Write

"But in its aimlessness, in its desperate commitment to the word, in its primal order of birth and rebirth, a poem remains the most general guarantee that we can still do something, that we can still do something against emptiness, that we haven't given in but are giving ourselves TO something."
-Miroslav Holub

"Poets have been known to be smug about their fine uselessness, but the Vietnam War led many poets of my generation to try to use poetry to make something stop happening. We will never know whether all that we wrote shortened that nightmare by one hour, saved a single life or the leaves on one tree, but it seemed unthinkable to many of us not to make the attempt and not to use whatever talent we had in order to do it. In the process we produced a great many bad poems, but our opposition to that horror and degradation was more than an intellectual formulation, and sometimes it tapped depths of bewilderment, grief, rage, admiration, that took us by surprise. Occasionally it called for writings that may be poems after all."
-W.S. Merwin

In an age of 140-characters and texts and holiday photo cards adorned with pictures, we hardly write anymore. We rarely just sit with pen and paper (and tea and candle) and ramble. Letter-writing seems archaic. Poetry feels obsolete. We want instant gratification and videos on demand and news in snippets. Even reading seems to be going away.

I am incredibly guilty of this. I go through spurts and hesitations with my writing. I took a poetry class where I wrote a poem a week, and that habit has since faded. This blog will go away soon. But I really do believe that writing gives me such unique pleasure, that its work is like exercise, we loathe to start, but we need it. So coming upon this New Year, I resolve to write more. It will be in different forms and forums, different guises and jests, but it will be good for me. Soothing. Nurturing. Healing.

Merry Christmas

"A human being is a part of the whole called by us 'the universe,' a part limited in time and space. He experiences himself, his thoughts and feelings, as something separate from the rest – a kind of optical delusion of consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening the circle of understanding and compassion to embrace all living creatures and the whole of nature in its beauty." – Albert Einstein

It's three in the morning on Christmas Day and I am just finishing up at the hospital. Of my last seven Christmases, I've probably spent about half of them at work. I will admit, it's never easy. There are mixed sentiments; on the one hand, there's a sense of pride in widening our own small lives to encompass those in need, a giving Christmas in a different sort of way. There a sense of duty, almost like filial piety; it is the right thing. But ultimately what I think about is that no matter what negative emotions I have about being here, patients must have so much more. I am here by choice to take care of those without that luxury.

That doesn't make it any easier. How hard it is to spend holidays alone in the hospital when friends and family gather and celebrate. How hard it is on our own spouses and families as they sacrifice with us, when we are not there. What a strain it places on our relationships. What it's like to see everyone else in anticipation of the holidays when instead, we dread the interminable call. How isolating it feels when no one else really understands what it's like to miss half your Christmases. Why scrolling down my Facebook feed of trees and presents and dinners and kids makes me feel a little resentment. And then, ironically, how we judge ourselves bad people for feeling that resentment.

There was recently a great JAMA article on "The Things We Have Lost" by Jennifer Best that describes those sacrifices we make as physicians, things like "absence from 'unique and unrepeatable events' - holidays, birthdays, weddings, and funerals." We feel like we can't talk about these losses because they are minuscule compared to the losses we witness in our work: the loss of independence or health or security or family. But tonight I break that silence. I hold vigil for what I've lost in caring for others holiday after holiday. It is quiet here. Peaceful.

Election

I purposely veer away from writing about politics in my blogs; politics is fascinating to me, but this is not the forum where I want to discuss it. I only write to say that this last election made me think of the classic American ballad "Casey at the Bat" by Ernest Lawrence Thayer. The last stanza really echoes how I feel.

Writing

"Writing is wonderful when you talk about it. It's fun to contemplate. But writing as a daily physical activity is not agreeable. You put on weight, you strain your gut, you get gout and chilblains. You're alone, and every day you have to face a blank piece of paper."
-Norman Mailer, The Spooky Art

I love this quote. There are so many things that fall in this category. Growing up, I loved the idea of classical music and mastering a difficult piece and performing. Oh, but I hated practicing daily. For so many years, blogging also had that same sheen. On occasion, I'd have that perfectly formed idea, pre-packaged and ready for delivery. But most of the time, it was sitting down to an empty screen and forcing myself to write. Now, I'm taking a class on poetry writing, and it's the same thing all over again. Sitting around a table with other hopeful writers drinking tea and reading blank verse is really fun. There's a lot to explore, wonder, learn, and imitate. But then you go home and you sit with idle pen and blank slate. It becomes a narrative of captivity (rather than a captivating narrative) (a quote from a long-time friend of mine, Revati). The daily exercise of writing is a lonesome and individual activity, intimidating, grueling, and challenging. But it is also necessary to get better, to capture those fleeting moments of illumination, and to become more than a dilettante. In part, this is why I am simplifying my life and obligations, to focus on passions I would like to cultivate, and I think I want to give writing a go.

Oxytocin

"There are no events but thoughts and the heart's hard turning, the heart's slow learning where to love and whom. The rest is merely gossip and tales for other times." - Annie Dillard, Holy the Firm.

