Behind Closed Doors: Surgery with an “Appy” Ending

If ever there were a physical example for proof of the argument in favor of evolution vs. creationism it would most certainly be the human appendix. What kind of spiteful, ill-humored God would purposefully place this useless and trouble-making stump at the beginning of our colon? In our ancient incarnation as ground dwelling pre-historic mammals, the appendix undoubtedly played a useful role, as it does in modern-day rodents and other such buck-toothed chewing machines. However, the relentless march of genetic progress, random as it is, has relegated the appendix, along with other vestigial structures such as the coccyx, the erector pilae muscles, and the plica luminaris to the trash heap of human appurtenances. It would be nice if the appendix minded its own business and didn’t trouble us. But like an unsolicited sales call, it troubles us to no end.

Appendicitis is inflammation of the appendix, and is a lot more common and potentially life threatening than one might think. Historically, the diagnosis of an inflamed and burst appendix was often a death sentence. Its rupture causes exposure of the contents of the bowel to the unprotected inside of the abdomen resulting in a condition known as peritonitis. This can lead to overwhelming sepsis due to gut bacteria in the bloodstream. Untreated, death will occur in relatively short order.

The first recorded appendectomy was performed in 1736 by French surgeon, Claudius Aymand, who operated on an awake 11 year-old for an appendix perforated by a swallowed straight pin. In 1804, the only person to die on the entire Lewis and Clark expedition was Sergeant Charles Floyd, due to an attack of suspected appendicitis.  At this time surgical anesthesia did not exist save for a shot of whiskey and a stick to bite on, nor did reliable surgery, and there were certainly no antibiotics to be had at any price. It wasn’t until the latter part of the 19th century with the advent of general anesthesia and more refined surgical technique that it was possible to treat and cure acute appendicitis.

About 250,000 cases of appendicitis occur annually in the United States, and the lifetime risk of an appendectomy is estimated at 12% for males and 23% for females. Thus appendectomies remain a common procedure.  In my family, both my wife and my daughter have had appendicitis followed by emergency surgery. Dana had hers in the first trimester of her third and last pregnancy. Kate had hers at the tender age of four.

As is the case in many doctor’s families, the three “Ds” of diagnosis were critical in identifying the problem. The first is “downplaying” of the complaint. “Are you dying? Cause a lot of my patients are…” is a common refrain in my house. Dana woke up in the middle of the night with vague peri-umbilical abdominal pain. “It’s just gas, go back to sleep!” I said and rolled over. Despite sitting in a warm bath for the rest of the night, Dana felt worse in the morning. She vomited and her pain had localized to the right lower quadrant of her abdomen. I said, “Maybe it was something you ate. I hope you feel better. Gotta go to work! Call me if it gets worse.” and I hurriedly rushed out the door to take care of my first case of the day. Fortunately we have an amazing friend we call Saint Gina. She is a nurse, and a super-mom, and as practical and able as they come. Dana called her to look after our boys because she was feeling too sick to get up. As soon as she arrived, Gina took one look at Dana and said, “You are going right to the hospital!”

The second “D” is “denial.” While I briefly considered that Dana’s constellation of symptoms might be appendicitis, I was far more worried about an ectopic pregnancy as that was entirely possible given her gestational age of ten weeks, a common time for such a problem.  In retrospect, it is good advice for physicians to leave the diagnosis and treatment of family members to others far more objective, and thus more competent. A surgical consult and an ultrasound revealed both a healthy intrauterine pregnancy, and a grossly swollen appendix. Therefore, the third “D” is for “dumb-ass!” which is what I felt like after the correct diagnosis was made. Fortunately, Dana underwent an uneventful appendectomy under spinal anesthesia, in order to minimize exposure to anesthetic agents to our developing fetus that eventually became our lovely daughter Kate.

