeavors: that we can create it, that it moves us. (My theory: there's a survival advantage from being able to distinguish among and to reproduce sounds of other animals.) Those that are truly gifted with it are sublimely lucky. For some, like my aunt, it's part of their metabolism. For the rest of us, most of us, there are pleasures to receive from those so gifted. And now, it seems, the benefit may be beyond the merely esoteric.

Looking In

After my recent "Family Guy" post, and a comment by the estimable bongi, I've been thinking about sharing. In the new-age sense of the term: letting people in on what you think or do or feel or other nerve-grating uses of the word. Y'know: "Thanks for sharing..."

I digress.

What I mean is that the esoteric world of surgery, so dramatic, and intimately knowable only to a small and generally comprehending audience, is quite isolated from those with whom we might most like to share it: family, close friends. I always wanted my son to see me do an operation (my wife did, once, when I was in training. But it was a small deal, and I wished she could have seen something more complicated). As much a part of my life as it has been, and as much as it took me away from his, I'd have loved to have had him watch it, just once. Demonstrate; explain. Perform, impress. Yet it's nearly impossible for a surgeon really to let people from the outside in on what it is that he or she does. I suppose it's not unique, but I think in most other fields it's more possible, easier to gain access. As thoroughly as it envelops us, as proud as we might be of what we've accomplished in learning it, what we do in the operating room must remain hidden from those we love. The fascination, the beauty, the talent (if that it be!): forced, by its nature, into secrecy. How many are the times I've wished it were otherwise. One of my proudest days was when my father-in-law, an anesthesiologist, came to town and spent the day in the OR with me. But he had business there. He's the only one.

Which reminds me of a story.

After years as a trial lawyer, my dad was appointed to the bench (meaning, to be a judge). As his days in front of the bench were winding down, I -- a freshman in high school, as I recall -- mentioned to him that I was sorry I'd never seen him in action, in court. Okay, he said, how about we have you come? Great!! Don't get your hopes up, he warned. It's pretty boring stuff, not like Perry Mason. As it turns out, he was entirely wrong. Other than the fact that the case was about a taxi and traffic, it was exactly like Perry Mason.

Dad was defending the taxi driver. There'd been some sort of accident in which the passenger was (not very seriously) hurt. It had been determined that the taxi was not speeding, but in Oregon there's this thing called the "basic rule:" when conditions warrant it, speed limits don't apply. If it's snowing, driving at the posted speed limit of, say, 35 mph, might be too fast. Common sense. So the plaintiff was on the stand, being interviewed by her attorney, and at some point claimed it had been raining. I saw the taxi driver lean over and whisper something to my dad. In turn, my dad leaned over and whispered to his Della Street, (actually, her name was Frances) who got up and left the courtroom.

When it was Dad's turn to cross-examine, after taking plenty of time, he got around to asking the witness about the rain: You're certain it was raining? Oh, yes. Do you recall seeing puddles in the street? I sure do. Splashes. Were the taxi's windshield wipers on? Yes, they were. People on the streets, using umbrellas? Absolutely. Umbrellas up the ass.

While he was doing this, Dad paced around the courtroom doing his tongue-of-death maneuver. It's hard to describe. When he was angry, my dad stuck his tongue part way out, flexing it (if that's the word) so that it became as thick as a Porterhouse steak, and clamped down like he'd bite it off if it weren't so impressively muscled. To us kids, it was a sign to head for the hills. One can only wonder what the hell the jury thought.

The doors at the back of the courtroom banged open, some heads turned that way. Papers in hand, the barest hint of a smile on her face, in trundled Della Street. Excuse me, Your Honor, my dad asked. May I have a moment? A nod of the judge's head, a back-flick of his hand. After Dad and Della conferred, Dad looked over the papers, and handed them to the judge. May I have these entered into the record, marked as an exhibit? So ordered.

Tongue active but unbloodied, Dad gave the papers to the witness, and asked her to read the title. They were, she read, from the Weather Bureau. The date? The day of the accident. And what is this column here? Precipitation. Can you find the heading for rainfall? Yes, here. And what does it say? Zero. Do you see the place for hail? Yes. Is any listed? No. Was there any snow that day? No. Was there any precipitation at all, precipitation of any kind? I guess not. Thank you. No more questions.

Well, yeah, okay. No sobbing confession on the stand, no close-up of those buggy eyes. There was no da dah, da DAH. But otherwise, it followed the script pretty well. I was impressed.

