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December 13, 2012

When Gray Cat met Progressive Flo*

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Res ipsa loquitur.

 *While Gray Cat has myriad fans around the globe, there are many readers who would be just as happy if I never ever mentioned her here again, much less featured her in posts like this.

I feel your pain.

Well, that's not quite true.

I mean, Bill Clinton used to say that all the time and no one really believed him but it sounded pretty good and hey, he did win reelection with it so there must be some psychological component that resonates with people.

But I digress.

Anyway, his white-footed cat was named Socks, not the most original appellation considering the circumstances.

But let's be lovers, not haters here.

The thing is, people who love cats and who have come to adore mine are quite vocal about it, while it's politically incorrect to say "I detest cats and yours most of all."

So the noise is all "Yeah, yeah, more Gray Cat, meow meow" but the silence is also full of meaning and emotion even if it can't be directly seen on screen.

It's a little like the comments on Tuesday's post about the praying resident.

Not one commenter thought UCLA did the right thing by firing the guy, and a couple people chided me for thinking at the time that it was the right thing to do.

I hope those people don't hate me for thinking that.

But I digress yet again, this time from a point I think worth making, namely that the act of praying with that patient at her request — in the minds of myself and the majority of my fellow UCLA anesthesiology faculty and residents at the time and most certainly our chairman — opened up a vista of potential horror to us that I did not see addressed anywhere by any of the commenters on this post.

What we feared after hearing the facts of the event was that this resident might — might, mind you, because there is no way in the world we could ever have learned except the hard way — logically, based, on his behavior at the patient's bedside, be inclined to stop his scientifically-based thinking in the midst of a life-threatening crisis in the OR in an anesthetized patient and instead pray for her. 

The very possibility of that happening mandated his firing. 

That was the thinking then and it might well be the thinking today.

So before you start in with how wonderful a doctor he was to feel his patient's fear and loneliness and do what he could to lessen it, consider that as an anesthesiologist his job is not to hope and pray that things go well but to use every bit of his intellect, training, and experience to make that happen.

Prayer when an anesthetized, paralyzed, intubated patient suddenly experiences a cardiac arrhythmia or oxygen desaturation and increased airway pressure has NO PLACE in the flow chart in my operating room — nor will it ever.

And you had better hope that's true if you're the patient on the table under the care of a God-fearing, born-again Christian anesthesiologist.

bookofjoe is like a box of chocolates: You just never know where a post that leads off with a picture of Gray Cat will take you. 

December 13, 2012 at 04:01 AM | Permalink


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Comments

6.02*10^23

i did not mean to imply you were an anesthesiologist -

i said "i" just can't think like an anesthesiologist in this case - an expression frequently used in this blog -

so the resident manifested disordered thinking and was a potential ticking bomb like a terrorist or a witch hunter because he attempted to comfort a woman before surgery by participating in a one-off prayer at her request - therefore he must fired - off with his head

Posted by: sherlock | Dec 14, 2012 12:41:26 PM

Sherlock,
I am not now, nor have I ever been, an Anestheasiologist. I am the issue of a Psychiatrist (maternal parent) and trial Attorney (paternal parent).

Both of my parents' professions call for the utmost in diligence in the observation of human beings' behavior. The lessons that I learned at the family dinner table in my preadolescent period would fill several books.

Disordered thinking was a common thread. I did my best to describe our cultural embrace of the thought disorder known as "magical thinking" as applied to both the broad and the narrow manifestation in my analogy and analysis of the praying resident conundrum.

How dangerous is magical thinking? I believe that we are all well aware of the impact that 19 middle-aged men with box cutters (and, four hijacked aircraft) have had on the world. That particular act was both entirely unique and solely driven by the "magical thinking" thought disorder.

Does a training program that prepares a physician for a lifetime of split-second life or death decisions have a duty to observe the student for signs that the student may not be able to perform as trained? I'd say that the assessment of the student's capacity to follow normal protocol in all circumstances is a measure at least as important as the student's grasp of the fundamental treatment protocols.

Turning to the common legal analogy: a dog does not get "one bite" immunity - viciousness can be inferred from the totality of the circumstances. We can deduce that certain dogs have the propensity to bite from their demeanor and conditions of life.

We know that certain humans have the propensity to chug along through life without placing a strain on the social fabric - until they cease chugging along and act out - shredding the social fabric and themselves. Our society has made attempts to filter out some of these people where their thought disorders could cause unacceptable harm given the social position the individual might reach.

The resident manifested disordered thinking. That's a potential ticking bomb. UCLA made the call, in violation of civil law, to filter the disordered thinker from their residency program. I support their decision.

Perhaps I have given you some additional insight?

Posted by: 6.02*10^23 | Dec 14, 2012 11:06:16 AM

Also:

> I hope those people don't hate me for thinking that.