As luck would have it – both bad and good – Kate would soon emulate her mother. Early one evening when she was four years old, we decided to see “Harry Potter and the Chamber of Secrets” at our local theatre. Kate had been feeling a little poorly for most of that day and was a touch irritable. For Kate, irritable meant that she smiled only 95% of the time rather than 100%, so I thought a movie would cheer her up and off we went.  She sat on my lap spellbound (no pun intended) with the film. I noticed she felt a little warm, and was aware that every time my hand rested on her stomach she stiffened. As we walked up the aisle at the end of the movie, she seemed to limp a bit. By the time we got home, I could tell she was sick. I laid her down on the kitchen table and proceeded to play surgeon. “Does your tummy hurt?” I asked. “Yes. First it hurt in the middle and now it hurts down here.” pointing at her right lower quadrant at a place called “McBurney’s point” named after the surgeon who initially described the signs of appendicitis. Textbook answer. “Does it hurt more when I press, or when I let go?”  I gently pushed then released the spot to which she pointed. She winced as I let go, and with a sinking feeling I knew we were going to the hospital. The latter sign indicates an inflamed appendix and a resultant angry peritoneum, the lining of the abdominal cavity.

It was now pretty late in the evening, and the emergency waiting room at our local hospital was totally empty. Literally, crickets chirped. Nevertheless, we sat for what seemed to be an eternity. Finally, I couldn’t take it anymore and in my best doctor voice I approached the intake nurse and said, “Listen, my daughter is febrile, has peri-umbilical pain that has localized to the right lower quadrant, has rebound tenderness and is guarding. Could we please see the doctor on call?” She looked at me; her expression narrowed, and with a voice dripping with condescension said, “My! We are using big medical words, aren’t we? Are we a nurse or something?” I resisted the urge to push her smug face in and replied in as level a Clint Eastwood voice as possible, “No, we are a doctor or something. Should I use smaller non-medical words so you understand them?”  I was being a total jerk but didn’t care. This was my daughter after all.

Once in the ER, a quick urine test was negative and a blood test revealed a high white count. Ultrasound again clinched the diagnosis.  Kate was a trooper through it all, bravely enduring a urethral straight catheter and a needle poke for a blood sample without so much as a whimper. Because our local hospital had neither pediatric surgeons nor pediatric anesthesiologists, and I felt more comfortable on my home turf, I arranged for a friend, Mike Harrison, one of the best pediatric surgeons in the country to see her immediately in the city. Surgery was quick and went well. Her appendix was nearly ruptured and I considered myself lucky to live in an area with so much choice and talent available.

It is truly amazing that such a little vestigial tube of flesh can cause so much trouble, but it most certainly does. Dana remembers her appendectomy as the time that our two elder boys, then age two and four were given free rein in the kitchen and on the computer. As she lay in bed suffering while her doctor husband was taking care of his own patients instead of his ailing wife, they went to town on the snack drawer. Then primed with sugar, they printed hundreds of pictures of Pajama Sam, Sly Fox, and Putt Putt the talking car, heroes of their favorite “Humongous Entertainment” games.

Kate remembers enjoying Harry Potter a lot despite the pain in her stomach, her quick trip to the hospital where daddy worked, and the popsicles after surgery. I remember being humbled and thankful that we live in a time and place where we have immediate access to such wondrous medical technology, and an appendectomy is considered minor surgery. Though perhaps I should reconsider that final thought, as minor surgery is always something that happens to someone else.

Jeffrey Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice.”

East Meets West: Finding the Harmony Between Traditional and Alternative Medicine

Have you ever seen someone with uniform, dark purple, bruise-like circles on their back or on the back of their neck? Although frightening at first glance, cupping is an ancient Chinese medicine practice that has been used in the Chinese culture for thousands of years to treat the ailments of athletes, the ill, and the injured.

History of cupping. Although the true origin of cupping is uncertain, the earliest recorded use was by a famous Chinese alchemist, herbalist, and medicine man named Ge Hong (281-341 A.D). Hong and other medicine men of the time believed that the body contains “Qi”, the energy of life. They worked to identify a way to mobilize blood flow in order to promote the flow of “Qi”, which is located primarily in the five major pathways.  He documented this in his written account of cupping, A Handbook of Prescriptions. In this book he recorded he was able to treat half of the ill and injured he encountered through the practices of cupping and acupuncture.