Later, I mentioned the tongue thing to Dad. Did he know he was doing it? Sure, just to impress the jury. That I didn't believe, not for a minute. Too creepy for that. Way too creepy.

And, Of Course, There's This:

The words are by Mark Twain, a tone-poem, if you will, that he wrote but was not published, at the urging of his family, until after his death.

Memorial Day

Hillary the Horrible

[Until now, I thought I was done with my weekend rants. But once again, I find myself needing to vent. So turn away, all ye who want it not.]


In my state we have a female governor and two female senators. I voted for every one of them, happily, and will again. I married a woman, and thus into a family of nine of them; my mom was one, too. I like women. I have no problem whatsoever with the idea of a woman as President of the United States. In fact, I'd love it. I even heard Hillary speak in Seattle a couple of years ago, and was impressed as hell. She'd be a great president, I thought. That was then.

The campaign Hillary has run in the past couple of months has filled me with disgust. The demure dredge-it-up/deny-it-down racial stuff. The gas tax pander; Bosnia fantasy. That was minutiae, background noise. They all do that (although what was the Bosnia thing? Hallucination or lying? Either way...) But the Florida/Michigan maneuvering is pushing it. I agree the rules are stupid, caucuses are crazy, the DNC made itself a fine mess. But she, along with everyone else, agreed to the rules, and is now acting as if breaking the rules is the only way to follow the rules. Now, she says, on the twenty-yard line, they must be ignored. But she went further, invoking Florida 2000 and Zimbabwe 2008. Yep, Zimbabwe. She's saying, basically, that abiding by the rules, the election becomes fraudulent. And her arithmetic isn't all that good, either.

At some point, her supporters need to wise up. It's not about misogyny; it's not guys taking it away from girls. It's this one. This woman. She ran a lousy campaign for the first several months, and a dishonest one later. Time and again she has shown there is no level below which she won't stoop, and it's unbecoming. It's the feminist thing to do, to say THIS woman is wrong. She's a woman, and she's wrong, and the two have nothing to do with each other. It's not about her ovaries. It's about her outages. Has there been sexism? Sure there has. Just as there's been racism. For each of them, in both directions, for and against. Not a pollster, I, but I'd guess it approximates cancellation.

Now, finally, the last straw has been laid on the back of this camel. In responding to why she shouldn't drop out in June, she points to the Robert Kennedy assassination in June 1968. To the immediate wave of disgust, she disclaimed by saying, well, the Kennedys have been on my mind lately, as if to say it was sort of a slip of the head, like Bosnia maybe. Except that she said the same damnable thing two months ago.

Hillary Clinton is perfectly happy to de-legitimize the whole process in the name of her own personal gain. She's fine with setting up a situation wherein if she loses, her supporters will have been made to see it as a personal slap in the face to all women; by her definition, any outcome that doesn't give her the nomination was, prima facie, unfair to her, to women, and therefore to support "her opponent" (as she likes to refer to him) is betrayal of women everywhere.

Especially in Zimbabwe.

Hillary Clinton is the opposite of change in how politics is done. She's the epitome of saying anything, doing anything, excusing anything as long as it promotes one's own narrow political interest. Barack Obama, while hardly perfect and maybe not even able to succeed in his message of change, is miles higher than her in tone and tactics.

I dislike her for making me dislike her. Were she the nominee (which, thankfully, seems all but impossible) I'd have a moral dilemma. I will not vote for John McCain. In many ways, I respect him. I admire his bravery in Vietnam, and doubt I'd have been as strong. He's been known to take tough political positions. But I think his "straight talk" has been seriously compromised, and he's happily distorted his own record when it suits him. Mainly, his policies on the war and the economy are too much a continuation of the Bush disasters: he even goes further than Bush on tax cuts, increasing the curse on the next generations. His foreign policy "expertise" is anything but; his military judgment shown false. But really: I consider myself a person of principles. As such, despite how much I'd hate to see a McCain presidency with its pre-failed economic policies, crazed right-wing judges, discredited foreign policy bluster, and phony anti-lobbying posture masquerading as ethics, to vote for Hillary would be to legitimize her tactics. And that I couldn't do. I'd have to withhold a vote, and that pisses me off.

Note to Senator Obama: Please don't yield to those who think she should be on the ticket. Then I'd really have a moral dilemma.

Uh Oh...

