It's back...

I just realized I had missed the winter! There's nothing better than holding a boiling hot cup of tea in front of the chimney in my room watching that insane november rain slither down the glass.
Ok so I don't really have a chimney in my room, but I definitely have a glass window! And a reasonably warm cup of tea. But hey, I can dream can't I??

Off to work now. We have a new team of residents/interns coming in today so I'm afraid It's gonna be a long one... Can't even start to imagine what traffic's gonna be like in this insane weather!
Have a good winter everyone!

No Comment...

No comment, because I can't say how it feels to connect with someone like you do when that someone is your patient. And even less when you spend hours in that room talking and talking and end up wondering if you'd ever meet someone as interesting, as insightful as them, and with a story as captivating as theirs...

There's no describing it. Much like there's no describing what it felt like when I got this note after saying goodbye to Mel, who was leaving the country for good. It felt like saying goodbye to an old friend.

Goodbye Mel, All the best.

Cinema Paradiso, a Blast from the Past

There is nothing better than that feeling you get when you come across something from the past. I don't know, I guess this may be the appeal, the incentive, or maybe the lure, that makes people dwell in it so often, and sometimes indefinitely. Ranging from that once-in-a-while sweet, harmless nostalgia to downright pathological, disabling failure to progress, this feeling of familiarity and comfort found in one's past is probably, and to my experience, the reason why so many people struggle or fail to move on to new pastures.

The other day I tagged along with M. for a short DVD shopping trip. We were both flipping

through the monumental stacks of DVDs, and were ready to go home, nothing of note having been caught in our respective nets, when I heard the clerk making a recommendation to a girl (and a nice looking one at that!). I overheard: "you should try Cinema Paradiso..."

Instant flashback to 1990. I was eight years old, and we had just moved to a new place in Beirut. A brand new TV set, a brand new VCR and a nice VHS to christen it with.

Cinema Paradiso, an award-winning film by Italian filmmaker

Giuseppe Tornatore. I remember it so vividly; it was late, one of the first quiet nights in the post civil war era. The living room engrossed in the somber yet elucidating light provided by a solitary candle placed on top of a run down coffee table, I waited, anxiously observing the clock's every move, in anticipation because at midnight, we get to enjoy the luxury of electricity again.

I fell asleep on the couch, to be woken up at midnight by my mother, who was just as anxious as I was to watch that new movie.

Perhaps ironically, the theme of the movie circles around letting go of one's roots, of one's past and all that it entails, as it so powerfully follows the life of Salvatore di Vita, affectionately called Toto, as he morphs from that 5 year-old kid with so little on his mind, through a hormone-laden teenager, and into a grown man with aspirations to a career and success.

Always the sucker for blasts from the past, I jumped on that thing like there was no tomorrow; I drove back home in a daze, and the mere sound of the two words "Cinema Paradiso" brought my mom to tears. To say that watching this movie 20 years down this long road was an emotional experience would be a masterpiece of understatement. So many powerful scenes, and a theme and topic that remind me so poignantly of my own childhood, my own journey through life, proved to be nearly too much to handle. I guess that my having been through the experience of leaving home and loved ones behind meant that I identified with Toto in the movie.

Ironically, a movie riddled with nostalgia, departures, and separation from the past, has reunited me with mine in a way my clumsy words will never be able to describe.

Why so afraid of the past?

First LVAD implant in Lebanon - The misconceptions surrounding a highly successful operation

"A team of AUH surgeons has successfully carried out the first artificial heart implant operation in Lebanon, saving the life of a 37 year-old man and father of four".

That is the claim of many renowned media sources in Lebanon. Click here to read the official AUB article by Maha al-Azar.

I'm currently, and incidentally, on the Cardiothoracic surgery rotation at AUH. Yey me. I was surprised by a phone call on Thursday night and a friend screaming at me for not telling them that the first "Heart Transplant" in Lebanon was performed at AUH. Shocked, I thought to myself, there's no way I didn't hear about that one!! Then came another call, another newspaper article, another overheard conversation... All with one, or two, or three things in common... The misconceptions, the misconceptions, and the misconceptions. I just thought there were too many scientific blunders on the part of the media and their reports have been massively misleading at best. The following is a roundup of the misconceptions I thought people should be aware of...

Misconception 1 - This is NOT a Heart Transplant...

...And even if it were, it would not be the first one in Lebanon. The first heart transplant in Lebanon (a real heart transplant) was performed at the Hammoud hospital in 1999. Click here to read about that.
This is an LVAD, or Left Ventricular Assist Device (more on that later) implant. The original heart is still in place!

Misconception 2 - This is NOT and Artificial Heart Implant...

This is an LVAD (Click here), NOT an artificial heart. Let me explain. An LVAD, as its name implies, is a pump that merely assists the biologic heart in its function. It neither takes over its function nor does it replace it or completely take over its role. It ONLY assists it in its function by taking some of the work off its back... The biologic heart is still in place, functioning properly with the help of an assistant, if you will.