"Life is not about writing great books, amassing great wealth, or achieving great power. It is about loving and being loved. It is about savoring the beauty of moments that don't last." - Sue Suter.

Love is perhaps life's greatest mystery. Where does it come from? Where does it go? What do we talk about when we talk about love? It seems so simple and yet so large both at once. It can be such an overwhelming life-force and at that same time curiously irrational. It feels so important, and somehow different from all the other things we think important.

Philosophers sometimes talk about "emergent" or "second-order" properties, things that characterize a system but cannot be found in the components of the system. A baseball player doesn't have "teamwork" per se, but when you group a bunch of them together, "teamwork" emerges. A single neuron may not think, but a network of them might have the novel and irreducible property of consciousness. I have not yet read a philosopher bold enough to tackle love as an emergent property, but that is what fascinates me most. We live in a physical, deterministic world. How does love fit in?

Poets and writers love to ponder the transience of love. The unrequited love, the love lost, the entreaty of love, the many masks of love - these inspire libraries of literature. We don't know what it is. We don't know why it exists. We vow to love endlessly. We decide to move on. "All things come to an end. / No, they go on forever." (Ruth Stone, "Train Ride"). We struggle with the feeling that love is so powerful, so irrefutable, and so out of our control. We try to reconcile the pure, perfect love from poetry, pop songs, and promises with the dingy sheen of practical love, love that fatigues and confuses and leaves us wanting.

I don't have a particular direction in this post. It comes from being at the most beautiful wedding this last weekend and also thinking about dear friends who may, someday, part. In seeing the many manifestations of love and thinking about its many faces in my life, I realize I know so little of it and want to know so much more. Love feels simultaneously mundane and magical, perfect and incomplete, ritual and personal story. We make ourselves vulnerable. We become gourds and vessels. We drink and thirst. We invite our friends to dance madly into the night. We invite our friends to hold vigil. There is no greater mystery.

Settle

“Our worst fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, ‘Who am I to be brilliant, gorgeous, talented and fabulous?’ Actually, who are you not to be? You are a child of God: your playing small doesn't serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We were born to make manifest the glory of God within us. It is not just in some of us, it is in everyone and as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.” – Nelson Mandela (1994)

Should you settle? Should you settle for a job that doesn't maximize your full potential, a relationship that leaves you wanting, a meal that is lukewarm? Should you settle for getting three wood for your two sheep when you really want wheat? (Should you settle for a half-hearted pun when you know you could write better?)

It's so easy for us all to say do not settle. You have this one life, this limited set of opportunities, all heart and ambition, so carpe diem. Who wasn't inspired by "Dead Poets Society"? We all remember being teenagers and thinking we could achieve anything, everything. Isn't that the American Dream? Work hard enough and life will be "better and richer and fuller" (James Adams, 1931).

Does it ever scare you that we will chase dream after dream and find them ephemeral, fleeting? That we will never be satisfied (still listening to "Hamilton"), that we will keep following the rainbow but emerge empty handed. I can always dream bigger dreams. I can always imagine something that just might make me happier. We live in a society where we always want more: the bigger house, the spiffier car, the latest phone. We want to show off our relationships, our kids, our jobs, our diplomas, our connections. We are always looking for the next big thing, trying to trade up, pursuing the unknowable, unattainable, and yet unspeakably coveted.

I worry about this. I worry that I want too much, that I have passed or will pass over something perfect in pursuit of a mirage. That settling isn't bad. That being content is more important than being fulfilled if by our very nature, we cannot be fulfilled. There are no bounds to human want, no bounds to human curiosity. "I burn, I pine, I perish" ("10 Things"). It is our obligation to ourselves not to succumb to the hubris of Greek tragedy. It's not to say we should want no more, but to say that in some facets of life, we accept the cards we are dealt with gratitude and find happiness in what we have.

I worry about the opposite as well. A life without purpose is like motion without moving. I should not settle to live in a world with injustice, suffering, immorality. I should not settle to live a personal life plagued by injustice, suffering, immorality. Idealism, even if I know it cannot be fulfilled, has a place. Humans were meant to dream.

"Harlem"
Langston Hughes

What happens to a dream deferred?

Does it dry up
like a raisin in the sun?
Or fester like a sore--
And then run?
Does it stink like rotten meat?
Or crust and sugar over--
like a syrupy sweet?

Maybe it just sags
like a heavy load.

Or does it explode?

(FYI, being post-call tends to draw these types of posts out of me)

Green

“Never doubt that a small group of concerned citizens can change the world. Indeed, it's the only thing that ever has.” – Margaret Mead

We live in a world of stuff. We are consumers, buying things, using them up, discarding them, acquiring more. As I look at the next generation of cell phones and computers, contemplating upgrades, I start worrying about our preoccupation with having things. It's not that I find this hobby superficial or silly (though in a way, I do), but it's because I worry it's ruining our world. Like health care, our resources in this world are finite. Our consumer-driven culture will end up consuming those limited resources. Even if we recycle all that we buy, the cost of manufacturing the new goods and reclaiming the resources of the old worries me. I've been thinking about carbon footprints, global warming, and other environmental issues recently, and I worry that the legacy we are leaving to future generations is more problem than solution. While reducing waste, improving our commuting routines, eating less meat, and composting all make a difference, I think we need to overhaul our cultural disposition to consume. I also struggle with the itch to use stuff up and get more, but I'm trying to curb that. It is our responsibility to rein in waste, to protect our world.