Another item from the American College of Surgeons:

COLLEGE OPPOSES RECOMMENDATION TO INCREASE PAYMENT TO PRIMARY CARE

On Friday, May 16, the American College of Surgeons and 13 surgical specialty societies sent a letter expressing strong opposition to a Medicare Payment Advisory Commission (MedPAC) recommendation, which calls for increasing payments to primary care physicians, while cutting reimbursement for all other physician services. The payment reductions for other physician services, including major surgical procedures, would occur because the pay hike for primary care must be budget-neutral. Only two of the 17 MedPAC Commissioners....opposed the recommendation. In their correspondence to MedPAC Chair Glenn Hackbarth, JD, the College and the other surgical societies noted that primary care is not the only specialty experiencing significant challenges in today’s health care environment. The letter cites several difficulties facing surgery, including decreased reimbursement, surgical workforce shortages, and increased practice expenses, especially for professional liability. Copies were sent to leading congressional committees with jurisdiction over Medicare policy. The letter concludes by noting that “[if] this recommendation is acted upon, the ones who stand to lose the most are not America’s surgeons but rather the patients who rely on the life-saving care that only surgeons can provide.” [Interesting side note: the Chair of the P.A.C. is a JD, ie, a lawyer!]

I've been known to say, when my clinic and the non-clinic docs in town were even more acrimoniously at war than they now seem to be, that the insurance companies must love it: set us upon ourselves, grabbing at whatever is offered lest the other side make an even less-favorable but exclusive deal. This sort of thing will get worse before it gets better. If it gets better. Which it won't.

It's amazing, isn't it? In our lifetimes -- who'da thunk it? -- we're actually going to see cataclysm: events are moving so fast, we're living in the time of the passing of the tipping point on oil, on the federal budget crisis, and we'll bear witness to the collapse of health care in the US. And there's a good chance that in my dying breath, as we rise up as a nation and begin killing one another, I'll be able to say, recalling the pivotal 2008 election which turned on race and religion and spouses and fear of the dark instead of on energy and budgets (and infrastructure, and health care, and environment....), "I TOLD YOU SOOOOOOO00000oooooooooooooooooo......."

Family Guy

When I saw my brother-in-law dazedly slugging toward the house, blood streaming down his face in impressive rivulets, I sprang into action. Well, okay, not so much me as his wife, and my wife, and another of their sisters. But I did, eventually. Maybe not "sprang," exactly, but went over to have a look. And determined that on this Sunday morning, on an island, he'd need a few sutures. No problem. We had the whole cast of characters on hand.

It helps, on a Sunday on an island, to have the keys to the clinic. If the one holding the keys is the head nurse and clinic manager, sister-in-law to the subject, and weekend host, so much the better. What good is a surgeon, after all, with nothing to put in his hands?

So up we loaded D., pressuring appropriately the wound (rendered, it turns out, by a branch let loose by D. as he... well, I won't embarrass him...) and drove to the clinic. J. (not really a giveaway since the entire family of nine kids and two parents and, at one time, dog, thus initiate the spelling of their names) let us in and quickly gathered the needed utensils in a treatment room. With D's wife looking on admiringly, and ably assisted by J, I prepped the skin, infiltrated a little local (after calling for the stuff I'd need, all knowledgeable-like) and whipped in a few sutures, flashing my best instrument-tying technique in a blur of man and machine melding. We cleaned the place up and were out of there, the whole concerto from entry to exit having taken only fifteen minutes. Compare, if you will, to any day in any ER in any location. Helps to have friends in high places, especially on an island.

The image that remains in my memory is that of D's wife watching. D is a contractor and a builder and I've seen his work many times. Impressive stuff. And whereas throwing in a few scalp sutures isn't the acme of my work, it was the only way she could ever have seen me do what I do, and I liked that. Flipping the tip of the needle holder through a nicely proportioned loop of nylon; laying the sutures down in perfect intervals, bringing the skin together exactly, not too snug under a surgeon's knot, back flipping the next loop. Things I've done since I was a med student (less well, then), and hardly the equivalent of building a multi-million-dollar-home; but it was nice to let them, for a moment, into a corner of my world and how I live in it. Makes it real, after years of being the guy who was too busy to show up.