But of course I don't hate you, Joe. I don't even mildly dislike you. I also don't think that you hated that young man, merely that you disagreed with him. There is plenty of room for appreciation and even genuine affection in the midst of disagreement.

That's how civilized societies work. Somehow BoJ has remained a civilized society despite inspiring thought-provoking conversations on real issues.

It's a nice boost to the faith in humanity.

Posted by: Nathan | Dec 14, 2012 10:12:43 AM

6.02*10^23

"It is exactly this kind of complacency in making life-and-death decisions that made UCLA's decision to terminate the residency entirely rational. I support the decision." -

so a juror maybe complacent about imposing the death sentence - ok - i get that -

firing a young resident for a one-off prayer while attempting to comfort a woman before surgery because a juror maybe complacent about imposing the death sentence - hmm - seems like a stretch to me -

i just can't think like an anesthesiologist

Posted by: sherlock | Dec 14, 2012 4:16:33 AM

I know why Gray Cat spells her name as she does: the A is for anesthesiologist.
If it is not possible to Think Like An Anesthesiologist, is it possible to Think Like An Anesthesiologist's Cat? I study the picture; I see that she begins, appropriately, by engulfing herself in sensation, and has trained her companion not only to filter out the painful and ungratifying, but also to provide the most pleasurable variety, in abundance.

Posted by: Flautist | Dec 13, 2012 8:43:55 PM

Grey Cat could easily run his own blog. Albeit, a low-impact blog, the Drudge Report of napping, so to speak.

Posted by: mrG | Dec 13, 2012 4:43:56 PM


We live in a demon-haunted world.  Irrational belief systems have consequences.

More than 50% of adults in the United States believe in demonic possession.  68% of Republicans and 49% of Democrats polled in October 2012 state that they believe that "demonic possession" is real. See PPP Poll here: http://www.publicpolicypolling.com/pdf/2011/HalloweenRelease%2BResults.pdf

Widespread belief in those invisible, intangible, and undetected by any scientific measurement, demons is anathema to a modern society. Sweden is 85% atheist and polling Swedes about demonic possession would be a waste of time.

We in the U.S. still engage in the ritual killing of humans. There exists no discernible difference in today's practice over those of Cotton Mather's Salem Witch trials. 

We call our ritualized killing of humans "execution" and, since 1976, every jury that has sat in judgment of an accused murderer has been, "death qualified" - a panel made up of jurors who agree to impose a death sentence. 

There is no room on any jury for people who won't agree to kill another human where capital punishment is a possibility. When polled, "death-qualified" jurors always respond that they believe in God. One study of Harris County (Houston) Texas jurors who had imposed death in at least one trial (some jurors served on more than one jury panel that imposed the death sentence) stated that their imposition of a sentence of death was "God's Will" and that God would intervene to save the innocent. These jurors clearly had no grasp of the consequences of their decisions where they ascribed all outcomes to "God's Will". Indemnification by deity.

It is exactly this kind of complacency in making life-and-death decisions that made UCLA's decision to terminate the residency entirely rational. I support the decision.  Truth be told, doctors do bury their mistakes.

However, the decision was a civil wrong. The Civil Rights Act of 1964, 42 U.S.C. Sec. 2000e et seq. (as amended) prohibits employment discrimination based upon religion, where religion is defined as:" The term “religion” includes all aspects of religious observance and practice, as well as belief, unless an employer demonstrates that he is unable to reasonably accommodate to an employee’s or prospective employee’s religious observance or practice without undue hardship on the conduct of the employer’s business." 42 U.S.C. Sec. 2000e(j).

Making the argument that a one-off prayer caused the employer "undue hardship" is a losing proposition.  In the early 1980's the United States was deeply involved in the "born again" Christian revival movement. President Jimmy Carter was, and is, an avowed "born again" Christian. No jury in the mid 1980's would find the termination of that residency a lawful exercise of the employer's rights where the employee was exercising a protected activity in the workplace.

Posted by: 6.02*10^23 | Dec 13, 2012 1:23:36 PM

Mary Sue said it well. In short:

1. Treatment AND Prayer = Good.
2. Treatment OR Prayer = Bad.

I inferred that the resident had enough common sense to be acting on Principle #1, and so was doing no harm--not even a harm by omission. His colleagues presumed he was sliding--or would slide--towards Principle #2. I think that was an unfair leap on their part.

One CAN have it both ways:

"Praise the Lord and pass the ammunition."

"Trust in Allah, but tie your camel."

Etc.

Posted by: PT | Dec 13, 2012 12:19:09 PM

Oh, man! I thought this post was gonna be about Flo. I love Flo!

}:-(

(Gray Cat's cool, too.)

Posted by: MsRadoo | Dec 13, 2012 10:57:00 AM

There was once a young man whose grandmother was going into surgery. As a woman of faith, she believed that her fate was ultimately in the hands of the Almighty. But as a practical woman, she also understood that the skill of the attending professionals would have a significant impact on her immediate fate.