What is cupping? Along the five main pathways found on the back, cups are applied to the skin. The pressure in the cup is reduced, or “vacuumed”, either through suction or heat, in order to bring the skin and superficial muscles up towards the top of the cup. While the suction is active, the cup is slowly moved causing the skin and muscles to move along with the cup, providing an acupuncture-like therapy for the pathways in the body.

The process of cupping. Generally, glass cups are used for cupping therapy. These cups come with a top valve that attaches to a small vacuum pump. This pump allows the therapist to decrease the air pressure in the glass cup at the beginning of the process. In addition to the cups, oil is used to allow the cups to move smoothly on the back. The oils used are generally infused with medicinal herb extracts that provide a heat sensation when the cups are moved during the therapy session.

Cups are left in place for about ten to fifteen minutes, allowing the skin to redden in a circular shape due to the pulling of the skin and superficial muscles, breakage of capillary soft tissue, and accumulation of blood that occur in the skin inside the depressurized cups during the process. The circular shapes that appear after the cupping session can range from light red to dark purple and can last anywhere between three days to a week, depending on the patient’s condition and the cupping session provided.

How does cupping help? Cupping is known for increasing “Qi”, the overall blood flow in the body, and is also commonly used for muscle aches and pains, particularly of the back. However, it is also used to treat coughs, asthma, and common cold-like symptoms. Many people undergo cupping therapy because it helps to release toxins, activate the lymphatic system, increase blood flow, clear stretch marks, and, in some cases, help to clear veins.

It is believed the circular marks that appear after a typical cupping session are an indication that the disease or affliction has been moved from the deeper layers of the tissue to the surface. The moving of the toxins, dead or static blood, and other waste products towards the surface allows the newly oxygenated blood to heal the underlying areas, that have been preciously infected with disease or injury.

How cupping has helped my family. Being of Chinese decent, cupping has been used at home for many generations. This is not to say my family is not both supportive and well versed in Western medicine (my mother works as an ICU Registered Nurse in a local hospital), but we believe that the use of Chinese medicine, such as cupping, is an effective alternative or complement to modern medicine for everyday health, wellness, and recovery.

My family uses Chinese medicine and therapies, such as cupping when muscle pains or cold-like symptoms appear. When a family member falls ill cupping is performed as a supplement to Western medicine in order to provide comfort and to help speed up the recovery process. My mother, who suffered a rotator-cuff injury two years ago, underwent surgery and used cupping soon afterward. It allowed her muscles to relax and helped increase the blood flow present in her body, providing her comfort during her surgical recovery.

Samantha Yin is a Chinese American from Temple City, CA. She is currently pre-med  studying Nutritional Science with an emphasis in Physiology and Metabolism at the University of California Berkeley.

 

Who Are Those Men in White Coats?


What comes to your mind when you hear the term “home birth?” Fear? Disgust? Happiness perhaps? How about if I throw a statement like “having an epidural is practically like giving your baby drugs” at you? If you’re anything like most childbearing families in America, one of these has struck a chord and you probably need a glass of wine to calm yourself down right about now (go ahead, no judgment here).

No matter which end of the spectrum you fall, I’m willing to bet you had some sort of a reaction. It’s interesting how those topics bring out an opinion in all of us, isn’t it? You’re probably saying “well now that you’ve got me all riled up, what’s your point lady?!?!”

My point is that birth is personal.

I have 4 children. The first two were unmedicated hospital births with a midwife. The second two were born at home.