Says It All

In the latest email bulletin from the American College of Surgeons:

....Practice Management Webcasts for 2008 and early 2009 include:

• July 9, 2008 - Negotiating Better Third-Party Contracts
• July 23, 2008 - Practice Valuations ... What's Your Practice Worth?
• Aug. 6, 2008 - Compensation Formulas of Successful Practices
• Aug. 20, 2008 - Effective Personnel Management
• Sep. 10, 2008 - Dealing with Difficult People
• Sep. 24, 2008 - Maximizing Patient Collections
• Oct. 1, 2008 - Scheduling Techniques for Improved Productivity
• Oct. 22, 2008 - ICD-9 Coding & ICD-9 Changes for 2009
• Nov. 5, 2008 - E & M Coding ... Beyond the Basics
• Nov. 19, 2008 - CPT Coding & 2009 Updates
• Dec. 3, 2008 - Bottom-Line Budgeting for 2009
• Dec. 17, 2008 - Billing Compliance: Avoiding Fraud and Abuse
• Jan. 14, 2009 - Creating a 2008 Management Work Plan
• Jan. 28, 2009 - Analyzing the Financial Health of Your Practice
• Feb. 11, 2009 - Medicare Update for 2009
• Feb. 25, 2009 - Advanced CPT Coding
• Mar. 11, 2009 - E & M Coding ... From An Auditor's Perspective
• Mar. 25, 2009 - ICD-9 Diagnosis Coding for Doctors & Staff
• Apr. 8, 2009 - Appealing Third-Party Claims
• Apr. 22, 2009 - Effective Governance and Management of Your Practice
• May 6, 2009 - Benchmarking Practice Productivity and Profitability

Anyone wonder why I quit?

Yeah, I acknowledge that you can't avoid this stuff, and it's better to be smart about it. But trust me: this is but a teensy sampling of that with which we are regaled, pretty much daily. All I ever wanted to do was take care of patients. I had this silly idea that if I did a good job of it, the rest would take care of itself.

Faint Praise

Syncope. Great word. SIN-co-pee. (I prefer SINK-oh-pee.)

Summertime, during college, I worked on a construction crew. One job was in the woods, following behind a D-9 CAT as it pushed down trees, clearing a path for a sewer line (the job I then had building manholes killed the guy that took over for me when I returned to college. That's another story). I'd saw 'em up with a chainsaw, buck 'em up with an axe. Filling the wait time, I kept that double-bladed axe sharp as a scalpel, honing it with a broad file, the metallic hrrizzzzzz, hrrizzzzzz and the sway of my hardening shoulders convincing me I was Paul Bunyan. In one of my moments of brain-body disconnect (I also nearly produced a sagittal section of my head with the chainsaw, cutting a log lying across a gully, above me), I tried whittling with that axe, whizzing it past the fist that held my would-be chunk of wood sculpture. Gee, I thought. I could really hurt myself; and with that, I did it again, this time slicing into me just beyond the sino-thumbic M-P joint. It bled quite a lot.

After a few comical moments, wherein I grabbed my thumb and flagged down the CAT driver, who hopped off with a first aid kit and tried dabbing an iodine ampulet into the considerable flow, I found myself in the office of a nearby doc. "Lucky you didn't get the tendon," he said. And then, "Oh, it looks like you did..." As he readied his suturing materials, he suggested I lie down. "Naw, " I blustered. "I'm gonna go to med school. I've dissected frogs. This stuff doesn't bother me." So I watched as he injected some local and began sewing. It wasn't the blood, or the hurt. It was the sensation of feeling some sort of tug as the needle passed: I thought I could hear it or something. An awl through leather. Weird. About the time he looked at me and suggested again that I lie down, I said I thought I might go ahead and lie down...

I've seen a lot of people faint over the years. Since an episode during internship when a friend of a patient who'd insisted on watching as I sewed him up fell like a log, straight and unfettered, to a concrete head-lacerating floor, I've anticipated it. Still, it happens. Nearly always, on arousal, the fainter is embarrassed. Don't be, I'd tell them. It's natural. There are some situations when it's best to lie down, and when we fail to recognize them, or act, our brains are wired to see to it that we do. I always liked that explanation. I think it might even be true.

It's interesting. For some threats to our well-being, our adrenals squeeze like a fist and out comes the "fight or flight" response. Pumped up, ready to go. (Or is that "fired up...") For other situations, the better choice is "sit down and shut up." When you think about it, it makes sense. For a threat before which you remain more or less intact, a racing heart and fleet feet seem right. If, however, things take a turn such that your pipes are open with fluids leaking out, it might be wise to shut things down. So I think fainting is nature's way of telling you to cool it. If you're too dumb to get your brain at or below heart level, your head will make the move for you. And turn down the pump at no extra charge.