As the fated hour approached, she began reflecting on her life. On the likelihood of a woman her age surviving the anesthesia--let alone the procedure. And as she was talking to the anesthesiologist, in an unwonted display of emotion and vulnerability, she asked the professional to pray with her.

The man declined. He was not a man of faith but of science, believing the two to be mutually exclusive. She would be better served in putting her faith in his training, in his experience, and in his not inconsiderable abilities. He told her he was confident in her survival, and then walked away to begin preparations for the procedure. The woman's young grandchild witnessed the entire exchange, unnoticed, in a chair across from the bed.

As it turns out, the woman died from complications arising from the procedure. Not due to any error by the anesthesiologist or the surgeon but due to her body's inability to cope with the trauma of the surgery. But of course, the young man did not know this. He only knew that his grandmother was no longer alive. He vowed to become a doctor himself, mostly as an unconscious reaction to his own feelings of powerlessness on that day.

Fast forward to the start of the young man's promising career, as an anesthesiology intern. The faith instilled at his grandmother's knee is little more than a memory, soon to be relegated to the role of superstition. By the time he reaches the age of the anesthesiologist who refused to pray with his grandmother so many years ago, he will have much the same attitude.

With one difference: he remembers that day. And when he stops to see a patient whose procedure he will be observing, she asks him to pray with her. He knows, now, that it wasn't the lack of medical benediction which caused his grandmother's demise, but he also knows that the patient's mental state has a difficult-to-quantify but undeniable impact on her success and recovery. Knowing this, and remembering his own past experiences, he chose to pray with the woman. After all, it's her life that's at stake...why not do everything in his power to bring about a successful outcome?

Think like an anesthesiologist?

Posted by: Nathan | Dec 13, 2012 10:23:24 AM

I wonder why you (and the UCLA faculty) are under the assumption the choice is an either/or between prayer and medical skill.

I'm frequently in prayer at my desk at work. Do my coworkers notice? No, it's silent. Do my surgeons notice? No, they're just glad everything they need to do their job is at hand. Do I pray that, say, the skin graft magicallly shows up? No, I get myself on the phone to UPS and explain I need it now Now NOW while praying for the patient's healing, the doctor's skill, and the continued strength of the patient's loved ones.

Maye it helps, and maybe it doesn't, but firing someone for praying (Muslim, pagan, or even Christian) is a violation of several nondiscrimination in employment acts and is just as messed up as if you got fired for exercising your right to not pray.

Posted by: Mary Sue | Dec 13, 2012 9:52:20 AM

Why would a single episode of unexpected runs of premature ventricular contractions out of the blue in an otherwise healthy patient an hour into a total knee replacement lead me to prepare fresh syringes of emergency drugs for use in the event of unexpected cardiac arrhythmia and arrest for EVERY SINGLE CASE I'VE DONE EVERY DAY FOR THE PAST 35 YEARS only to discard the unused, untouched syringes every night after my cases are done, then do it again the next morning?

"Why would a single act convince the institution a flood will follow? That such behavior needs to be stamped out, once and for all?"

"Why can't we respond with some sense of proportion?"

Because YOU might be the patient with the unexpected arrhythmia.

Think like an anesthesiologist.

Posted by: bookofjoe | Dec 13, 2012 9:25:19 AM

Regarding the Praying Anesthesiologist: Why would a single act convince the institution a flood will follow? That such behavior needs to be stamped out, once and for all?

Why can't we respond with some sense of proportion?

This is the same kind of leadership paranoia that leads us to today's news that our government is now allowed to investigate millions of Americans in the name of counter-terrorism (Wall Street Journal, front page).

Posted by: JohnM | Dec 13, 2012 8:40:21 AM

Connections, connections... I'll tell you where this post has taken me - I see GC sacked out on her heated box, then read the line "Yeah, yeah, more Gray Cat, meow meow", then I get an immediate earworm of this old ditty

http://www.youtube.com/watch?v=5JuVHCJVYf4

that just about drives me around the bend, so I try to drive it out of my head with another possibly less aggressive earworm, and I come up with "Squilli, echeggi la tromba guerriera" from Verdi's Il Trovatore, for whatever reason, so I have to SEE it too, and I find this from a Royal Opera House production

http://www.youtube.com/watch?v=yLkhfYi-kzE

which drives out the previous earworm but gives me an eyeworm too, since now I'm thinking that if they'd just worn ONLY those black things that lace in back, that would've been just perfect. So I got the Kinky Costume Chocolate from the box. Not bad, Gray Cat.

Posted by: Flautist | Dec 13, 2012 7:32:43 AM

Team Gray Cat.

Posted by: YesBiscuit! | Dec 13, 2012 6:06:40 AM

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