The implanted LVAD.

An Artificial heart, the Jarvik.

In contrast, an "Artificial Heart" is... well... an artificial heart! It is a complete heart-like pump that replaces the biologic heart, which is taken out of the patient on the OR table. It is still an experimental technology with only limited success in the United States.

Misconception 3 - This is NOT a life-saving device...

The AUB article also states that the operation saved the life of the 37 year-old patient. I am sad to point out that this is not the case. An LVAD implantation is what we call a "bridge to recovery" or "bridge to transplantation" procedure. This device is designed to help keep cardiac performance at an acceptable level for a limited amount of time pending one of two events:

- The recovery of a mildly diseased heart as a result of decreased workload afforded by the LVAD: Bridge to Recovery.
Or:
- The availability of a matching donor heart for transplantation: Bridge to Transplantation.

The LVAD used in this case was the Heartmate II by the Thoratec corporation and is claimed by Thoratec themselves to be able to provide circulatory support for only up to ten years. Now keeping in mind that these ten years are the result of the most optimistic and optimized calculations, it is clear that we should be expecting 5 to 10 years, more realistically, before there is a need for a new intervention. And we would still be optimistic in that we are neglecting all the possible complications that the poor guy could face.

I am not trying to rain on anyone's parade, and least of all the patient himself or the thousands of others with heart problems. I just think it's a shame how the media are having a field day with his story and modeling it, be it willingly or unknowingly out of lack of scientific knowledge, to fit the textbook picture of a world-class achievement in medicine, or that of the wonderful doctor or hospital saving lives by the millions. That this life has been saved is simply not true, and while I am truly ecstatic that this operation took place where I work, and even more ecstatic to see its success and the time it gave our 37 year-old father of four, I cannot emphasize enough how much of a temporary solution this is for our patient, who is, at the end of the day, whom we should think about before anyone or anything else. I can only hope he and his family know what the future holds for them.

This is a milestone in the practice of Cardiothoracic surgery in Lebanon, one that I am proud to witness during my young career. I just can't stand it being taken out of context in this manner. The authors of these articles and their sources shoud be reviewed.

Espen Lind Fuentes Holm Sing Halleluia...

One of my all time favorite songs...
I Came across this version a few weeks ago. I've been meaning to post this here but i never got around to it.

I think These guys sound amazing. They interpreted many other classics including David Gray's Sail Away, Seal's Kiss From a Rose and songs by U2. They also have a few songs of their own. Great music.

Dear Sarah...

I came in and you were there. I sat at the table and you were around.

With your fresh looks, you stood out from the crowd. With your enticing smile, you caught my eye. There is something about you that played with my mind all night. Is it that smile? is it your hair? Or is it just as simple as your being at such odds with all of our dearly held ideals, self-ordained stereotypes and mundane ideas and clichés of the laws of attraction, that I just couldn't let it go?

So I told you. And from that moment, you knew my secret. You blushed and smiled. I did the same.

I was struck, and I knew so little. At an unfair disadvantage. But I will brave it.

I told you, and it wasn't that simple. He has your heart.

It's not to be. Not for now, maybe not ever. Or maybe...

Thank you for a pleasant night.

Yesterday, the day it all went wrong...

Have you ever felt like a stone surrounded by glass? Like you couldn't make a move without something or everything shattering and crumbling down in a deafening rumble and screaming racket? Minutes or seconds later, you look back: nothing more than a hole in the ground, where once all the great plans you had just built up seconds -or years- ago stood tall. Nothing left... Be it an hour, a day, or an entire lifetime, actions and their consequences are the same. Well at least they act the same. With a little hindsight on things that have happened in my life as far back as 15 years ago, or as recently as yesterday, I realize how strong and steady of a truth it is that when you make decisions, life starts moving so fast that it's not like you're moving through it anymore. It just starts happening to you.
It's strange to realize that this holds true at all scales... Whether it's your career choice, or that crush you decide to finaly do something about after so much hesitation. You just make the slightest move and it puts in motion some restless unstoppable mechanism, like thousands of cogwheels all spinning, each at its own speed, but all equally inexorable in their relentless thundering stride toward that common end point, like an army marching to the Valkyrie.

Here we go. I didn't know I was on one of my late night ramblings again... I didn't get the memo! I'm rambling again. It must be the melancholy found in the resignation to a few concequences of a choice made in the past, no matter how distant, with a certain goal in the future, no matter how remote.

The Emergency Room... Oh the Anarchy!

If I had one word to sum up the ER and what comes through there in a day, it would be Chaos. But it's amazing. Challenging in a way I could never have imagined. It took me 2 days to realize that what you can learn in one day of an ER clerkship really amounts to more than you will learn in 2 weeks of patient care and follow up on the ward floors. There is no comparison. You can see, examine, process, and discharge 10, 15 patients a day with ranges of problems so varied it'll make your head spin!