Well, nothing's perfect. Why we should keel over when someone else is in trouble escapes ready explanation, at least by me. Maybe it's slop-over, an individually exaggerated form of communally-needed empathy. You know you should help, you want to help, but shit-oh-dear: gotta take a pass! Of course, it might ensure that you'll have a second chance when you both wake up.

JB

It can't have escaped notice that of late my blogging has wandered from the prime directive to inform and entertain about surgery and surgeons. So this post splits the difference. It's about friendship, and it's about a surgeon. I've mentioned him already.

Not entirely by intent, in recent years I've become more of a recluse than is my nature. Time was, I had lots of friends. In college, we were a group of four guys who ate nearly every meal together, went on dates together, did funny bits up and down the Northeast Coast; and there were a few others, my freshman roommate included, that were close and with whom I've stayed in occasional touch. Med school included new pals; with one or two I have rare contact. During surgery training, my wife and I had several couples who were much more than typical friends; not all of them were medical, and the friendships intersected in all possible combinations. I knew we were lucky, and I loved it. Once I started in practice, things narrowed into mostly professional acquaintances. Sitting in the doctors' lounge when there was a moment, shooting the breeze. Non-medical friends were fewer, and mostly consisted of people with whom we shouldered solidly on sidelines of our sons' sports sagas. Those were good friendships, too; but time, and our son, have moved on.

In the last few years of my practice I was so busy and so exhausted I really had time for little of life outside work. Since retiring, I've finally gotten close to my wife's large and noisy and wonderful family. They, entirely, are my friends now. Which ain't' half bad, except that they're all over an hour away. But as of a couple of weeks ago, I'm reminded of what I've been missing: JB and his wife were here for a few days, and now their absence feels like a hole.

On paper, there should have been problems: he's conservative, I'm liberal. He's religious, I'm not. I'm old, he's older. Where we both trained, ten years apart, he cut a wide swath; I came and went without fanfare. But here he was, after corresponding for about a year, and a brief meeting for only a couple of hours in San Francisco a few weeks ago. With his wife, whom I'd not met, he flew up from his place near Yosemite to spend four days with me and my wife, whom he'd not met. We've been married about the same amount of time (longer than many of my readers are old); our wives got along great. JB and his wife, Jeannie, met in Vietnam: he a surgeon, she a surgical nurse. Clearly, it was a central event in their lives. That, and the entry into it of their much-loved son. If our wives were unsure, JB and I knew with some instinctual certainty that it'd work. And it did. Despite certain philosophical differences, we have much in common. I'd even go so far as to say that we have our differences in common, although I'm not sure I know what I mean.

Going through surgical residency and war, which are not in all ways dissimilar, leaves a person with experiences that can't be fully imagined by others, and which bind people who have, no matter their other differences. JB and I did both: the former pretty much exactly alike, the latter less so in that he was a fully-trained surgeon and I just a general medical officer. But it translates well. His video from then (warning: parts are very graphic for people not used to trauma surgery -- and there's some of his writing here), though much more intense than one I could ever make, has overlap with my experience; some of it quite exactly. At the least, we both know war as much more than an abstraction or a slogan, and have seen its futility and horror at its worst (me, a little less than he!), and its fellowship at its best. And having had many of the same surgery teachers, we have stories to tell. Tell them, we did.

Amazing to me, we also have in common the abandonment of busy and successful surgical practices in our fifties, and for the same reason: it wasn't as much fun as it had been. A sense of it literally killing us (in his case, the signs were unmistakable). To do that, I'd say, requires a certain sensibility; maybe more than anything else, that decision alone tells me we're of similar cloth. It wasn't easy; nor free of worry, or of deep ambivalence. Whether on the basis of these things or not, there was an instant feeling of commonality and of trust. And that led -- preconditions set out in a couple of emails to the contrary -- to the ability to talk about politics, and religion, and life, without worrying that differences would break us down.

We ferried to Lopez Island and spent the day with my sister- and brother-in-law, talking incessantly on the way up, and back. I perfectly grilled some halibut, taking (of course) full credit for the entire meal made over the previous couple of days by Judy. Making up part of the smallest crowd ever (literally: the smallest ever!) at Safeco Field, we went to a Mariners' game, and afterwards to a luscious chocolate shop and talked till midnight. It's been a while since I've done that, unconscious of the time.