When my husband and I were pregnant with our first child, the idea of home birth didn’t even cross my mind. I didn’t know anybody who had done it, save for a woman whose daughter I attended school with in my small North Dakota hometown - and she was known as an “eccentric hippy.” When I was 8 1/2 months along, our neighbors across the street had a baby with the help of a midwife in their home. I remember the mother gushing about how wonderful this birth was compared to her other two hospital births. I honestly thought she was clueless - me, the mother of none, to her the mother of three. When she asked why I wasn’t having a home birth I rattled off something about safety and medical equipment and my midwife…blah, blah, blah. Iʼm amazed when I look back on how opinionated I was about home birth - and birth in general – even though I had never experienced it.

My mom gave birth to 7 children, including one breech baby, all naturally. Iʼm so thankful to her for instilling in me faith in my body first and faith in what everyone else can do for me (insert medical intervention here), second. I believe if more women understood childbirth and were taught to embrace the pain (which is extremely different than “liking” it, by the way), more women would value their birth experience instead of loathing it.

The pain of childbirth is unlike any other pain a human being experiences. It’s not like a toothache that needs to be soothed or an infection that needs to be stopped. The pain tells a woman how things are progressing and leads her to react as her body dictates. For example, while laboring with my first and third, I had back labor which made me want to be on my hands and knees. As it turns out, both of those babies were posterior, or face-up (hence the back labor) and my instinctual position helped them turn and relieved the pressure. In other words the type of pain I experienced, led me to do what was needed to safely delivery my babies. Being medicated via epidural takes away a woman’s ability to read her body’s cues, because that is what the pain really is - a message. Delivering a posterior baby is harder and often leads to the need for intervention (Pitocin to speed labor or C-section to deliver). Does this mean that women who have epidurals never have posterior babies that turn during delivery? Of course not, but the incidence of posterior position is indeed higher with an epidural.

In my first two deliveries in a hospital, even though I was completely coherent and listening to my body, there were still people telling me how to manage what I was feeling:

Donʼt drink that!”…But, Iʼm thirsty!

Lie down so I can check your blood pressure!”…But, Iʼm trying to concentrate and lying down slows my contractions!

Donʼt mind the two residents in the corner with clipboards – they’re just watching.”…Total strangers just watching me get naked and do the most intimate and humbling thing Iʼll ever do?!? Awesome.

Push!”… But Iʼm not ready to push!

Donʼt push!”… But I have to push! Seriously?

We all know that animals tend to go to the darkest, quietest place around to deliver their young. Having a midwife attend my third and fourth births in the comfort of my home that was exactly how I wanted it – and that’s exactly what she did: facilitate a delivery that worked best for me. Not one that worked best for everyone else.

When people learn that Iʼve had a home birth, one of the first reactions I get is defensiveness. Weird, right? Birth is not a contest, ladies. Itʼs not about who can tolerate the most pain or who can do the most dangerous things without consequences. Did I win a gold medal for delivering my 11lb. 3.5oz boy at home? No! (Although, I do think heʼs a bit of a first-prize-at-the-county-fair-blue-ribbon-type-of-baby, I mean 11+ pounds…sheesh). Home birth is not for everyone – but remember, neither is hospital birth.

Natural birth vs. medicated birth vs. C-section vs. home birth, this will probably always be an ongoing debate. Itʼs rare (though not impossible) to find a doctor supportive of home birth, maybe because few have ever witnessed one. And although studies all over the globe point to the safety of home birth in low-risk pregnancies, American doctors (for the most part) favor the medical model of childbirth. This leads to many parents, especially first-timers, not being told all their options!

A dear friend, who is newly pregnant, recently asked what advice would I give a first timer. Without hesitation I said “Do your homework!” And not about which drapes match the crib sheets. Know your options, know why you want what you want, and make choices accordingly so that your wishes won’t be sabotaged, but instead supported with honest information. Does birth always go as planned? Never! But it can be incredible no matter how difficult, painful and/or long it is. After I had my last baby (the blue ribbon prize winner) and he was resting on my chest in the birth pool, I said to my husband “I feel so sorry for you that you never get to experience that the way I did.” It was hands down the most empowering thing Iʼve ever done - and IT WAS HARD. Regardless of the birth plan you chose I wish all women feel that way about their birth experiences.