On any typical day you can see:

-The prissy church choir girl (girl being a serious misnomer here, seeing as how she was 74, but hey...) who "burnt" her hand trying to put out a blanket, placed a bit too close to a candle, caught on fire near the church store room. She had two of her fingers covered with melted nylon which stuck after cooling down. She came to the ER not because she had a burn, but because she had no idea how to remove this thing of DEATH that had entrapped her silly fingers!!!

And then minutes later...

-The poor 24 year-old construction worker (A.) who had a 6-kg rock fall over his head from the top of a 9-storey building while he was out for a walk on his break. He sustained multiple fractures of the skull, and was brought to the ER with his mashed brains pouring out the top of his head. Scientifically speaking, and to put things in perspective for my med readers, the brain CT report was significant for multiple skull fractures reaching the base of the skull, severe depression of a part of the calvarium deep into the brain causing midline shift, trans-tentorial herniation, and severely increased intracranial pressure with all of its sequelae.

We stabilized his vitals after 3h of fighting and 4 L of I.V. fluids.

The poor guy died in the ER exactly 48 hours later.

This is a small idea of the spectrum of sights and colors we see on a day at the ER. But what struck me the most is surprisingly not the patients. It was not the drama, the excitement, the rush of dealing with life and death. It was the patients' families. Why? It became apparent to me how everyone saw nothing but themselves, nothing but their own, and just dismissed everything and everyone else in complete and utter disregard.

As poor A. was expiring in Trauma 1., we were also handling a patient (in S2) with mild head trauma. He had been hit by a car at low speed and hit his head against the windshield. He was awake and oriented, and his studies all came back negative, so basically he was fine. All he had left was a small laceration on his forearm that we had to suture before we could send him home. Naturally when the alarms went off on A.'s monitor screaming that he was going into severe tachycardia and O2 desaturation, we all left S2 to go check on A. and see if there was anything that could be done. Obviously there wasn't.

Now imagine this. Coming out of Trauma 1, heavy with heartache and shaken to your core by your first ever encounter with death and a patient who slowly died in your hands, you and your resident take a tough walk out to the ER waiting room and make sure the parents know that their worst nightmares have come true; "we are truly sorry to have to tell you that your son passed away 2 minutes ago. There was nothing more we could have done."

Now imagine walking back into the ER, in that state of mind, to find an obnoxious old lady, S2's grandmother, in a panic, screaming at you and yelling all sorts of nonsense asking you how it was possible for "doctors" to leave his wound uncleaned, knowing that she was coming to see him. She hates the sight of blood apparently.

How could we? how could we have such disregard for her great presence and not have wrapped him up before we tried to help a truly dying person? I don't have an answer to that.

This was even more destabilizing to me when I thought back at A.'s parents' reaction when we told them what had happened. Actually it was not in any way worse than the old lady's panic. No. Even less dramatic in my opinion.

So is worrying about a loved one an all-or-none sentiment? Can anyone worry, but at the same time have as little as an ounce of consideration? Can anyone worry, but realize that there are priorities and that there are always people who are worse off??

The answer is, YES, worrying is an all-or-none sentiment. From the stupid prissy choir girl who came for a hand-cleaning session, to the exceedingly unfortunate A., rest his soul, brought in by the Red Cross with only a few breaths of life left in him, and to the mind-twistingly annoying and naggy fat boy who twisted his ankle and had no signs of injury remotely indicating even as much as an X-Ray, you will be surprised to see that the parents all act in the same craze, the same insanity, and the same "treat-my child-first" attitude. You will be surprised to know that sometimes it is even reversed, that families of patients in dire emergencies will seem more composed and cohesive than families of patients with petty scratches not even worthy of a band aid. And for now, this is what makes the ER stand out.

Patient Insanities on 10 North... Have a Laugh

Well I figured it was about time I shared some more stories about our dear patients on the surgery rotation. Here are the three cases that spring to mind... Actually there's a fourth one, but she deserves a post of her own so come back soon ;)

The crazed grumpy old man on 10 North.

K.H. has been driving all the floor insane for about a week now. Anxiety attacks, flamboyant claims and accusations that make me wanna scream out in anger... To put things in perspective, one of his latest complaints was having a nurse that smiled too [damn] much!! He even told her that to her face! Hilarious and sad... The poor guy has been one of the most complicated medical cases we've seen so far, with several operations, intestinal leaks and what not... Understandable? Granted. But it is still annoying, and yet funny in a marginally twisted sense, if you see what I mean, to hear him complain about things the world of medicine has never known, like diarrhea caused by walking!!