In this post, I thought I'd be describing JB in more detail and better than I had in a previous one (he was highly amused by the "wiry" moniker.) But I'd risk embarrassing myself (as if I haven't done that before!) or having it come off as hero-worship. So I'll just say this: JB is about as real as they get. No artifice. Honest. Knows who he is, and why, and what that means for him. Hell of a story-teller. A little paranoid about us liberal types.

I like him. I like his wife. We all got along, and well. For the first time in a long time, I felt I was spending time with a friend, it felt good, and I miss it.

[Update, 10/10: How things change. I guess it's the oldest friends that are the best ones, after all. Preferring to believe Barack Obama is a closet Muslim, JB finally had enough of me pointing out that he wasn't. Concluding I was an America-hating, terrorist-loving Jew, he kicked me to the curb like the remnant of a retread. I missed him for a while, even then. And I still miss the person I thought he was.]

[Update #2, 10/17: Watching the Ken Burns/Lynn Novick Vietnam series on PBS, I thought of JB many times; even thought I might see him. One story in particular, of a man triaged for death but saved by another surgeon, sounded like one he'd told. So, not knowing what to expect, I contacted him.

Having gone through several family tragedies and a couple of major, life-threatening health issues, he's back to the man I once knew. We've resumed our communications, and it makes me happy. Who knows? Someday there might be a reunion. Life. What a deal.]

Dougie

"Ready...." A long pause, milking it for all it was worth.

"Aim...." Blindfolded, I squirmed. I figured it was what he wanted.

"FIRE!!...." Then ...nothing. Not a surprise. This was, after all, payback. "C'mon," I said, making it sound like begging (which it was, partly.) "Just shoot me." Tick, tick.

Pkkfftack. Buried right next to my spine, deep and painful. Fair enough. Otherwise, he'd have told my mom.

Like many kids, it was by indifferent luck that Dougie and I survived childhood, and each other. On this particular occasion, we'd been shooting one another with a BB gun he'd borrowed from a neighbor. Unlike our Daisys, this one had some oomph; you could pump it more than once. Because we weren't totally clueless, we'd been using protection: the shootee wore a diving mask and a raincoat, and was dashing between trees across the street from Dougie's house. The shooter, from a window in Dougie's bedroom, took shots at the victim as he zigged the space between the trees.

Given the distance, and the precautions, it was fairly harmless, although it's hard to say where all the pellets ended up. After Dougie had had his turn as prey, he peeled off the mask and coat and ran toward the house. Who could blame me, really? It was such a clear shot. I fired one more time.

Being one year the younger, he was used to abuse by me. But this time he was really pissed, and I was scared of what I'd done. He'd screamed, "MY EYE!!!," and slapped his hand over his face, stopped dead for a moment, then run into the house and upstairs, hand still in place. (No one else, of course, was home.) I was cold-fingered and, I'm sure, white-faced as he removed his hand. The welt was within the hairs of his eyebrow, sparing his eyeball for no particular reason. He was, among other things, threatening to tell my mom.

The firing squad was our negotiated settlement, a way to retribution for him, and a promise to remain silent, for me. It's my recollection that he had to dig the pellet out of my back. Impressed with its power, we fired the gun again, at some sort of metal pan, and it went right through. Or dented it pretty good. Don't remember which.

I hog-tied Dougie once, playing cowpersons and Native Americans. Accidentally dropped him on his chin, causing enough bleeding that he thought it was coming out of his eyes. Another time my brother was showing us how to swing a golf club. I was looking over his right shoulder, Dougie over his left. My brother is right-handed. Enough said. Sounded like a coconut.

The time when actual death was among the possibilities (although I guess the golf club came close) involved bows and arrows. The real kind, with metal tips, albeit not the hunting variety. We'd been at a field at Reed College, where there were straw-stuffed archery targets. Shooting at those static circles got boring in about five minutes, so we did the natural thing: started aiming straight up into the air and seeing how close we could get ourselves to where the arrows came down. Pretty close, as it turns out. Ssshhppt. Couple inches from the shoe. Well, maybe a foot or two. Until one went up so high we lost sight of it.