Soni Albright is the mother of four and a home birth supporter living in Houston, TX.  

Behind Closed Doors: You May Get Groceries and Other Adventures in Childbirth

Ask any doctor you meet to describe the most amazing thing that they
 have ever experienced in their career, and I would lay strong odds that 
most would say childbirth. Of course everyone in all of history has been present for at
 least one birth, and mothers for at least two. But I have always felt
 it has been a great privilege to be present for so many. I have witnessed thousands, and have even had to help deliver a few babies myself when things moved faster than the obstetrician or midwife expected, and I along with the nurse were the only ones present. It may be trite to call it a miracle, but for lack of a better word, it really is. The first breath and cry of a baby as the lungs expand with life-sustaining 
air, is like a brilliant white sail snapping full on a crisp ocean 
breeze. Even after the thousands I have seen, I still have a catch in
 my breath, and a skip of my heart with every new birth.

As the Chief of Obstetric Anesthesia at my hospital, I feel doubly professionally privileged. Not only do I get to participate in the clinical care of obstetric patients, but also help administratively, working with a wide array of health professionals, from obstetricians, to OB nurse, to pediatricians, to midwives, and even doulas. We are all focused on the health, and comfort of our patients with the common goal of ensuring a safe delivery and a healthy baby. We also strive to provide an individual experience for every one of our patients that respects their wishes and expectations for the birth and beyond.

Sometimes these goals are in conflict. There are few
 areas in medicine that garner so much public attention and generate
 such heated discussion as birthing options. Should one try for a home
 birth? A water birth? Should we be like Tom Cruise and remain totally
silent during delivery so the baby remains free of negative engrams? Hospital versus birthing center? 
Natural versus epidural? Vaginal versus C-section? There is a lot to
consider. One thing is for certain, childbirth is now safer than it ever 
was in all of recorded history. Take a walk in any 18th or 19th century cemetery and read the gravestones. They are a cold and stoney reminder of the high price of pregnancy and childbirth in the past. It was not unusual for a man to out live three or four wives, or for a mother to bury several of her babies. Fortunately, in our lifetime, this is no longer the case.

With choice however, comes controversy. Despite the theoretical
 ability to perform well-controlled birthing studies, in practice it’s not so easy; thus many issues we would like definitively resolved just
 aren’t. Even 90% probability leaves 10% uncertainty. Why do we have so many C-sections, approaching nearly 30% nationally? Does choice of pain relief matter? Does increased fetal monitoring lead to more frequent and unnecessary interventions? Do 
fertility treatments that allow older mothers to bear children, with
 an increased chance of twins, triplets, and beyond increase risk? Should anybody be allowed to have fertility treatments? Octomom anyone? I, for one, have mellowed with both age and experience in thinking there is one right answer. I believe in choice and intuition, but I also believe in science, and data-driven answers. My personal journey in the birth of our first child outlined below is illustrative of some of these dilemmas. Let’s just say, I was young, I was a new anesthesiologist, and I was faced
 with a challenging situation…of course hilarity ensued.

When Dana and I found out we were expecting our first child in the 
final months of my anesthesia residency, we simultaneously became inundated with good wishes and overwhelmed with advice on how to prepare for the big day. As a new anesthesiologist, I truly believed that we were the good guys and helped make the process of birth a lot more comfortable and safe. But not everyone is always on board with our efforts, even today. Miranda Kerr, the Victoria’s Secret supermodel and wife of erst while “Lord of the Rings” elf Orlando Bloom, has opined in the current issue of Harper’s Bazaar, U.K.

The Aussie who is on the cover of the August issue, told the magazine
 that she decided to have a natural birth without any pain medicine 
after watching baby-bonding videos. Kerr saw that babies without an
 epidural come out and go straight for the breast.

“Then they showed the ones (babies) right after the epidural, and that 
didn’t happen,” Kerr said. “The baby was a little drugged up, and I
 was like, ‘Well I don’t want that.’ I wanted to give him the best 
start in life I could.”