[Note]: "Patient is not doing very well, complaining of general anxiety and unable to tolerate hospital stay. He is pain free and is refusing to take his anti-hypertensives and anxiolytics by mouth. He refuses to ambulate for fear of diarrhea." Making sense are we? LOL

[Plan]: "Start I.V. Lexotanil"

The nice and healthy middle aged Man on 9 South.

M.D. is A previously very healthy, strong man. After extensive surgery, he seems to be recovering nicely, and is happy to see me every time I walk into his room. Always a good sign to see a patient greet you with a smile. It is so rewarding and puts an inexperienced mini-physician such as yours truly at ease and makes the job that much easier. I walk into the room, M. smiles and brags about how well he's doing, is always anxious to show me how good his breathing is getting, or how comfortable his lazy-boy chair is, with its fancy electric recline and foot support functions. Me, smiling "I wish I had one of those at home, Mr. D!!" It has been a pleasure following this one up. He's staying till the end of the week.

[Note]: "Patient is doing very well, tolerating regular diet, passing stools and flatus, ambulating freely and using incentive spirometer as instructed. Bowel movements normal, no pain or discomfort reported upon defecation. Patient is pain free and has no new complaints. Plan for discharge soon."

The distant old lady on 10 North.

S.D. was a 70-something-year old lady we followed up for about a week, some few weeks ago. I had completely forgotten about her, until I met K.H.

She had her own set of problems, like being too good to look at us med students, or letting us examine her without her attitude, or having not one, but two of her private nurses in her room taking care of her and making our lives miserable... Case in point: M. my colleague was about to draw blood from S.D.'s arm. It was her first time doing that, and she was looking for the vein, taking her time to locate it with some degree of certainty. After all, you don't want to poke her majesty for nothing! Some odd 20 seconds later, S. just lost her patience (bear in mind that M. hadn't even picked up a syringe yet!) and with her face turned away from M., called her nurse and said: "ta3e shoufe hayde shou 3am ta3mel sarla se3a!!" Translation "come here and see what this one is doing, it's been an hour!" Priceless!!

[Note 1 ]: "Patient is pain free as confirmed by private nurse. She is non compliant and refused to be examined, claiming that the nurses already gave her a physical."

[Note 2 ]: "Patient is pain free as confirmed by private nurse. Physical exam not done because patient is sleeping"

And for the record, all that the nurses do is take temperature and blood pressure and stuff like that so...

Difficult patients are a real challenge! I still need to work on that area! Something about them shakes my confidence! But they're funny to tell your friends about!

S.D. and K.H. ? a match made in heaven! We couldn't help but try and imagine what these two would be like living together! Imagine the children!!!

Those of you calling out outrage, relax. We're not making fun of our patients. It's not like that. It's just that these few cases are too entertaining to forget. So we document them! See? it's a noble cause! But seriously, they all get the same respect and standard of care... Rightfully so!

A Sunday From Hell

I had been dreading this day for a while. Sunday, July 20, 2009. Bidding farewell to loved ones, saying goodbye to friends. All on one day seemed like torture. And it turned out to be even worse.

This just in: friend and fellow blogger wondering: "Is it true that Lebanon is now nothing more than a pit stop?" This is a question to ask indeed...

I live here, I grew up here, and even for me this is just a pitstop.

For everyone who woke up one day and decided they wanted more from their lives than this place had to offer; For everyone who is contemplating the thought of leaving; nothing more than a pitstop. That Sunday, I said my goodbyes to my aunt in the evening, and to one of my best friends from childhood later that night... Very eloquently, this sucks.

Flashback to Sunday, late afternoon:

It was a long drive to Ballouneh, where my auntie N. lives. LiveD. Mixed emotions flying in the air. There was a distinct feeling, or taste, to that trip. Everytime we went on that noisy drive singing silly music and hopeless songs, there were great times. Barbecues, nargileh, and that sweet feeling of a family reunion every few weeks. Not this time though. This time round, this warm familiar feeling was overshadowed by foreseen grief and heartache. N. is going to Canada. She's taking her incommensurately adorable kids -this from a hardened official kid hater, remember?- and she's going to start a life somewhere else.

Somewhere where she won't have to worry about making ends meet every month, somewhere where people are actually people, somewhere... Don't worry, I'm not gonna start another tirade about our dearly cherished country, if one can call it that. No, I've done that before (read). What matters now is where she's going, and who she's leaving behind. This is the second time that this country has done this to my family. And what's worse is that it's about to do it again. I'm going to have to leave, again, for my residency. And that Sunday, this was always on my mind and I felt like I was suffocating.

My grandmother worse for wear, my grandfather's voice choked out of him as he desperately tried to hold back his tears, my uncles and other aunts in no better shape, and my tears clouding my last sights of N. and her kids, we left Ballouneh for a silent trip back to an insipid Beirut.

Goodbye N. We love you so much. We miss you already.