Quickly computing the consequences, we sprinted in opposite directions. Dougie ended up scronched several yards away, having pulled his jacket up over his head. As if guided by the judgment of fate, the arrow returned to earth by way of Dougie's jacket and the space between his elbow and his left side. As I learned in anatomy class many years later (for this is a surgical blog), there were any number of comparatively vital structures within a shaft-breadth or two. No negotiations were required to keep us both silent about that one.

It wasn't all bad. We got hold of a couple of Army-surplus intercoms and strung wires between our houses, which were on the same block, around the corner from each other. Securing permission from every intervening neighbor, we ran the wires along fences and property lines. Battery powered, the boxes weren't very potent with that much wire between them, and there was no call buzzer. You had to lean pretty close to hear anything. Sometimes we could alert the other of a call by scraping something across the metal face of the box; usually, though, we'd call on the phone, and then hang up and carry on using the intercom.

Charmed by electricity, I did once try to electrocute Dougie, in the guise of a "lie detector" which a brainy friend and I put together. In actuality it was a battery and a capacitor to which we hooked a couple of wires and then talked Dougie into affixing them to his fingers. Asked him a question, and then zapped him. We were too young, I'd say, to be called assholes. Idiots, more properly.

Amazingly enough, Dougie and I maintain the friendship that started nearly sixty years ago. Exuding enthusiasm from every orifice, he teaches astronomy and cosmology, and the actor in him has made his planetarium show the talk of greater Portland. He played his guitar at my wedding. We call each other on birthdays (his was last week) and see each other on rarer occasions. Always it's easy and comfortable, and for the past many years, pretty much risk-free.

Jock

On first meeting over the years, many patients have asked me if I played football. I'm sort of a big guy and, during some cycles of my life, have actually looked in reasonable shape. The answer would be in the affirmative, with the qualifier that in general I was comparatively lousy at it. Slow. Not particularly agile; hypo-endowed with the killer instinct. (I was captain of the high school team, and was honorable mention all-city, on a team that finished dead last and never won a game. At halftime of my final game an assistant coach finally got to me: the Knute Rockne rah-rah never worked, but this guy managed to shame me. You coulda been a leader, you dogged it, etc etc, such that I got a little steamed had a noteworthy second half, made a few tackles, a sack or two, blocked a punt; so the opposing coach gave me a nod at voting time.)

Probably it was my first game that did me in. I knew literally nothing about football before high school. My dad, unrealistically wanting bragging rights, convinced me to turn out for the freshman team, and to sign on as a fullback. I didn't know that position from the missionary position, which I also didn't know. Within a day or so, after observing me trying to execute a cutback, the coach said, uh, I think you need to be a lineman. We practiced, I learned, vaguely, what I was supposed to do, and we had a game. Before play began, the guy across from me said "I'm gonna kill you, mutherfukker" after which, when the ball was snapped, he popped me one in the face, resulting in a bloody nose and a revelation. Returning to the huddle as the quarterback called the next play I said, "Hey, I have a bloody nose..." He continued the play-calling. "Excuse me, I have a bloody nose. I need to lie down." With derisive disbelief, the quarterback looked and said, "You BABY!" It was then that I realized in football, you play hurt. Your mommy doesn't give you a cold wash rag and say nice things while gently squeezing your nose.

I kept playing for the next four years, mostly screwing around with my buddies, not too worried about the score. We shared an attitude.

In college, at the end of freshman year, during which I mostly rode the bench, I discovered rugby and never played football again. Our team was actually good; we were East Coast champions, beating much larger schools, Ivy League heavyweights, and I got inspired enough actually to get in shape, run a few miles a day, pump a little iron. Despite the fact that the team was run by a rival fraternity I made my way to the A team by dint of making myself better than the favorite (and frat-brother) of the leadership.

In five years of football and four of rugby, I was never seriously hurt until I returned to my college during the first year of med school. My former team was playing a traditional rival in rugby, and that team was a man short; I was pressed into action, playing for the enemy against my old mates. In a desperation tackle I lunged at a halfback, caught his collar and hung on, somehow managing to detach the tendon of the flexor digitorum profunda of my right ring finger. The required surgery was just before a pathology final. Operating my old-fashion microscope, with its clunky machinery, right hand in an above-elbow cast, was a challenge. And the professor was unamused when I hollered out half-way through the practicum, "Would someone like to come over here and twist my knobs?" It did, however, lead to a romance with a classmate that lasted a couple of years...

[I have realized I've told part of this before. Which means it's confirmed: I've officially run out of things to say. Sorry.]