There is little doubt, if I were fortunate enough to be in that genetically
 privileged baby’s booties, I would leap like Legolas, straight for 
Miranda Kerr’s perfect breasts, drugged up or not. And for the record, here is Victoria’s real secret. The fertile Queen became a huge fan of pain medicine for labor. One of the world’s first
 anesthesiologists, John Snow was celebrated for his ability to safely 
gas Her Highness senseless with chloroform during the births of her 
last two children. For this skill, and perhaps his success in
identifying and halting the source of a horrific cholera epidemic in
1854, he was named by a 2003 poll of British doctors as “the greatest
 physician of all time.” Is it a coincidence that we have the word 
“snowed” to describe the state of blissful lack of awareness?

Faced with our impending delivery, one of our first tasks
 was to register for a childbirth education class. I must admit, as an
anesthesia chief-resident with a fair amount of experience on the 
obstetric floor, perhaps a little arrogantly harbored doubts about 
the value of this undertaking. I had seen numerous complicated birth-plans crafted in these classes burst into flame at the
 unyielding onslaught of the dragon’s breath of labor pain. I looked at 
the glossy brochure brought back from Dana’s first OB appointment. The misty cover picture was a mother gazing down at her 
preternaturally chubby baby nestled against her breasts; its inner 
copy was filled with words like “holistic” and “toxin-free.” I began to 
cynically snicker… and was immediately shot
down with “the look.”

Here is some hard earned marital advice. Do not laugh at your pregnant
 wife. Even if in the past she has been a willing co-conspirator with
 you against the excesses of modern baby marketing, just 
don’t do it. To this day, one of the biggest arguments in the history 
of our twenty-two year marriage was about the exorbitant cost, and
“real need” of designer crib linens and bumpers. Give up. Just buy
 them.

On the very threshold of the first day of birthing class, empathy 
pillow in hand, Dana paused and made me solemnly swear that I would 
not let the teacher or anyone else in the class know that I was a 
doctor, and even worse, an anesthesia resident. She made me promise 
that I would listen attentively, wouldn’t snort derisively, roll my eyes, or sigh heavily… no… matter… what. In order to cement this 
deal, she gave me “the look” once again, and I knew I had no choice. I 
even agreed to carry the empathy pillow and go “hee-hee-hee, 
hoo-hoo-hoo” when prompted. I introduced myself to the doula-educator who seemed a touch too sweet, and 
had an edge I immediately recognized as pure passive-aggressiveness. Kind of like Dolores Umbridge for all the Harry Potter fans out there. I
surveyed the room and the ten or so other couples scattered about. Some were bewildered and dazed newbies, and a few were clearly repeat
 parents, bored and all been-there-done-that.

The first few classes were actually fine, nothing too controversial. Most of the topics were blandly informational, about such 
things as the early changes of pregnancy, lactation, mood swings, and and 
must-have baby equipment. The routine was to present paired related 
topics, like nutrition and exercise, stretch marks and skin-care: so 
far, so good. I was dutiful. I was attentive. I was respectful. I
 took pains never to wear my scrubs to class, or discuss my day in the 
operating room. When asked, I said I was a student, which was sort of 
true. It would be an exaggeration to say that I enjoyed the class, but 
all in all it wasn’t horrible. So we continued to attend. And then one
 week, late in the curriculum, things took a decided turn for the
 worse.

On that fateful evening, we arrived a little tardy to find the teacher at the whiteboard busily scribbling away. Everyone seemed 
unusually hushed and serious. Her ample rear-end wiggled, and the
 dry-erase marker squeaked as she wrote. The two topics of the night
were already delineated on either side of the board – doubly 
underlined in her flowery script:

“Unexpected Fetal Demise” and… “Risks of Epidural Anesthesia”

Dana shot me a warning glance as she could tell I was starting to get
 riled up. She painfully squeezed my hand after we sat down on the
 floor - no chairs allowed here - the empathy pillow accusingly thrust
 between us.