Anesthesiology and Critical Care

"Love. You can learn all the math in the 'verse, but you take a boat in the air that you don't love, she'll shake you off just as sure as the turning of the worlds. Love keeps her in the air when she oughta fall down, tells you she's hurtin' 'fore she keels. Makes her a home." - Serenity (2005).

This will be my last post about medicine. I might have some lingering thoughts about other facets of this strange life we live, but for now, I think I have accomplished what I wanted to with this blog, and it's time to step back. I started writing here on September 1, 2006, when I knew nothing of this ship I was boarding. It was the day before orientation for medical school. Ten years later, I have written over twenty two hundred posts, most of which are essays on becoming a physician, musings on the inner workings of medicine, reflections on the emotional and subjective experience of medicine, and stories of my life during medical school, residency, fellowship, and (hopefully) the beginning of a career. There is no way to summarize this, and while I want to make grand sweeping statements on what this means with flowery and literary-device-laden language, it's really not necessary. Someday, I might highlight those blogs that I am most proud of, but for now, I let this website speak for itself.

This is the path I chose, from the many I could traverse. It has been harrowing, lonely, exhausting, dangerous, frightful, upsetting, and profoundly sad. But it has also been enlightening, inspiring, heartening, beautiful, transformative, and dare I say it, fun. As a career, I am so happy to be an anesthesiologist and intensivist. My day-to-day and week-to-week work life is filled with moments of sheer wonder, great pride, meaningful connection, poignancy, and growth. I can think of no other vocation I would instead choose.

I thank all of you who have read this blog, and I apologize that it is coming to an end. I hope I have shared some glimmer of the magical and miraculous world I see every day. I hope to continue writing in the future and contributing to the literature of medicine in different forums and settings. Like every other incredibly difficult decision in my life, I have very mixed feelings about this, as evidenced by my lollygagging in saying good night. But here it is: please contact me (you can always post a comment) if you'd like to continue the conversation on medicine. I greatly appreciate your patronage, and I hope you have enjoyed reading. I have loved every facet of this. Good night.

In ancient Greece, the Asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The rod of Asclepius is a roughhewn branch entwined with a single serpent.

With respect, love, and passion,
Craig

Last Words

I make little notations to myself about blogs I want to write. I jot them down on scraps of paper, saved emails, and notepad documents titled "temp." Some of them make little sense to me when I find them again (kind of like trying to write down my dreams). Some feel so big and important that I want to set aside dedicated time to write conscientiously. Unfortunately, the window of opportunity is closing. For a lot of reasons out of my control, this blog is making its last rounds.

One note I wrote to myself was, "Anesthesia is not easy; discuss risk taking and dependence on surgeons." I don't specifically remember what stimulated that idea. There's a great deal that I could say (and have said in the past). Anesthesia is one of the few specialties that depends heavily on the skill of another professional. The doctor on the other side of the drapes affects almost everything I do. For the same surgery, two different surgeons may require very different anesthetic plans. Whether the surgeon is speedy or slow, loses a lot of blood or loses nothing, requires deep anesthesia and paralysis or manages with little - it all affects my decision-making. I have written before that anesthesiology is protecting the patient from the (necessary) surgery and surgeon, and I really believe that. It's no small thing to cut into someone, and my job is to safeguard the patient while that happens.

Of course, the skill of the anesthesiologist affects the surgeon. What I do can profoundly change the surgical conditions from whether there's excessive bleeding to how much the brain swells. I can think of very few other symbiotic medical specialties; perhaps obstetrics and neonatology, but not much else.

It's easy to underestimate how difficult anesthesia is. There is a metaphor of the Stanford undergraduate being a duck; on the surface of the pond, she appears serene and relaxed, but under the water, she is paddling furiously to stay afloat. Sometimes, that's how I feel with anesthesiology. Although we show a calm demeanor above the drapes, we may be working tirelessly to mitigate risk and optimize every single aspect of the perioperative period.

The Impact of Anesthesiology

I hadn't seen this when it came out almost four years ago, but the New England Journal of Medicine for their 200th anniversary (such an impressive milestone) asked the question, "What has been the most important article in NEJM history?" This blog concluded that the first description of anesthesia in 1846 by Henry Bigelow was the most significant report, surpassing even articles on aspirin for heart attacks, tPA for stroke, and development of vaccination. Indeed, the field of anesthesiology allowed advancement of surgery and the surgical subspecialties. Before anesthesia, no one would even consider an elective procedure; it would be terrible to put someone through pain and agony for a disease process that was not life-threatening. But with inhaled ether, and later similar compounds, we made possible so many other advances in improving human health.