Under “Risks of Epidural Anesthesia” she had drawn an elaborate
 diagram. In the middle was a big circle with the word “Epidural” in 
it. Several spokes extended from the center like a wagon wheel. At the
 end of each spoke were other circles, some big, some small. And then
 she started to write in each of them… In the first big circle she 
wrote, “Nerve damage, Possible Paralysis!” in the next, “Chronic Back
Pain!” and the next, “ Use of Caine Drugs and Narcotics = Toxic, May 
Cause Future Addiction in Baby!” and the next, “Interferes with 
Breast-Feeding and Attachment!” then, “C-Section nearly Guaranteed!”
And then starkly, “Death!!” Undoubtedly she felt the ultimate
 catastrophe gleefully deserved two exclamation points. Finally, in the 
tiniest, loneliest, most distant circle attached to the growing wheel 
of anxiety she glumly wrote in small letters, “…you may get pain 
relief.” And that was it 
for me. I lost it.

I imagined myself a superhero, like Clark Kent ripping off my striped oxford
 button-down to reveal my scrubs with the crimson “S” beneath. Only in
 my case it was an “A” for Anesthesiology! I leapt to the board, grabbed the marker from the startled woman, and drew my own 
wagon wheel. In the big central circle I wrote, “Trip to Grocery 
Store” and then the spokes: “Horrific Flaming Car Crash!” and, 
“Kidnapped by Aliens and Anally probed!” and, “Poisoned by Botulism!”
 and so on. Finally in a small circle I wrote, “… you may get
 groceries.”

Needless to say, we were invited not to come back to class after that.

I could tell Dana felt sort of relieved, even co-conspiratorial. She smiled at me, and I was reminded once again that I had married the right person. Later, in the 
hall, several of the dads clapped me on the back, and made me feel
 a little better. A few of the experienced moms mouthed, “Thank you!” Of course
I knew that some of them had epidurals with their first pregnancy, and as far 
as I could tell, they were alive, they all walked just fine, and not
one of them had cocaine-addled junkie toddlers in tow.

Jeff Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice”.

Behind Closed Doors: Our Heroes, Something Given and Something Gained

An empty operating room in the witching hours of the night is as spooky as any haunted house. Most of the rooms I work in do not have outside windows. Like a casino, or an underground bunker, “daytime” is relative. Even so, I often get goose bumps whenever I walk alone into an operating room to set up for an emergency nighttime case. I am the first to arrive. The noises, bright lights, and bustle of the many concurrent routine operations of the day are replaced by the low hum of the air ducts and the soft fluorescent glow of monitors and machines. The room is cold and mostly dark as I enter, and it is easy to imagine the lingering spirits of all the people who have undergone operations in here. Shadows play in the far corners of the room, and distant footsteps from outer halls echo off the linoleum floors, stainless steel tables, and pallid green walls.

I’m still a bit groggy from my few hours of sleep before the after-midnight summons to the hospital. The call is followed by a foggy and wind whipped drive south over the Golden Gate Bridge. Sporadic northbound headlights of oncoming traffic pierce the gloom, and still startle me despite the hundreds of such nighttime trips. The bridge has no median barrier, and the center lane markers are flimsy moveable rubber pylons. Like invisible hands, sudden ocean gusts shove my car into the oncoming lane. I repeatedly correct my course and drive cautiously, with the window open to stay awake and alert, bracing myself with the cold night air.

Night cases are often transplants of one sort or another. The frequency of organ transplantation has greatly increased over the past four decades due to better tissue preservation, immune suppressing drugs, surgical techniques, and technology such as operating microscopes and Jedi sabre-like argon beam coagulators that cauterize the thick, bleeding edge of a transected liver. Kidney transplants are now routine, as are heart, lung, liver, pancreas, cornea, and recently even face transplants.

In 1968 the famed Dr. Norman Shumway performed the first heart transplant in the United States at Stanford. Ten years later, one of my college friends, Sam Poole, had heart transplant #120 by Dr. Shumway. These transplants were still so new that Sam’s mother, Victoria, wrote an inspiring book about him called “Thursday’s Child” subsequently made into a Hallmark movie starring Rob Lowe in one of his first screen appearances. What I remember most about Sam was his incredibly infectious enthusiasm and lust for life. His body ultimately rejected the transplanted heart despite the steroids and cyclosporine immune suppression therapy that made his skin thin, his bones brittle, and ruined his kidneys. We have come a long way since, and those who undergo transplants can live long and healthy lives.

The case I am here for is a kidney transplant. Like soldiers, firefighters, and police officers, doctors and nurses often engage in dark and decidedly inappropriate humor as a way to deal with the illness and death to which we are exposed. We joke about “donor-cycles”, and Darwin Awards. However, there is no levity when one considers the source of transplanted organs. Specifically, this case is an en-bloc kidney transplant: not one, but two kidneys. The paired donor organs come from a child.

I am a father of three healthy teenagers. I can’t even begin to imagine what it would feel like to make the decision to donate your child’s organs following an unthinkable, and tragic death. It is simply beyond my capacity. So now, in the middle of the night, in a dark and silent operating room I am setting up to transplant this dead child’s kidneys into a man suffering from end-stage renal failure. I look at my wristwatch at the time: 2:12 A.M.

The wristwatch is a 1960 vintage Swiss made Pierfa quartz, as old as I am, with a bright gold Speidel Twistoflex band. I have just had it repaired after the many years it sat unused in my dresser drawer. It belonged to my father, Lieutenant Commander L. Bush Swisher, Jr., who was a young and perpetually smiling Navy anesthesiologist from Morgantown, West Virginia. The watch is one of the few possessions I own from my dad, who suddenly, and with only the briefest warning of a severe headache, suffered a bleeding intracranial aneurysm on a sunny but bitterly cold morning in late January of 1968. He died two weeks later, just before twilight in a small hospital intensive care unit in Glen Cove, New York at the age of 34. I never had a chance to say goodbye. Had this happened today, we may well have saved him. Novel calcium channel blocking drugs, high resolution CT scans using catheter angiography, and the ability to thread small metal coils into the ballooning aneurism, greatly diminish the risk of arterial rupture, bleeding, and death. But not in 1968… and my life, and the lives of my mom, brother and sister were forever changed.

Now, as I stand at the head of the bed after successfully inducing anesthesia on the middle aged man comfortably asleep before me, I intently watch the surgeon as he carefully places the tiniest of circumferential sutures connecting the vessels of the donor kidneys to the recipient. And then I feel the presence of someone right behind me… It is 3:23 A.M. The room is hushed as everyone concentrates on the task at hand. The hissing rhythmic sound of the ventilator is hypnotic as it delivers each breath; pauses then sighs as the anesthesia machine scavenges the expired gas. It is a child- a very sad and frightened child. I don’t know why, but I envision a six-year-old girl, and I do not turn around. I can’t… because I am in turn scared and overwhelmingly sad. At that moment, the surgeon releases the arterial clamps. The mottled gray-blue donor kidneys begin to pink with new blood and life, and I feel a gentle touch on my shoulder… and I know… I absolutely know without any doubt, that my dad is standing behind me as well. A calm, warm, reassuring feeling suffuses me, and just as suddenly as I was stricken with grief, I become unable to contain an emotion I can only describe as pure joy. I close my eyes and see a boyish, broadly grinning young man in Navy dress whites extend his hand to a little six-year-old girl. Holding hands, they recede from me… away from the bright overhead lights whose beams are focused on the living pulsatile kidneys that are a precious gift and a new beginning for the sleeping man before me.

I look at my watch and it has inexplicably stopped… It is now 3:25 A.M., and I see no point in ever having it fixed.

For my Dad.

Jeffrey L. Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice”.